Transoesophageal echocardiography (TOE) is often the initial investigation of choice for imaging acute and chronic aortic disease including dissection and ectasia. It is also used in the placement of endovascular stent grafts, to monitor deployment of the stent, and to assess results.1 It is ideally suited because of the close proximity of the oesophageal imaging window to the arch and descending thoracic aorta. However, endovascular stent grafting is increasingly being performed under regional and local anaesthesia and it is impossible to tolerate a TOE probe for the length of the procedure. We therefore investigated the feasibility of imaging the thoracic aorta using a device originally developed for intracardiac echocardiography. The ultrasound-tipped catheter (AcuNav, Siemens, Mountain View California) is 90 mm long and 3.2 mm (10 F) in diameter compared with 9 mm (27 F) for a standard TOE probe. The imaging range is from 5.5–10 MHz and it has colour (5–7 MHz) and pulsed Doppler (4–5 MHz) capabilities. There is only one imaging plane, but transverse and intermediate views are possible because the …

Objectives: open surgical intervention for aneurysms of the distal arch and descending thoracic aorta is associated with high morbidity and mortality. Stent grafts offer an attractive alternative treatment for these aneurysms. The aim of this study was to assess the morbidity and mortality of endovascular treatment for these aneurysms with stent grafts.Design, patients and methods: a prospective observational study was performed of 37 consecutive patients treated from July 1997 to October 2000 (30 at Guy's and St. Thomas' and 7 at Sheffield). Indications included degenerative aneurysms (n = 18), false aneurysm (5), acute dissection (4), aortic transection (4), aneurysm related to previous surgery for coarctation (3), chronic dissection (2) and traumatic dissection (1). Nineteen were performed as elective and 18 as non-elective procedures.Results: three non-elective patients died in hospital (in-hospital and 30-day mortality 8%) and one suffered a stroke with spontaneous full recovery. No elective patient died. One patient with a persistent proximal endoleak required conversion to open repair at 6 weeks. Two patients with persistent flow into the sac at 24 h spontaneously thrombosed at subsequent 3 month follow-up. Two further patients developed new distal endoleaks at 3 months and required distal extension cuffs. One patient died at 28 months of aortic rupture. Serial CT scans had shown prolapse of the stent graft into the aneurysm sac and the patient died just before planned endovascular repair. No patient suffered paraplegia or renal failure. Intensive care facilities were only required for patients who needed them preoperatively.Conclusions: thoracic stent grafts can be performed with low morbidity and mortality. They offer a realistic alternative to open surgery. Long term follow up is required to assess their durability.

Crit Care 1999, 3 3 ( (s su up pp pl l 1 1) ):P1 I In nt tr ro od du uc ct ti io on n: : Critically ill patients requiring intensive care are at risk of iatrogenic ocular damage.Studies have reported an incidence of eye problems of up to 40% in critically ill ventilated patients.We conducted this study to assess the incidence of ocular complications in our intensive care unit where all patients are cared for according to an eye care standard.M Me et th ho od ds s: : All ventilated patients over a 2 month period were included.Ophthalmic assessment was performed on admission and repeated every other day during the period of ventilation.At each assessment the average Ramsey sedation score over the previous 24 h, the presence of tracheal secretions and the presence of ventilation associated pneumonia was noted.Eye care performed was recorded.R Re es su ul lt ts s: : Sixty patients were included.One patient developed corneal exposure keratopathy.No patient developed conjunctivitis or corneal ulceration.Further advice on appropriate measures of eye care was given in five cases (8%).Nine patients (15%) had large amounts of respiratory secretions with positive microbiological results.C Co on nc cl lu us si io on n: : This study confirms that the use of an eye care standard is associated with a low incidence of ocular surface complications.The incidence of ocular complications in this group of patients is far lower than previously described.

Purpose of study: The aims of this study were to determine the incidence of restenosis following carotid endarterectomy with primary closure of the arteriotomy and to observe the natural history of disease progression in the 1st postoperative year. Methods: The study group consisted of a consecutive series of 126 patients undergoing carotid endarterectomy. Duplex imaging was performed preoperatively and at 8 weeks, 6 months and 1 year postoperatively. Results: Five patients (4%) had a residual stenosis. At 12 months, the overall restenosis rate was 15%: 8.5% for males and 28.9% for females. None of these restenoses were symptomatic. There was no significant difference in the diameter of the internal carotid artery between male and female patients (U=896, P=0.60) and no significant difference in the diameter of the arteries that had restenosed at 12 months and those that had remained patent (U=391, P=0.33). Conclusions: Carotid endarterectomy with primary closure is associated with a low incidence of restenosis in men, but not in women. Criteria for selective patching should consider both gender and vessel calibre.

International Journal of Clinical PracticeVolume 53, Issue 7 p. 504-504 Article Referee's comments PR Taylor MChin FRCS, PR Taylor MChin FRCS Consultant Vascular Surgeon Guy's Hospital, LondonSearch for more papers by this author PR Taylor MChin FRCS, PR Taylor MChin FRCS Consultant Vascular Surgeon Guy's Hospital, LondonSearch for more papers by this author First published: 01 October 1999 https://doi.org/10.1111/j.1742-1241.1999.tb11788.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume53, Issue7October-November 1999Pages 504-504 RelatedInformation

Crit Care 1999, 3 3 ( (s su up pp pl l 1 1) ):P1 I In nt tr ro od du uc ct ti io on n: : Critically ill patients requiring intensive care are at risk of iatrogenic ocular damage.Studies have reported an incidence of eye problems of up to 40% in critically ill ventilated patients.We conducted this study to assess the incidence of ocular complications in our intensive care unit where all patients are cared for according to an eye care standard.M Me et th ho od ds s: : All ventilated patients over a 2 month period were included.Ophthalmic assessment was performed on admission and repeated every other day during the period of ventilation.At each assessment the average Ramsey sedation score over the previous 24 h, the presence of tracheal secretions and the presence of ventilation associated pneumonia was noted.Eye care performed was recorded.R Re es su ul lt ts s: : Sixty patients were included.One patient developed corneal exposure keratopathy.No patient developed conjunctivitis or corneal ulceration.Further advice on appropriate measures of eye care was given in five cases (8%).Nine patients (15%) had large amounts of respiratory secretions with positive microbiological results.C Co on nc cl lu us si io on n: : This study confirms that the use of an eye care standard is associated with a low incidence of ocular surface complications.The incidence of ocular complications in this group of patients is far lower than previously described.

CLINICAL MESSAGE Coronary artery disease causing impaired left ventricular function may present as intermittent claudication in the absence of significant occlusive lower limb arterial disease.

Objectives: to compare the outcome of patients undergoing non-elective abdominal aortic aneurysm repair at two hospitals under the care of a single vascular surgeon.Design: prospective and retrospective audit of 6 years of emergency and urgent infrarenal abdominal aortic aneurysm surgery.Setting: Lewisham and North Southwark Health Authority.Subjects: one hundred and forty-five patients who underwent emergency (46) or urgent (99) repair of an abdominal aortic aneurysm.Primary outcome measure: hospital mortality.Secondary outcome measures: acute renal failure, intensive care and hospital length of stay distal ischaemia and return to theatre.Results: mortality was higher at hospital 2 than hospital 1 (28% vs. 9%, p = 0.0068). There was no significant difference in age, sex, cardiac history, hypertension, diabetes, smoking, renal impairment (all p>0.05). There was no difference in operation time, blood loss and base excess at the end of surgery between the two groups (all p>0.05). APACHE II scores on admission to ICU were similar in hospital 1 and hospital 2 (median 16 vs. 14, p>0.03). Pulmonary artery catheters were placed in 18% of patients at hospital 1 compared with 96% at hospital 2. Patients at hospital 2 received more crystalloid (median 2990 vs. 2300 ml divided by, more colloid (median 4775 vs. 1500 ml), and more inotropes (median 1 vs. 0) than those at hospital 1 in their first 24 h on ICU (all p<0.001). The volume of urine passed in the first 24 h was similar (median 2410 vs. 2000 ml, p = 0.12) yet the incidence of acute renal failure was higher at hospital 2 compared with hospital 1 (30% vs. 6%, p = 0.001). ICU length of stay of survivors was longer at hospital 2 (median 3 vs. 2 days, p = 0.0018) as was hospital length of stay (median 17.5 vs. 12 days, p = 0.0002).Conclusions: the outcome at both hospitals is at least as good as other reported series, but it is interesting to note that the hospital which used less pulmonary artery catheters and less intervention (in the form of colloid and inotropes) showed a reduced mortality. These data may be important is assessing the different therapeutic strategies employed postoperatively in the ICU.

Introduction all pulses in the right leg were easdy palpable. A source of arterial embolism was not clinically evident The use of indwelling central venous catheters for Emergency angiography showed an occlusion of the long-term access for therapeutic regimens is becoming mid-left common iliac artery extending to the mid increasingly common, and the complications asexternal iliac artery. The right common, external and sociated with these hnes are well recognised. Cominternal iliac arteries and the left femoral, popliteal plications associated with insertion include and proximal trifurcation arteries were reported as pneumothorax, haemothorax, inadvertent arterial entirely normal. The appearance strongly suggested puncture, cardiac tamponade, and catheter emarterial embolism. Thrombolysis was inappropriate, bolisation. Long-term problems encompass sepsis and as the left leg had developed a neurosensory deficit. venous thrombosis. Paradoxical embolism has not preThe left groin was explored under local anaesthesia viously been described originating from a central venand an embolectomy was attempted. Adequate inflow ous line. We report a case of acute lower limb ischaemia could not be established, and this was felt to be due occurrmg as a result of paradoxical ebolisation of to organisation of previous emboli. A femorofemoral thrombus arising from an indwelling central venous crossover graft was performed using a polytetracatheter, fluoroethylene graft which successfully revascularised the left leg. Abdominal ultrasonography and transthoracic echoCase Report cardiography both failed to identify an embolic source. Subsequent transoesophageal echocardiography re-

Objectives: The aim of tills study was to develop a scoring system to predict the outcome of long femorocrural and femoropedal bypass grafts performed for critical limb ischaemia.Setting: Teaching hospital.Methods: An analysis of 109 consecutive femorodistal bypass grafts performed for critical lower limb ischaemia between June 1991 to December 1994. Factors shown to affect the outcome were: inflow, number of patent calf vessels, graft material, straight pow to the foot and patent pedal vessels. These variables were weighted according to their relative significance (multivariate Cox regression) and a scoring system (ranging from 0 to 10) was developed.Results: Patients with a preoperative score of 0-4 (n=35) showed a secondary patency of 36% at 1 month, 12% at 3 months and 0% at 10 months (Cum SE = 6.90/0.0). Secondary patency rates for the 46 patients with score 5-7 were 88.7% at 3 months, 56.3% at 12, and 45.1% at 2 and 3 years (Cum SE = 9.82), while the respective values for the 28 patients with score 8-10 were 92.7%, 88.5% and 81.7% (Cum SE = 8.08). The difference was highly significant (p = 0.000) in all tests of equality. In addition, the median total hospital cost was pound 12600 for the group 0-4 compared with pound 8100 (group 5-7) and pound 4400 (group 8-10) (p=0.0085).Conclusions: This preoperative scoring system appears to correlate well with the outcome of distal revascularisation io single calf or pedal vessels. If applied to patient selection, it could significantly reduce the total hospital cost per leg saved. A prospective testing of its predictive ability is needed and is in progress.

In early series the majority of carotid endarterectomies were performed in patients with amaurosis fugax (AFx) or transient ischaemic attacks (TIAs) who were thought to have atheromatous ulcers of the carotid bifurcation or the internal carotid artery (ICA). The degree of stenosis was considered to be of secondary importance. We compared our own data with two British series undertaken in the early and late 80s/early 90s. This reflects the broadening of indications and the change of practice for carotid endarterectomy over the years, on the one hand towards including patients who are at greater risk of perioperative stroke (previous CVAs vs TIAs, crescendo TIAs and stroke in evolution), and on the other towards patients who have had no symptoms attributable to the carotid lesion (asymptomatic cases, combined carotid and cardiac procedures).

Peripheral vascular disease affects a large number of elderly people but is symptomatic in only a few cases. Most of these will not be considered for surgical or radiological revascularisation procedures unless their disease affects the suprainguinal vessels. The traditional advice to stop smoking and keep walking is important but, in addition, thought should be given to the secondary prevention of cardiovascular disease in these patients. Thorough assessment and modification of their risk factors, including their lipid status, should be performed and aspirin should be prescribed to all patients who can tolerate it.

One-stop clinics are becoming increasingly popular with both patients and their general practitioners. Traditionally, vascular patients have needed to attend hospital two or three times for clinical examination and investigations. We have introduced a one-stop clinic for patients with lower limb arterial disease (LLAD) and aortic aneurysms. In 92 clinics over 2 years, 1194 new patients and 1409 follow-up patients were seen, with LLAD being the largest single category comprising 40% of the patients seen, followed by varicose veins (25%), carotid disease (12%), and aortic aneurysms (8%). Overall, 57% of patients had non-invasive imaging performed, either in the clinic or on a separate visit. Performing all LLAD and aortic scans in the clinic requires 1.9 h of imaging time per clinic. Extending in-clinic scanning to patients with varicose veins and carotid disease would increase this to 3.9 h of scanning per clinic and require a duplex scanner and an additional technologist in the clinic.

In order to compare the outcome and costs of femorodistal grafting in diabetic and non‐diabetic patients presenting with critical limb ischaemia we analysed a consecutive series of 109 femorodistal bypasses, 38 (35 %) performed on people with diabetes and 71 (65 %) on non‐diabetic patients. The same aggressive revascularization policy was used in both groups with the decision to operate based on the presence of a calf or foot vessel on preoperative intra‐arterial digital subtraction angiography (IADSA). Data were collected prospectively and the median follow‐up was 15.4 months (range 0 to 42 months). There were no significant differences in 30‐day (5.3 % vs 4.2 %) and in‐hospital mortality (13.2 % vs 14.1 %) between the two groups. Life table curves at 3 years in diabetic and non‐diabetic patients showed 48 % vs 60 % survival, 76 % vs 72 % knee salvage, 45 % vs 56 % limb salvage, and 38 % vs 47 % secondary patency. Although there was a trend for diabetic patients to perform less well, there was no statistically significant difference in these outcome measures. In cost comparison the only significant difference was found in the total hospital cost, which was £9181 in diabetic, compared to £6350 in non‐diabetic patients (p = 0.026, Mann‐Whitney). However, this cost was significantly less than that of primary amputation in either group (£15500 and £12040, respectively). Femorodistal reconstruction in both diabetic and non‐diabetic patients, whenever feasible, is a cheaper option than primary amputation, even though vascular surgery may be more expensive in people with diabetes. © 1997 by John Wiley & Sons, Ltd.

Background The past decade has seen an increase in the use of distal arterial bypass grafts for treating critical lower limb ischaemia. However, this surgical policy is associated with variable results. The aims of this study were to identify factors that affect outcome and to calculate the cost of such surgical interventions.

BJS (British Journal of Surgery)Volume 84, Issue 3 p. 423-423 Surgical Workshop Temporary left external axillofemoral bypass during repair of a leaking type B aortic dissection Mr. P. R. Taylor, Corresponding Author Mr. P. R. Taylor Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKDepartment of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorY. P. Panayiotopoulos, Y. P. Panayiotopoulos Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorA. J. P. Sandison, A. J. P. Sandison Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorH. K. Aduful, H. K. Aduful Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorC. H. Wood, C. H. Wood Department of Anaesthesia, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this author Mr. P. R. Taylor, Corresponding Author Mr. P. R. Taylor Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKDepartment of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorY. P. Panayiotopoulos, Y. P. Panayiotopoulos Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorA. J. P. Sandison, A. J. P. Sandison Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorH. K. Aduful, H. K. Aduful Department of Surgery, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this authorC. H. Wood, C. H. Wood Department of Anaesthesia, United Medical and Dental Schools, Guy's Hospital, St Thomas' Street, London SE1 9R7, UKSearch for more papers by this author First published: 06 December 2005 https://doi.org/10.1046/j.1365-2168.1997.02603.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume84, Issue3March 1997Pages 423-423 RelatedInformation

The development of new technology has led to renewed interest among both surgeons and radiologists in the treatment of infrarenal aortic aneurysms by endovascular techniques. Parodi and Palmaz pioneered the endovascular repair of aortic aneurysms using a straight stent graft. 1 Chuter et al. developed a means of deploying a bifurcated graft via the transfemoral route 2 and other series have been reported recently. 3 However, all new techniques have a learning curve. We report a case of fatal internal iliac artery embolism associated with insertion of a stent graft used to treat a symptomatic abdominal aortic aneurysm.