Abstract Aim Over 4100 elective abdominal aortic aneurysm (AAA) cases are performed each year in the UK. In our tertiary centre the anaesthetic pre-operative protocol for these patients includes a chest x-ray (CXR), because some risk factors for aneurysmal disease (smoking, older age) cross over with those for lung cancer. This study was performed to see if the CXR changed management in AAA patients. Method A retrospective radiology review of 191 consecutive patients who had an elective AAA repair at one unit in 2017-2018 was carried out. Computed tomography angiogram (CTA) and CXR findings were compared. Where an abnormality was reported, patient records were reviewed and the impact of the abnormal result on the patient journey assessed. Results Of 191 patients, 148 had pre-op CXRs. Of the CXRs, 60 reported abnormalities, most of which were minor (cardiomegaly, atelectasis, reticular shadowing). Of the 60, 28 had no lung abnormalities on CTA, 18 had not had a reported CTA, 8 corresponded with the CTA and 6 had a different chest abnormality reported on the CTA. 2 patients had CTs of the chest following CXR findings and no patients had an operation cancelled or delayed due to findings on CXR. Conclusions Each CXR costs around £20 including reporting and administration time. In addition, there is inconvenience to the patient and additional radiation dose. None of the pre-operative CXRs resulted in a change to patient operative management therefore the requirement for pre-operative CXR was removed from the units’ protocol.

Objective: Vascular surgical specialisation is associated with improved outcomes. We aimed to assess the effect of anaesthetic specialisation on outcome following major vascular surgery.Design: Retrospective cohort study.Methods: Patients undergoing major vascular surgery (lower limb revascularisation, elective and ruptured abdominal aortic aneurysm repair, endovascular aneurysm repair and carotid endarterectomy) over a five-year period were identified from a prospective database. The primary outcomes were death within 30 days and death within two years of surgery. Potential risk factors for mortality were assessed using multivariate logistic regression modelling.Results: The analysis cohort comprised 1155 patients followed up for a median of 583 days. Mortality within two years of surgery was 16%. For the overall cohort, care from vascular anaesthetists was independently associated with reduced 30-day (odds ratio 0.22; 95% CI 0.12-0.62) and medium-term mortality (0.31; 95% CI 0.18-0.55). For elective patients (n = 851), vascular anaesthesia reduced two-year mortality (odds ratio 0.29; 95% CI 0.15-0.58; P=0.0004) though not 30-day mortality (odds ratio 0.55; 95% CI 0.15-1.95; P=0.35). For emergency patients, care by a vascular anaesthetist influenced neither 30-day mortality (odds ratio 0.33; 95% CI 0.08-1.41; P=0.13) nor medium-term mortality (odds ratio 0.45; 95% CI 0.17-1.21; P=0.11).Conclusions: Anaesthetic specialisation reduced early- and medium-term mortality rates following major vascular surgery. If replicated by prospective studies, these results suggest that vascular surgery services would benefit from specialised anaesthetic support. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: The aim was to determine whether folate supplementation improved arterial function in patients with peripheral arterial disease (PAD).Methods: Individuals with PAD were randomly assigned to receive 400 mu g folic acid (45 patients) or 5-methyltetrahydrofolate (5-MTHF (48) daily, or placebo (40) for 16 weeks. Primary endpoints were changes in plasma total homocysteine (tHcy), ankle: brachial pressure index (ABPI) and pulse wave velocity (PWV). Secondary outcomes were changes in plasma inflammatory markers.Results: Plasma tHcy was significantly reduced in folic acid and 5-MTHF groups compared with controls: median difference: -2.12 (95 per cent confidence interval -3.70 to -0.75) mu mol/l (P = 0.002) and -2.07 (-3.48 to -0.54) mu mol/l (P = 0.007) respectively. ABPI improved significantly: median difference 0.07 (0.04 to 0.11) (P < 0.001) and 0.05 (0.01 to 0.10) (P = 0.009) respectively. Brachial-knee PWV (bk-PWV) decreased significantly in individuals receiving 5-MTHF and tended to be reduced in those taking folic acid compared with controls: median difference: -1.10 (-2.20 to -0.20) m/s (P = 0.011) and -0.90 (-2.10 to 0.00) m/s (P = 0.051) respectively. Plasma levels of inflammatory markers were not affected.Conclusion: Folate administration reduced plasma homocysteine, and slightly improved ABPI and bk-PWV.

Objective: To evaluate homocysteine (Hcy) levels in patients with peripheral arterial disease (PAD) as compared to unaffected controls, and to review the clinical effects of therapy aimed at lowering homocysteine in PAD patients.Methods: MEDLINE, EMBASE and Cochrane databases were searched from 1950 to December 2007. We selected observational studies and trials that evaluated Hcy levels in patients with PAD compared to unaffected controls. We also included trials on the effect of Hcy-lowering therapy (folate supplementation) in PAD patients. Continuous outcomes were pooled in a random effects meta-analysis of the weighted mean difference between comparator groups.Results: We retrieved 33 potentially suitable articles from our search. Meta-analysis of 14 relevant studies showed that Hcy was significantly elevated (pooled mean difference +4.31 mu mol l; 95% C.I. 1.71, 6.31, p < 0.0001 with significant heterogeneity) in patients with PAD compared to controls. As all 14 studies consistently demonstrated raised plasma Hcy levels in PAD patients, the significant heterogeneity in this meta-analysis probably arises from differences in the degree of Hcy elevation.The effect of folate supplementation on PAD was tested in eight clinical trials but clinically important end points were inconsistently reported.Conclusion: Patients with PAD have significantly higher Hcy levels than unaffected controls. However, we did not find any robust evidence on clinically beneficial effects of folate supplementation in PAD. (C) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

This paper, like others before it, concludes that carotid stenting (CAS) is less cost-effective than carotid endarterectomy (CEA). As a surgeon, this appeals to my own prejudices, but will it stand up to the more critical gaze of enthusiastic stenters? The authors have developed a cost-effectiveness model based on procedural costs for both CEA and CAS in their own institutions in the Netherlands and clinical outcomes from the ECST,1European Carotid Surgery Trialists' Collaborative Group Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Google Scholar a Cochrane Review of randomised controlled trials2Ederle J. Featherstone R.L. Brown M.M. Percutaneous transluminal angioplasty and stenting for carotid artery stenosis.Cochrane Database Syst Rev. 2007; 4: CD000515Google Scholar (RCTs) and the Global Carotid Artery Stent Registry (Wholey3Wholey M.H. Al Mubarek N. Wholey M.H. Updated review of the global carotid artery stent registry.Catheter Cardiovasc Interv. 2003 Oct; 60: 259-266Google Scholar). The crucial questions are 1) Do the costs in this paper reflect wider practice? 2) Are the clinical outcomes used by the authors reasonable? The issue of costs is relatively straightforward. By providing a breakdown of how these were calculated (Table 1), we can all compare and contrast with our own figures. The paper overestimates CEA costs for my own unit as we discharge patients within 48 hours of operation, don't use TCD and in the UK an interventional radiologist costs roughly the same as a surgeon, rather than half as much (though I like the Dutch valuation). We don't run a stenting programme but those that do will no doubt find similar faults with the CAS costs. However, it does seem clear that the kit used for CAS is considerably more expensive than that used for CEA. So, if the benefit of a shorter hospital stay is lost, do the clinical outcomes of CAS justify this additional expense? This rather polarised debate boils down to which outcomes you choose to believe. For those you don't like you can always invoke the “learning curve”, “evolving techniques” or “my own results”. By basing their model on results from the ECST (an old trial), Cochrane database (disputed trials) and the Wholey registry (not a trial) the authors will be subjected to familiar criticisms. They have, however, used the best available evidence. By using different scenarios and sources of data they have endeavoured to do this in an even-handed way. The crucial figure (fig. 3) in this paper, comparing costs and QALYs, finds the Cochrane RCTs showing a clear advantage for CEA, with the Wholey database winning the argument for CAS over ECST (in what could be argued was a rather uneven contest). Both sides will draw comfort from this, but how were such conflicting results obtained? The explanation is found in Figure 1, where the confidence intervals for major and minor stroke rates following CAS in the Cochrane trials and the Wholey registry do not even come close to overlapping. The learning curve or selective reporting? You decide. What this paper contributes is a useful model into which individual centres can put their own figures. Differing local costs and outcomes will make the case for one technique or the other. It is incumbent on manufacturers of stenting equipment to also look long and hard at these figures. In any normal marketplace if an expensive technology has no proven advantage over a cheaper alternative, producers would be forced to cut prices or go out of business. But the healthcare economy is not a normal marketplace and clinicans are rarely swayed by economic arguments. If we were, this paper suggests that we should no longer be debating this subject.

A 12-day-old term male neonate presented with septic arthritis, multiple skin and intrabdominal abscesses and a mycotic aneurysin of the right internal iliac artery. He was diagnosed as having methicillin resistant staphylococcus aureus (MRSA) septicaemia and deemed unsuitable for surgical treatment of the aneurysm. Coil embolisation of the internal iliac artery was performed, followed by a successful recovery and with no evidence of residual or recurrent infection. The authors describe a method of treating internal iliac mycotic aneurysms in high-risk patients by endovascular means, which we believe has not been attempted in this precise scenario before.

We present a case of a superficial femoral artery aneurysm in an 83-year-old female who presented with right thigh pain and a pulsatile mass. Computerised tomography revealed a superficial femoral artery aneurysm, which was subsequently resected and bypassed. The femoral and popliteal veins were found thrombosed and the long saphenous vein was, therefore, spared. Aneurysms of the superficial femoral artery are rare. A complete vein map should be obtained prior to bypass to avoid sacrificing what may then be the most important channel for venous return, the long saphenous vein.

Introduction: Endovascular aneurysm repair (EVAR) has been suggested as a technique to improve outcome of ruptured abdominal aortic aneurysm (AAA). Whether this technique becomes an established treatment will depend, in part, on the anatomy of ruptured AAA.Methods: The anatomy of intact and ruptured AAA seen in a university department of vascular surgery over 5 years was reviewed. Aneurysm anatomy was assessed with spiral computed tomographic angiography. Suitability for EVAR was assessed from the dimensions of the proximal neck and common iliac arteries. Neck length less than 15 mm, neck width greater than 30 mm, and common iliac artery diameter greater than 22 mm were declared unsuitable for EVAR.Results: Three hundred sixty-three patients with intact AAA and 46 with ruptured AAA were identified. Larger intact aneurysms were significantly associated with longer renal artery-bifurcation distance and more complex proximal neck architecture. In this sample, patients with ruptured AAA were more likely to have larger aneurysms with shorter and narrower proximal necks. Significantly more intact aneurysms were morphologically suitable for endovascular repair compared with ruptured AAA (78% vs 43%; P < .001).Conclusions: Ruptured AAA are less likely to be suitable for endovascular repair than are intact AAA, most probably because of larger diameter at presentation. Open repair will likely remain the treatment of choice in most patients with ruptured AAA, because of current morphologic constraints of endovascular repair.

Purpose: To report a case of colonic infarction following endovascular abdominal aortic aneurysm (AAA) repair in a patient with both internal iliac arteries (IIA) unobstructed by the endograft. Case Report: A 73-year-old man presented with blue toes as a result of emboli from a 6.4-cm AAA. As he was medically at high risk for open repair and his aneurysm morphology was suitable for a modular bifurcated endovascular graft, a Zenith endograft was used to exclude the aneurysm. Twenty hours after the successful procedure, in which both IIAs were preserved, the patient regurgitated coffee-ground vomit; an upper gastrointestinal endoscopy found a small Mallory-Weiss tear and antral gastritis. A proton-pump inhibitor was begun, but his symptoms progressed. Laparotomy revealed transmural ischemia and infarction of the upper rectum, sigmoid, descending colon, and the splenic flexure; a colonic resection with formation of Hartmann's pouch and colostomy was performed. He made a slow but uncomplicated recovery. Conclusions: Colonic necrosis can complicate endovascular AAA repair even when both IIAs are preserved. Advantageously, the clinical signs of severe colonic ischemia in endograft patients are not obscured by aftereffects of a laparotomy.

PURPOSE:To compare measurements of aortoiliac length obtained with spiral computed tomographic angiography (CTA) and aortography in patients undergoing endovascular aneurysm repair.METHODS:The distances from the lower-most renal artery to the aortic bifurcation and from the aortic bifurcation to the common iliac artery (CIA) bifurcation were measured using both CTA and aortography in 108 patients with abdominal aortic aneurysms.RESULTS:The level of agreement between CTA and aortography was high, with 69% of aortic and 76% of iliac measurements within 1 cm and > 90% within 2 cm of each other. Mean differences were -0.35 +/- 1.20 cm and 0.25 +/- 1.10 cm, respectively, for aortic and iliac lengths. Aortography overestimated renal artery to aortic bifurcation length in comparison to CTA (p = 0.003), particularly in patients with large aneurysms (> 6.5 cm) and lumen diameters > 4.5 cm (p < 0.0001). Measurements of CIA length were shorter by aortography than CTA (p = 0.02).CONCLUSIONS:There is a high level of agreement between CTA and aortography in the measurement of aortoiliac length, but aortography overestimates renal artery to aortic bifurcation length in patients with large-diameter aneurysms and wide aneurysm lumens. CTA is sufficiently accurate in the majority of cases to be used as the sole basis for the construction of endovascular grafts.

Objectives: To determine the incidence of common iliac artery (CIA) aneurysms in patients with abdominal aortic aneurysms (AAA) and to evaluate the relationship between AAA and CIA diameter.Methods: Spiral CT angiography was used to measure the maximum diameters of the abdominal aorta and the common iliac arteries of 215 patients with AAA.Results: The medium CIA diameter was 1.7 cm - significantly greater than the published mean of 2.25 (2 S.D. = 0.85-1.65) cm of an age-matched, non-vascular population. Thirty-four patients (16%) had unilateral and 26 patients (12%) bilateral CIA aneurysms greater than or equal to 2.4 cm diameter. Eight-six vessels (20%) were affected. Right CIA diameters were wider than left CIA diameters (p<0.0001, Wilcoxon marched-pairs signed rank test). The correlation between AAA size and CIA diameter was weak.Conclusions: The AAA population has abnormally dilated common iliac arteries. In this population, common iliac artery aneurysms should be defined as those greater that 2.4 cm diameter. 20% of CIAs in patients with AAA are aneurysmal according to this definition.

Aneurysms do not decrease in size in the presence of a lumbar endoleak, and some expand significantly. A number of aneurysms increase in size despite no evidence of an endoleak on computed tomography (CT). Patterns of thrombus distribution may be able to predict patients at risk from persistent endoleak via lumbar vessels.

Background Aortic aneurysm anatomy is crucial when considering patients for endovascular repair. The aim of this study was to determine the proportion of patients with aortic aneurysm suitable for endovascular repair with three different graft-stent systems.Methods Spiral computed tomographic angiography was used to assess the anatomy of 154 abdominal aortic aneurysms. Measurements were made of aneurysm neck length and diameter, renal artery to aortic bifurcation length, common iliac artery diameter and length, and external iliac artery diameter. Aneurysms were assessed for anatomical suitability for currently available aortoaortic, aortobi-iliac and aortouni-iliac devices.Results Six patients (4 per cent) had a distal aortic neck suitable for implantation of a straight aortic graft. Fifteen patients (10 per cent) had arterial anatomy suitable for implantation of a bifurcated graft and 85 (55 per cent) patients were suitable for endovascular repair with an aortouni-iliac graft. The primary reasons for unsuitability were: proximal neck length less than 1.5 cm (44 patients), proximal neck diameter greater than 3.0 cm (12), and angulation of the proximal neck (three). A further ten patients were considered unsuitable for an aortouni-iliac graft because of bilateral common iliac artery aneurysms (four), tortuous iliac arteries (four) and narrow external iliac arteries (two).Conclusion The aortouni-iliac device has the widest applicability of the currently available endo vascular systems but open repair remains the only option for a large proportion of patients.