SUMMARY: Treatment of sacral insufficiency fractures (SIFs) has traditionally been conservative, but several patients have been treated with percutaneous sacroplasty. Unfortunately, in the setting of severe, bilateral SIFs, cement may not withstand shear forces present at the lumbosacral junction, and surgical hardware may not provide adequate fixation in osteoporotic, cancellous bone of the sacrum, leading to eventual pseudarthrosis. Thus, we propose a novel technique in which guidance with CT fluoroscopy allows placement of a transiliosacral bar in conjunction with sacroplasty.

Revascularisation by angioplasty or bypass of narrowing and occlusion of the tibio-peroneal segment is done infrequently compared with the more proximal arteries, particularly the superficial femoral artery. The indication for intervention is critical limb ischaemia and the pattern of disease when it predominantly affects the calf arteries is most commonly seen in diabetics. Surgical bypass is the orthodox technique, with well-documented long-term results. Balloon dilation has recently been tried, particularly using the sub-intimal technique. The advantage of minimal invasiveness has to be set against the inapplicability of the method if severe calcification is present, as is often the case in diabetics, the high restenosis rate, and the absence of controlled trials showing good evidence of long-term patency.

Abstract Background In 1999 an emergency vascular service for Bristol and Avon (including Weston-Super-Mare) (population approximately 1 million) was initiated. Methods Collaboration between Bristol Royal Infirmary, Frenchay and Southmead Hospitals provides week-on–week-off vascular cover for patients requiring urgent and emergency interventions within 24 h. The rota accommodates National Confidential Enquiry into Perioperative Deaths and Vascular Surgical Society of Great Britain and Ireland recommendations, governance issues, and enhances emergency vascular care for Avon residents. Prospectively collected data for the first year (May 1999 to April 2000) are reviewed. Results There were 289 emergency admissions. (In-hospital referrals were not transferred but contributed up to 40 per cent of the extra emergency workload per unit.) Referrals were also accepted from seven Trusts outside the designated catchment area. Caseload included 86 patients with a ruptured or acutely symptomatic aortic aneurysm, of whom 69 underwent operation (30 per cent mortality rate); 17 patients were not operated on. Some 136 patients had critical leg ischaemia (43 acute, 93 chronic); angiography or duplex ultrasonography was performed in 105 cases (77 per cent); 39 patients (29 per cent) had undergone previous intervention for peripheral vascular disease; the mortality rate was 18 (13 per cent) of 136; 18 (13 per cent) of 136 patients required an amputation. Other cases included: upper limb ischaemia, 20 (7 per cent); paediatric emergency, seven (2 per cent); symptomatic carotid disease, five (2 per cent; four endarterectomies with no death or stroke). Some 5 per cent of referrals were inappropriate (venous ulcer, spinal stenosis, etc.). No outcomes were compromised by interhospital transfers. Vascular surgeons operated on nine high-risk patients away from their ‘base’ hospital. A consultant was the principal or assistant operator in more than 95 per cent of operations but, despite trainee rota adjustments, a designated vascular trainee was present in only about 40 per cent of cases. Conclusion Interhospital provision of emergency vascular services for a large population is feasible, does not compromise quality of care, and regulates emergency workload. Further attention to training issues is indicated.

Objective To prospectively compare a 3-D phase contrast (PC) magnetic resonance angiography (MRA) sequence (rephase/dephase) with digital subtraction angiography (DSA) in pre-operative evaluation for femoropopliteal grafting in peripheral vascular disease. Assessment of distal run-off vessels and suggested siting of distal graft anastomosis to the above or below knee segment of the popliteal artery was made.Methods: Twenty-two lower extremities booked for infra-inguinal vascular reconstruction were imaged pre-operatively using MRA and DSA. A PC rephase/dephase sequence which includes gradient motion refocusing (Siemens 1.0T Magnetom Impact TR 50 ms, TE 14/14 ms and 15 degree flip angle) and 3-D MIP algorithm reconstruction was used to obtain the MR images. Standard techniques were used to obtain the DSA images, and the mean and median time between imaging modalities was one month. Blinded review by a consultant vascular radiologist scored nine vessel segments for each limb and assessed which popliteal arterial segment would be most suitable for distal anastomosis.Results: The score from DSA and MRA agreed for 155/198 vessel segments (kappa 0.57) and the suggested siting for distal anastomosis agreed for 19/22 limbs (kappa 0.72). Eighteen limbs had surgery as planned (distal anastomosis to the above knee popliteal eight limbs, below knee popliteal 10 limbs). For three limbs the siting of the distal anastomosis suggested by DSA and MRA disagreed. The more accurate modality was proved for one of three limbs and showed MRA to be superior to DSA.Conclusion: Three-dimensional PC rephase/dephase MRA is a promising technique which compared well with DSA in the pre-operative assessment of distal run-off for femoropopliteal grafting.

Accurate diagnosis of internal carotid artery (ICA) occlusion is essential in the investigation of carotid disease yet may be difficult using Duplex. Traditionally contrast arteriography has been used to confirm the diagnosis despite its cost and potential dangers. Twenty-one patients with 23 ICA occlusions were evaluated by a 3-dimensional time of flight magnetic resonance angiography (MRA) technique. The cervical carotids and circle of Willis were imaged during the MRA examination which lasted 30 minutes. Confirmatory conventional angiography was performed in all patients. Using angiography as the gold standard, all occlusions were correctly diagnosed by MRA and 22 of 23 occlusions correctly diagnosed by Duplex. There was good agreement between MRA and angiography for all 42 ICAs imaged (Kappa statistic 0.83). Diagnosis of internal carotid artery occlusion is critical as it determines the need for operation. In this situation MRA provides a useful non-invasive complement to Duplex. A combination of non-invasive studies may enable arteriography to be rejected with greater confidence in this high risk group.

A questionnaire was sent to 39 hospitals, in the United Kingdom, 38 with a cardiosurgical unit and one with a cardiac radiology department. The object was to ascertain the commitment of consultant radiologists to cardiovascular radiology and cardiac radiology in particular and to evaluate training given to non-consultant radiologists in this subspecialty. Thirty-five (90%) departments responded, 33 of which had a cardiac radiology consultant. All but three of the 63 consultant cardiac radiologists report cine angiography. Of the 63, 26 perform one additional imaging technique and 21 perform two or more additional imaging techniques. The remaining 16 consultants only report on cine angiography. Only nine of 21 departments in which some form of cardiac radiology training was given, had a rotation through the subspecialty at registrar or senior registrar level. Twenty-one departments thought that an additional post in cardiac radiology would be sought if trained people were available.

A retrospective review of patients with coronary angiography was undertaken to establish the incidence of ventricular fibrillation and other serious arrhythmias and to identify possible causative factors, in particular whether the use of non-ionic contrast medium increased the risk of a serious arrhythmia. Out of 3660 patients reviewed there were 10 cases of ventricular fibrillation. In all cases, there were identifiable technical factors thought to have accounted for the arrhythmia. There were no cases of ventricular fibrillation complicating a technically satisfactory injection of ionic or non-ionic contrast medium. There was no significant difference in the incidence of serious arrhythmias between patients given ionic and those given non-ionic contrast medium.

An in vivo model of arterial thrombosis was developed in which either polytetrafluoroethylene (PTFE [Gore-Tex]) or autologous vein grafts were used to replace a segment of the femoral arteries of dogs. In one series of studies, 5 cm of PTFE and 5 cm of autologous femoral vein were used in each animal and blood flow was resumed for 1 hour. 111In-labeled autologous platelets accumulated in greater amounts on the PTFE grafts (93.6 × 106 platelets/cm) than on the vein grafts (2.6 × 106 platelets/cm) (P<0.001). Orally administered ticlopidine (30 mg/kg/day for 2 days), an established inhibitor of platelets, reduced platelet deposition on the PTFE grafts to 10.5 × 106 platelets/cm (P<0.01). In a second series of studies, PTFE grafts were interposed on both sides in each animal, and blood flow was resumed for 3 hours. With intravenously administered verapamil, a calcium antagonist, given perioperatively at 7.5 ug/kg/min, 12 of 16 grafts in eight dogs were patent compared with only 2 of 16 grafts in eight control dogs (P<0.001). Furthermore, platelet deposition on the grafts was reduced from 1,090 × 106 platelets/cm to 303 × 106 platelets/cm (P<0.001). Thus, both ticlopidine and verapamil are effective antithrombotic agents as a result of their inhibition of platelet activity in this model, and these results provide further evidence of a central role for calcium in platelet activation.

To quantitatively study platelet deposition on arterial prostheses and the effect of platelet inhibitory therapy with ticlopidine, 14 dogs underwent bilateral femoral artery excision and replacement with one polytetrafluoroethylene (Gore-Tex) and one autologous vein graft. Five dogs received 60 mg/kg/day of ticlopidine orally on four consecutive days prior to surgery. Nine untreated dogs served as controls. Collagen-induced platelet aggregometry studies were performed at the end of day 4. Autologous indium-111-labeled platelets were injected 24 hours prior to surgery to serve as aplatelet marker. All animals received heparin (1 mg/kg I.V.) 5 minutes prior to excision of the arterial segment. Grafts were removed 1 hour following resumption of blood flow and gently flushed with 30 cc normal saline. Radioactivity per unit weight of Gore-Tex, vein and blood was determined with a gamma counter. The relative radioactivity with respect to the internal reference standard, blood, is tabulated below. Ticlopidine treated dogs showed a 15-fold reduction in platelet deposition on Gore-Tex grafts and a 3-fold reduction on venous grafts. Platelet deposition was reduced significantly in Gore-Tex grafts (P<0.001) to a level comparable to that in autologous veins. Platelet inhibitory effect was also observed in collagen-induced platelet aggregometry. According to this “in vivo” data, ticlopidine appears to be a promising platelet inhibiting agent.