Duplex ultrasonography arteriography as first-line investigation for peripheral vascular disease

<p><b>INTRODUCTION</b>The gold standard for evaluation of the lower extremity arterial tree is catheter angiography. Duplex arterial-occlusive imaging or duplex ultrasonography arteriography, a noninvasive technique, is used as the first-line investigation in patients with peripheral vascular disease at our centre. Based on the results of duplex imaging, patients who require angiographic intervention then proceed with simultaneous catheter arteriography and intervention. This study aimed to compare the results of duplex imaging alone as the first-line investigation against the eventual results of catheter angiography, and to assess the impact of the former on patients' clinical outcomes.</p><p><b>METHODS</b>All cases involving patients who underwent duplex imaging followed by angiographic intervention, from May 2008 to February 2009, were discussed at weekly interdisciplinary meetings. Only patients who underwent lower limb imaging were included in the study. Those who were involved in grafts and stent surveillance studies, as well as those with incomplete duplex images were excluded.</p><p><b>RESULTS</b>During the study period, 113 duplex imaging studies of the lower limb followed by percutaneous transluminal angioplasty were performed at our hospital for peripheral vascular disease. The iliac artery was visualised in 40 images, but could not be visualised in 73 images. There was a potential change in management in three cases due to radiological differences between the duplex images and angiography films.</p><p><b>CONCLUSION</b>In our series, duplex imaging was found to be accurate enough to guide initial clinical management of patients with peripheral vascular disease. This modality is the preferred first-line investigation for such patients at our centre.</p>

Arteriovenous fistula aneurysm--plicate, not ligate

<p><b>INTRODUCTION</b>Arteriovenous fistula (AVF) created for haemodialysis can be complicated by aneurysm formation.</p><p><b>CLINICAL PICTURE</b>Ligation of the fistula is often required to prevent aneurysmal rupture and the life-threatening haemorrhage that ensues. Other methods of treatment involve using foreign bodies like mesh and grafts.</p><p><b>TREATMENT</b>We describe a new method in the treatment of this condition--plication. It involves plicating the excess free wall of the aneurysm with sutures and does not require resection or anastomosis.</p><p><b>OUTCOME</b>Early results show that this method shrinks the aneurysm size and reduces the risk of haemorrhage.</p><p><b>CONCLUSION</b>The AVF can continue to be used and the patient is spared the agony of having to go through the entire cycle of creating a new vascular access site.</p>

A case report of endovascular stenting in Salmonella mycotic aneurysm: a successful procedure in an immunocompromised patient

<p><b>INTRODUCTION</b>Mycotic aneurysms are associated with high mortality rates and are managed in the local setting with extra-anatomical bypass followed by ligation, exclusion and debridement of the aneurysm. This is the first case of successful endovascular stenting in an immunocompromised patient with Salmonella mycotic aneurysm.</p><p><b>CLINICAL PICTURE</b>A middle-aged man who was HIV positive had Salmonella septicaemia. He developed abdominal pain 5 days after admission and a computed tomography (CT) scan of the abdomen revealed infrarenal aortitis. He developed a mycotic aneurysm 3 weeks later.</p><p><b>TREATMENT</b>He opted for endovascular stenting and after prolonged antibiotic therapy and negative blood cultures, he underwent the procedure using a Talent stent, with an iliac extension.</p><p><b>OUTCOME</b>He was discharged 1 week after stenting and maintained on oral bactrim based on sensitivity. At 1-year follow-up, he remains well symptomatically and CT scan showed no endoleak or collection.</p><p><b>CONCLUSION</b>Endovascular stenting, though a fairly new procedure, can be successfully deployed even in a mycotic aneurysm in the right setting.</p>