Abstract Background Infection in the groin threatens both life and limb. In recent times virulent organisms, especially methicillin-resistant staphylococci, have proved difficult to treat. The obturator foramen bypass, although performed infrequently, represents an extra-anatomical solution to the ‘hostile groin’. The aim of the study was to examine the primary and secondary graft patency rates in 26 patients (28 procedures) performed in one hospital over 10 years. Methods There were 17 men and nine women with mean age of 65 (range 49–78) years. All procedures except one were performed with expanded polytetrafluoroethylene (6 mm in 24 patients; 8 mm in three). Twenty-one patients had critical ischaemia with rest pain or tissue loss. The inflow vessel was the common iliac artery in 25 patients and the lower abdominal aorta in three. The distal anastomosis was to the profunda in two grafts, to the suprageniculate popliteal artery in 24 grafts and to the infrageniculate popliteal in two. Results Patency rates were calculated with the Kaplan–Meier life-table method. There were nine primary failures (five in the first year and the remaining four between 2 and 5 years). All failed bypasses were re-explored. Three of nine bypasses required intraoperative angioplasty of the inflow, and one graft had angioplasty of the distal anastomosis. Six patients eventually had amputations, four above knee and two below knee, one of whom had a patent graft. Conclusion The obturator foramen bypass, although technically demanding, is a viable solution in the individual with groin sepsis and ischaemia. Frequently these patients have good calibre vessels above and below the problem groin.

We describe a simple and robust alternative to ultrasonic methods for the measurement of pulse propagation velocity (PWV) which detects the passage of the diameter wave as it passes two sites a known distance apart. Two probes each containing an infra-red emitting diode and a phototransistor are placed on the skin near to the vessel of interest. The energy returning to each probe depends on the amount of blood the beam has passed through, and this varies as the vessel pulsates. The output from each probe is displayed in real time on a portable PC. PWV is estimated beat-by-beat from the delay between the start of the systolic upswing in the signals from the two sites.In order to verify that our device measures changes in arterial diameter its signals were compared to those obtained simultaneously from an echo tracking pulsed ultrasound system. Transit time measurements from the two devices on the radial and femoral arteries in 6 subjects agreed closely. Additional validation experiments on 21 subjects undergoing cardiac catheterization have: shown that transcutaneous measurements of PWV using the infra-red device agree well with intra-arterial measurements obtained with a cannula and pressure transducer.We conclude that the optical technique for measuring PWV is a useful addition to the methods available for determining blood vessel elasticity. Its simplicity and ease of use make it suitable for large scale measurements in the 'field'. Three such studies are currently in progress.

De-endothelialisation is the main stimulus of intimal hyperplasia following vascular injury. In this study we investigated the time course of re-endothelialisation in balloon injured and Photodynamic therapy (PDT) treated aortas of New Zealand white rabbits. 20 rabbits underwent balloon denudation of the abdominal aorta and were then sacrificed in groups of 4 animals 0, 1, 2, 4 and 8 weeks later. 20 more rabbits underwent similar balloon denudation and were treated immediately afterwards with photodynamic therapy using the photosensitiser metatetrahydroxy phenyl-chlorin and endovascular illumination with 652 nm light. PDT treated rabbits were also sacrificed in groups of 4 animals at the same time intervals. A further 4 rabbits were sacrificed without any treatment to act as normal controls. The vasculature was perfusion fixed at 100 mmHg with 10% formal saline. The abdominal aortas were retrieved and five sections were cut from each aorta at 1 cm intervals, embedded in wax, sectioned and stained for endothelial cells using the Avidin Biotin complex/Horseradish peroxidase technique for use with the monoclonal primary antibody CD31 from the clone JC70. Endothelial covering was measured using a light microscope and Magiscan image analysis system. Normal arteries showed a near full (92.1% +/- 3.0, mean +/- SEM) endothelial covering. Endothelium was removed completely after both balloon injury and PDT. In balloon injury alone there was progressive endothelial re-growth with (54.1 +/- 72) covering at 8 weeks. In contrast, endothelial regrowth was retarded in the aortas treated with balloon injury and PDT, with only (7.1 +/- 2.9) of covering at 8 weeks. The slow pace of re-endothelialisation is consistent with greater production of intimal hyperplasia in PDT treated vessels.

Photodynamic therapy (PDT) has been proposed as a treatment for intimal hyperplasia (IH). We studied the effect of PDT on the development of IH following endothelial injury, using the photosensitizer Metatetrahydroxyphenyl-chlorin (m-THPC) and 652 nm illumination. 9 mini- pigs were used in 3 groups of 3. Pigs in the first group (balloon alone; BA) were anaesthetized and the lower 4 cm of abdominal aorta was denuded using a balloon catheter through the right femoral artery. In the second group (light alone; LA) the procedure was repeated, followed by illumination of the denuded area at an energy density of 20 Jcm-2 using a transparent PDT catheter. In the third group pigs were sensitized and an intravenous injection of 0.3 mg/kg of m-THPC 4 hours prior to balloon injury and illumination (PDT Group). Animals were allowed to recover for 8 weeks before being killed and perfusion fixed with 10% formal saline. 5 sections were cut from the treated segments and stained for elastin. Specimens were measured by a computerized morphometry system and the areas of the lumen (L), intima (I) and media (M) were measured. The degree of intimal hyperplasia was expressed as (a) I/M; (b) I/(I+M) and (c) I/(I+L) to take account of changes that could have occurred to the media and the overall diameter of the vessel. We found that when compared to BA controls, the lumenal area was decreased by 46% in LA group and increased by 44% in PDT group. The changes in the medical areas were minimal. These results show that both light alone and PDT produced more intimal hyperplasia than balloon injury alone (P < 0.002 for both groups, Student's t test). When allowance is made for the large increase in lumenal area associated with PDT the degree of intimal hyperplasia I/(I+L) was significantly reduced in PDT treated vessels when compared to those treated with light and balloon alone in spite of the greater absolute area of the intima in the PDT group. We conclude that PDT under the above conditions not only failed to prevent IH, but was associated with a significant increase of intimal area. The increase in the dimensions of the PDT treated vessels reduced the detrimental effect of IH and improved the overall diameter of the lumen.

OBJECTIVE:To investigate the effectiveness of photodynamic therapy (PDT) in eliminating proliferating vascular smooth muscle cells (VSMCs). This may have a potential role in reducing restenosis rates clinically. MATERIALS AND METHODS:Human VSMCs were successfully cultured from 15 long saphenous veins (SV) and seven restenotic lesions (RL) removed during revision coronary and peripheral vein graft surgery. Cultured VSMCs were incubated with photofrin at doses of 0-5 micrograms/ml for 48 h, and then exposed to 4 J/cm2 of polychromatic light. Cell destruction was quantified by a colorimetric assay using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide. RESULTS:Results are expressed as a mean percentage survival +/- standard error. Cells were minimally affected by either photofrin alone (SV: 95.5% +/- 5.3; RL: 119.8 +/- 4.8) or light alone (SV: 75.38% +/- 3.99; RL: 100.1 +/- 11.0). The combination of 2 micrograms/ml of photofrin and 4 J/cm2 of polychromatic light energy, i.e. PDT, was severely toxic to cells derived from saphenous veins (5.52% +/- 0.85) as well as cells derived from restenotic lesions (9.6 +/- 2.3). These doses are comparable to doses that can be achieved in vivo. CONCLUSION:PDT in the appropriate drug and light doses can eliminate human VSMCs, including those responsible for vascular restenosis.

The purpose of this study was to determine whether the addition of Photodynamic Therapy (PDT) using the photosensitizer Photofrin* (P*) following balloon angioplasty (BA) could prevent restenosis in an atherosclerotic animal model. Bilateral iliac atherosclerosis was created in 21 Yucatan miniswine. Six weeks later, P* 2.5 mg/kg was given IV 24 hours prior to BA (4 mm X 20 mm, 1 inflation). Following BA, swine were randomly allocated to receive PDT via a fiberoptic probe with laser energy or the same probe without laser energy. The fiberoptic probe had a 1 cm cylindrical diffusing tip and was passed co-axially through a custom catheter to ensure central location of the probe. A continuous wave argon ion-pumped dye laser tuned to 630 nm was used to provide a fluence of 100 J/cm2. Four weeks later, swine were sacrificed and vessels perfusion-fixed in-situ with glutaraldehyde and analyzed by ocular micrometry. Five occlusions occurred, all in the PDT + BA group. Percentage intimal thickness (mean +/- SD) was 51.0 +/- 29.5 in the BA group and 71.2 +/- 35.2 in the BA + PDT group (p equals 0.21). These results suggest that the addition of PDT following BA does not prevent restenosis.

Photodynamic therapy (PDT) is a promising treatment for vascular restenosis. Determining the site of the photosensitiser responsible for cytotoxicity during PDT is essential for planning treatment strategies. Vascular smooth muscle cells (VSMCs) were cultured from 6 individuals using substrate attached explant techniques and transferred into microtitire plates at 50,000 cells/well. Cells were arranged in 3 groups; the first group was incubated with 2 (mu) gml-1 of Photofrin for 48 hours, followed by polychromatic light illumination of 3 Jcm-2. In the second group the extracellular Photofrin was removed by washing cells just prior to illumination, and in the third group Photofrin was only added immediately prior to illumination. Results are expressed as mean percentage cell survival+/- SEM. Cells were minimally affected by extracellular Photofrin alone (91.9+/- 10.7). Photofrin in the intracellular and (intra+extracellular) compartments reduced VSMCs survival to (7.3+/- 4.9) and (8.8+/- 2.6). The mechanism of ablation appears to be due to activation of the intracellular rather than residual Photofrin in the extracellular medium

This report describes a patient who underwent a partial orchidectomy for testicular cancer, having already had a radical orchidectomy of the contra lateral side. He subsequently fathered two children. This policy may have a role in the management of men with an early germ cell tumour in a solitary testis who have not completed their family.

Proliferation of vascular smooth muscle cells (VSMCs) is the pathophysiogical basis of the restenoses which occur in 30-55% of patients undergone revascularisation. Prophylactic measures including pharmacotherapy, endovascular stenting and anti-gene therapy have so far failed to contain this problem. Photodynamic therapy (PDT) may selectively suppress VSMCs and decrease restenosis rates. We report 2 studies; the first examines the effect of PDT on an in-vitro model of NIH and the second involves using endoluminal ablation of an in-vivo model of experimental NIH of the rabbit's aorta.

Ross et al. (1987) performed a prospective study comparing the sensitivity and selectivity of various methods of initial radiological evaluation of the cervical spine. They concluded that a technically adequate three-view cervical spine series (later, anteroposterior and open-mouth odontoid films) can be used safely to eliminate instability. However, following this protocol in our patients still allowed us to miss the pathology. We would therefore suggest adding stress views (in flexion and extension) to the series when there is any suspicion of a high-energy injury. In situations where adequate stress views are impossible to obtain because of insufficient excursion due to painful muscle spasm, the patient should be seen again for further assessment and radiographs. This is in agreement with Herkowitz and Rothman (1984) who propose that a complete follow-up evaluation should be performed in every case of cervical injury. This should include a complete radiological examination, including stress films. The Accident and Emergency Department at the Royal Liverpool University Hospital sees over 5000 patients a month and of these approximately 100 require cervical spine radiography for trauma. The financial implications of this proposed management are obviously significant, but we believe they are easily justified when one considers the alternative, i.e. the economic burden of caring for a patient with permanent paralysis. Acknowledgements We would like to thank Mr J. C. Dorgan for allowing us to report on one of his patients, and also Professor L. Klenerman for help and advice in the preparation of this paper.