Open endarterectomy of the SPT segment: an experience.

The purpose of the study was to evaluate the results of open endarterectomy in short atherosclerotic occlusions of the SPT segment (superficial femoral, popliteal, and tibioperoneal arteries). Retrospectively, records from July 1999 to June 2004 of patients who underwent open endarterectomy of lower limb arteries were verified; 63 patients with 66 lesions had open endarterectomy of the SPT segment as a primary procedure. At the time of this study, there were 57 patients alive and six dead, with the cause of death being unrelated to the procedure. The patients had a mean age of 71 +/- 10.73 years, and there were 18 females and 45 males. All patients underwent routine follow-up at 1, 3, 6, and 12 months and yearly thereafter. Routine clinical examination and ultrasound were done to assess the outcome. The mean length of endarterectomized superficial femoral artery was 7.42 +/- 3.66 cm (range 2-15). The lesions involved were the superficial femoral, popliteal, and tibioperoneal arteries (SPT segment). The primary cumulative patency rate by means of life-table analysis was 48.8% at 5 years (mean 12.7 months, range 1-60). During follow-up, percutaneous transluminal angioplasty was necessary in nine patients, for a primary assisted patency rate of 85.1% at 5 years. The location of recurrent stenoses after endarterectomy was usually at one of the ends of the endarterectomy site. Once a preferred technique, endarterectomy is now overshadowed by bypass procedures. Our clinical experience suggests that, in a select group of patients with SPT segment occlusions, open endarterectomy is technically feasible and should be used in cases with insufficient vein for bypass grafting. It also can be used as an alternative to allow the long saphenous vein to be reserved for a bypass procedure in the future.

Transplantation of crossed fused renal ectopia.

Crossed fused renal ectopia is a type of congenital fused anomaly of the kidney. This type of kidney, when encountered, can be used as a donor organ to provide useful solution to the critical shortage of available organs for transplantation.

Microbiological profile of chronic ulcers of the lower limb: a prospective observational cohort study.

BACKGROUND: The aim of the study was to determine the microbiological profile of chronic lower-limb ulcers in a tertiary outpatient setting. METHODS: A prospective observational cohort study of 39 patients with lower-limb ulcers of more than 1 month duration, presenting to the leg ulcer clinic. Superficial swab and punch biopsy samples were taken from each ulcer. RESULTS: Mean age was 68.7 years. Venous ulcers were most common (51%) followed by arterial ulcers (13%), ulcers in people with diabetes having arterial disease (13%), unspecified ulcers (13%) and ulcers in people with diabetes (10%). The most common organisms were Staphylococcus aureus (38-44%) followed by Pseudomonas aeruginosa (26-28%). Biopsy and swab results were concordant in 18 (46%), had at least one organism in common in 10 (26%) and had no concordance in 11 (28%). Histological analysis did not show any cases of malignancy. Ulcer area was significantly lower after 2 months of treatment (P = 0.047). Venous ulcers had the best outcome at 2 months, whereas people with diabetes with arterial disease fared poorly. CONCLUSION: The microbiological profile of chronic leg ulcers has application to general treatment principles as well in guiding the necessity and choice of antibiotic therapy. Concordance between swab and biopsy results was poor; we recommend biopsy in the tertiary setting.

Iatrogenic entrapment: femoro-popliteal vein bypass graft.

A rare cause of occlusive vascular disease is the "Popliteal Artery Entrapment Syndrome." The most common cause of this problem is abnormal position of the popliteal artery caused by abnormal migration of the medial head of the gastrocnemius. An acquired form can occur because of tunneling defects by inadvertent placement of venous bypass graft medial to the medial head of the gastrocnemius muscle. We present 2 cases of iatrogenic entrapment of the femoropopliteal bypass graft. Investigations revealed compression of the graft with extension of the knee. Both cases were treated surgically. Intraoperatively there was evidence of compression of the graft between the tendons of the semitendinosus and the gracilis muscles and the medial head of the gastrocnemius muscle. Treatment involved division of the medial head of the gastrocnemius in 1 patient, and in the other, the tendons of gracilis and semitendinosus were divided. No compression of the graft was noted postoperatively by noninvasive test. No significant mobility issues caused by the division of muscle or the tendons were present in the postoperative period.

Late stent-graft migration secondary to separation of the uncovered segment from the main body of a Zenith endoluminal graft.

PURPOSE: To report a case of type I endoleak secondary to complete disruption of the sutures uniting the uncovered and covered segments of a bifurcated Zenith endoluminal graft, causing displacement and distal migration of the graft main body. CASE REPORT: A 76-year-old man had successful exclusion of an abdominal aortic aneurysm with a Zenith endoluminal graft in 1999. He continued to do well until the 4-year surveillance imaging [computed tomography (CT) and plain abdominal radiography] showed device migration and proximal endoleak, with consequent expansion of the aneurysm. A proximal extension stent-graft was inserted with good seal. The 1-month follow-up CT angiogram showed reduced aneurysm size and no evidence of any leak. CONCLUSION: This case shows that the failure of an endoluminal graft occurs at weak points in the construction of the graft, reinforcing the need for long-term surveillance. If detected promptly, such events can often be treated by another endovascular procedure.

Outcomes of a contemporary amputation series.

BACKGROUND: The aim of this study was to determine the outcomes of a contemporary amputation series. METHODS: A retrospective audit of 87 cases of major lower limb amputation from January 2000 to December 2002 from the Department of Vascular Surgery, Royal Perth Hospital, was conducted. RESULTS: The mean age of the study population was 70.1 +/- 14.3 years; the male : female ratio was 3.35:1. Comorbid problems included diabetes (49.4%), smoking (81.6%), hypertension (77.0%), ischaemic heart disease (58.6%), stroke (25.3%), raised creatinine level (34.5%) and chronic airway limitation (25.3%). Preamputation vascular reconstructive procedures were common, 34.5% in a previous admission and 23.0% in the same admission. The main indication was critical limb ischaemia (75.9%) followed by diabetic infection (17.2%). There were 51 below-knee (58.6%), 5 through-knee (5.7%) and 31 above-knee (35.6%.) amputations. The below-knee amputation to above-knee amputation ratio was 1.65:1. The overall wound infection rate was 26.4%; the infection rates for below-knee (29.4%) and above-knee (22.6%) amputation did not differ significantly (P = 0.58). Revision rates were 17.6% for below-knee, 20% for through-knee and none for above-knee amputations. Twenty patients (23.0%) underwent subsequent contralateral amputation. Thirty-nine patients (44.8%) were selected as suitable for a prosthesis by a rehabilitation physician; 31 (79.5%) used the prosthesis both indoors and outdoors and 6 (15.4%) used it indoors only within 3 months. Cumulative mortality at 30 days, 6 months, 12 months and 24 months was 10.1, 28.7, 43.1 and 51.7%, respectively. CONCLUSION: This series agrees with the current published work in finding that patients undergoing major lower limb amputation are older, with a high prevalence of comorbid conditions. Successful prosthesis rehabilitation depends on patient selection and a multidisciplinary approach. Despite a low immediate mortality, the overall long-term results of lower limb amputation remain dismal.

Pulsating varicose veins!! The diagnosis lies in the heart.

Right heart failure is associated with increased systemic venous pressure, which can be diagnosed clinically with the findings of elevated jugular venous pressure, pulsatile liver and distinctive cardiac murmurs (precordial systolic). Severe tricuspid regurgitation (TR) has occasionally been known to lead to marked pulsation of varicose veins. We report three cases that were referred to the vascular clinic of Royal Perth Hospital in which the patients involved had unilateral (right leg) varicose veins and chronic venous ulcers. On clinical examination all three patients had pulsations along the course of the varicose long saphenous vein up to the mid calf. The main differential diagnosis was arterio-venous malformation, which was excluded by compression of the sapheno-femoral junction and demonstrating absence of pulsation in the long saphenous vein. A venous duplex scan showed a grossly incompetent sapheno-femoral junction with abnormal wave forms. Two of the cases were managed conservatively with compression dressing. The option of sapheno-femoral junction ligation was reserved in one patient who had unsettling cellulitis and oedema of the lower limb in spite of compression dressing and optimal conservative management. All three patients had improvement in ulcer size at 3-month follow up with compression therapy. This article highlights that in cases of right heart failure the venous pressures can be felt as low as the mid calf level and that can be a cause of the venous ulcers. There should be a high suspicion of right heart failure in patients with late onset venous insufficiency.

Popliteal artery injury: Royal Perth experience and literature review.

BACKGROUND: Popliteal artery injury is uncommon but poses a significant challenge in Australian trauma care. Blunt trauma and knee dislocations appear to be associated with higher amputation rates. The aim of the present study was to review the authors' experience with this condition and discuss the best approach to investigation and management. METHODS: The medical records of all patients with popliteal artery injury (n = 19) who were entered prospectively onto the Royal Perth Hospital Trauma Registry from 1995 to 2003 were reviewed. Their demographic data, investigations, primary operative procedures, fasciotomy, primary and secondary amputation rates and mortality were determined. RESULTS: There were 17 male and two female patients with a median age of 34 years (range 17-62 years). Most patients (84%) were under 40 years in age. Blunt trauma was the commonest cause of popliteal artery injury (68.4%), and 84.6% of the patients had associated skeletal injury. The amputation rate in the present study was 26.3% (5/19). There were no intraoperative or in-hospital deaths. Three of 13 patients (23%) with blunt trauma underwent amputation, compared to two of six (33.3%) with penetrating injury. Two of three amputee patients in the blunt trauma group had dislocated knees. CONCLUSION: Despite technical improvements in management of popliteal artery injury, a high amputation rate is still seen, especially in patients with one or more of the following factors: extensive soft-issue injury, associated skeletal trauma, knee dislocation, and prolonged ischaemia time. Measures to reduce the amputation rate, ranging from more prompt diagnosis to modified surgical treatment techniques, are discussed.

Deep venous valve reconstruction for non-healing leg ulcers: techniques and results.

BACKGROUND: The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end-points at 2 year follow up for the management of non-healing venous leg ulcers in 137 patients. METHODS: Between October 1994 and November 1999, 137 patients (169 limbs) underwent deep vein reconstructions for non-healing venous leg ulcers of clinical, etiological, anatomical, pathological classification (CEAP) C6 class, as a 'last resort' treatment. End-points of the study were post-valve reconstruction, freedom from leg ulceration, vein valve patency and competency at 2 years. Primary refluxive disease was present in 96 patients (118 limbs). External valvuloplasty was performed in 12 limbs (19 valves) and internal valvuloplasty was performed in 90 limbs (144 valves). External supports were used in 16 limbs (16 valves). Multilevel (2-3) reconstructions were performed in 37 limbs. Forty-one patients had secondary valvular defects involving 51 limbs. Axillary-femoral vein or saphenofemoral vein valve transplant was performed for 29 patients (35 limbs) and three patients (three limbs), respectively, saphenofemoral venous transposition was performed in three patients (four limbs), and femoral/popliteal vein ligation was carried out in six patients (nine limbs). RESULTS: Two year results of external valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure with 2 year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants had a significant deterioration in valve patency and competence at 2 years: 58% and 47%, respectively, with 55.3% leg ulcer healing. It was also noted that single-level repairs or single valve transplants had lower ulcer healing rates than multilevel repairs or valve transplants with multiple valve stations. CONCLUSION: In a 2 year follow up, valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. Furthermore, these procedures appear more promising for primary than for secondary incompetence. Multilevel or multivalve reconstructions yield superior results to single-level repairs in medium-term follow up.