VENUM (Vascular Education iN Undergraduate Medicine): a multicentre evaluation of undergraduate vascular education in the UK.

INTRODUCTION: Vascular surgery is a recognised surgical subspecialty covering an array of circulatory conditions predominately affecting geriatric and diabetic patients. As such, a wide breadth of clinicians will see patients with vascular pathologies, but it is unclear how detailed their knowledge base is. Key to this is the education of medical students, which has been poorly documented during undergraduate training in the UK. VENUM aimed to establish students' perceptions of vascular surgery and their confidence in performing vascular objective structured clinical examination (OCSE) skills. METHODS: During the academic year of 2022/2023, final-year medical students were invited to complete a JISC survey (collaborative authorship). Seventy-seven research leads were recruited to disseminate the survey. Quantitative and thematic analysis was used to assess the data. RESULTS: In total, 240 final-year medical students completed the survey (54% female; 26 medical schools represented). Forty-five per cent of students reported never having had a vascular placement, 24% had never completed a vascular-focused clinical examination and 26% reported low confidence in performing ankle brachial pressure index measurement. An assessment of peripheral arterial disease morbidity was answered correctly in 17% of respondents compared with 92% for angina (chi-square test p<0.001). Students perceived the specialty to be non-inclusive and that early exposure to vascular surgery was required for better engagement with the specialty. CONCLUSION: Students have experienced little exposure to vascular surgery. This may affect future recruitment to vascular surgery and overall knowledge of vascular conditions in UK-trained doctors, which may affect long-term patient management.

A pilot multicentre randomised controlled trial of lidocaine infusion in women undergoing breast cancer surgery.

Chronic postoperative pain is common after breast cancer surgery. Peri-operative lidocaine infusion may prevent the development of chronic postoperative pain, but a large-scale trial is required to test this hypothesis. It is unclear whether a pragmatic, multicentre trial design that is consistent with expert guidance, addresses the limitations of previous studies, and overcomes existing translational barriers is safe, effective and feasible. We conducted a double-blind, randomised controlled pilot study in 150 patients undergoing breast cancer surgery across three hospitals in Western Australia. Patients received lidocaine, or equivalent volumes of saline, as an intravenous bolus (1.5 mg.kg-1 ) and infusion (2 mg.kg-1 .h-1 ) intra-operatively, and a subcutaneous infusion (1.33 mg.kg-1 .h-1 ) postoperatively for up to 12 h on a standard surgical ward, with novel safety monitoring tools in place. The co-primary outcomes were: in-hospital safety events; serum levels of lidocaine during intravenous and subcutaneous infusion; and annualised enrolment rates per site with long-term data capture. In-hospital safety events were rare, and similar in the placebo and lidocaine arms (3% vs. 1%). Median (IQR [range]) serum lidocaine levels during intravenous (2.16 (1.74-2.83 [1.12-6.06]) µg.ml-1 , n = 41) and subcutaneous (1.52 (1.28-1.83 [0.64-2.85]) µg.ml-1 , n = 48) infusion were comparable with previous trials reporting improved pain outcomes. Annualised enrolment approximated 50 patients per site per year, with high levels of protocol adherence and ≥ 99% capture of outcomes at 3 and 6 months. The adjusted odds ratio (95%CI) for postoperative pain at 6 months in the lidocaine arm was 0.790 (0.370-1.684). We conclude that this trial, as designed, is safe, effective and feasible in patients undergoing breast cancer surgery, and a larger-scale trial is planned.

The role of cardiopulmonary exercise testing and echocardiography prior to elective endovascular aneurysm repair.

INTRODUCTION: Cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) are common preparative investigations prior to elective endovascular aneurysm repair (EVAR). Whether these investigations can predict survival following EVAR and contribute to shared decision making is unknown. METHODS: Patients who underwent EVAR at a tertiary centre between June 2007 and December 2014 were identified from the National Vascular Registry. Variables obtained from preoperative investigations were assessed for their association with survival at three years. Regression analysis was used to determine variables that independently predicted survival at three years. RESULTS: A total of 199 patients underwent EVAR during the study period. Of these, 120 had preoperative CPET and 123 had TTE. Lower forced expiratory ventilation (FEV1), ratio of FEV1 to forced vital capacity, work at peak oxygen consumption and higher ventilatory equivalent for carbon dioxide were associated with increased mortality. Variables obtained from TTE were not associated with survival at three years although there was a low incidence of left ventricular systolic dysfunction and significant valvular disease in this cohort. CONCLUSIONS: CPET might be a useful adjunct to assist in shared decision making in patients undergoing elective EVAR and may influence anaesthetic technique. TTE does not appear to be able to discriminate between high and low risk individuals. However, a low rate of significant ventricular dysfunction and valvular disease in patients undergoing elective EVAR may account for these findings.

Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years.

Background: Juxtarenal abdominal aortic aneurysms pose a significant challenge whether managed endovascularly or by open surgery. Fenestrated endovascular aneurysm repair (FEVAR) is now well established, but few studies have compared it with open surgical repair (OSR). The aim of this systematic review was to compare short- and long-term outcomes of FEVAR and OSR for the management of juxtarenal aortic aneurysms. Methods: A literature search was conducted of the Ovid Medline, EMBASE and PubMed databases. Reasons for exclusion were series with fewer than 20 patients, studies published before 2007 and those concerning ruptured aneurysms. Owing to variance in definitions, the terms 'juxta/para/suprarenal' were used; thoracoabdominal aortic aneurysms were excluded. Primary outcomes were 30-day/in-hospital mortality and renal insufficiency. Secondary outcomes included major complication rates, rate of reintervention and rates of endoleak. Results: Twenty-seven studies were identified, involving 2974 patients. Study designs included 11 case series, 14 series within retrospective cohort studies, one case-control study and a single prospective non-randomized trial. The pooled early postoperative mortality rate following FEVAR was 3·3 (95 per cent c.i. 2·0 to 5·0) per cent, compared with 4·2 (2·9 to 5·7) per cent after OSR. After FEVAR, the rate of postoperative renal insufficiency was 16·2 (10·4 to 23·0) per cent, compared with 23·8 (15·2 to 33·6) per cent after OSR. The major early complication rate following FEVAR was 23·1 (16·8 to 30·1) per cent versus 43·5 (34·4 to 52·8) per cent after OSR. The rate of late reintervention after FEVAR was higher than that after OSR: 11·1 (6·7 to 16·4) versus 2·0 (0·6 to 4·3) per cent respectively. Conclusion: No significant difference was noted in 30-day mortality; however, FEVAR was associated with significantly lower morbidity than OSR. Long-term durability is a concern, with far higher reintervention rates after FEVAR.

Antecedentes: Los aneurismas de la aorta abdominal yuxtarrenal plantean un gran reto sobre si tratarlos de forma endovascular o mediante cirugía abierta. La reparación del aneurisma con endoprótesis fenestrada (fenestrated endovascular aneurysm repair, FEVAR) no esta consolidada, sin embargo, algunos pocos estudios, la comparan con la reparación quirúrgica por vía abierta (open surgical repair, OSR). El objetivo de esta revisión sistemática fue comparar los resultados a corto y largo plazo de FEVAR y OSR para el tratamiento de los aneurismas aórticos yuxtarrenales. Métodos: Se llevó a cabo una búsqueda de la literatura en las bases de datos Ovid Medline, EMBASE y Pubmed. Las razones para exclusión fueron series con menos de 20 pacientes, aquellas publicadas antes de 2007 y los trabajos sobre aneurismas rotos. Debido a las diferencias en las definiciones, se utilizaron los términos "yuxta/para/suprarrenal"; se excluyeron los aneurismas de la aorta tóracoabdominal. Los resultados primarios fueron la mortalidad a 30 días/intrahospitalaria y la insuficiencia renal. Los resultados secundarios incluyeron las tasas de complicaciones mayores, tasa de reintervención y tasas de fugas internas. Resultados: Se identificaron un total de 27 estudios, que incluían 2.974 pacientes. Los diseños de los estudios incluían 11 series de casos, 12 estudios de cohortes retrospectivos, un estudio caso­control y un único ensayo no aleatorizado prospectivo. La mortalidad postoperatoria precoz agrupada tras FEVAR fue del 3,3% (i.c. del 95% 2,0­5,0), comparado con el 4,2% (i.c. del 95% 2,9­5,7) tras OSR. Después de FEVAR, la tasa de insuficiencia renal postoperatoria fue del 16,2% (i.c. del 95% 10,4­23,0) comparada con el 23,8% (i.c. del 95% 15,2­33,6) después de OSR. La tasa de complicaciones mayores precoces tras FEVAR fue del 23,1% (i.c. del 95% 16,8­30,1) comparada con el 43,5% (i.c. del 95% 34,4­52,8) después de OSR. La tasa de reintervención tardía tras FEVAR fue superior que tras OSR: 11,1% (i.c. del 95% 6,7­16,4) y 2,0% (i.c. del 95% 0,6­4,3), respectivamente. Conclusión: No se observaron diferencias significativas en la mortalidad a los 30 días, sin embargo, FEVAR presentó una morbilidad significativamente menor que OSR. La durabilidad a largo plazo es una preocupación con muchas mayores tasas de reintervención después de FEVAR.

Influence of psoas muscle area on mortality following elective abdominal aortic aneurysm repair.

BACKGROUND: The effect of sarcopenia based on the total psoas muscle area (TPMA) on CT is inconclusive in patients undergoing abdominal aortic aneurysm (AAA) intervention. The aim of this prospective cohort study was to evaluate morphometric sarcopenia as a method of risk stratification in patients undergoing elective AAA intervention. METHODS: TPMA was measured on preintervention CT images of patients undergoing elective endovascular aneurysm repair (EVAR) or open aneurysm repair. Mortality was assessed in relation to preintervention TPMA using Cox regression analysis, with calculation of hazard ratios at 30 days, 1 year and 4 years. Postintervention morbidity was evaluated in terms of postintervention care, duration of hospital stay and 30-day readmission. Changes in TPMA on surveillance EVAR imaging were also evaluated. RESULTS: In total, 382 patient images acquired between March 2008 and December 2016 were analysed. There were no significant intraobserver and interobserver differences in measurements of TPMA. Preintervention TPMA failed to predict morbidity and mortality at all time points. The mean(s.d.) interval between preintervention and surveillance imaging was 361·3(111·2) days. A significant reduction in TPMA was observed in men on surveillance imaging after EVAR (mean reduction 0·63(1·43) cm2 per m2 ; P < 0·001). However, this was not associated with mortality (adjusted hazard ratio 1·00, 95 per cent c.i. 0·99 to 1·01; P = 0·935). CONCLUSION: TPMA is not a suitable risk stratification tool for patients undergoing effective intervention for AAA.

Modelling the growth of popliteal artery aneurysms.

BACKGROUND: Popliteal artery aneurysms (PAAs) comprise up to 85 per cent of all peripheral aneurysms. Few longitudinal studies track their progression. This study aimed to track the growth of asymptomatic PAAs in a hospital-based ultrasound service, and compare models of aneurysm growth. METHODS: This retrospective single-centre cohort study included patients who had a PAA on arterial duplex ultrasound imaging of the lower limbs between 1 January 2011 and 1 January 2016. Progression of PAA size and progression to event or intervention were the primary outcome measures. RESULTS: Some 282 images were analysed: 47 limbs with PAA were included in a cohort of 32 patients (15 had bilateral PAAs). Twenty patients also had an abdominal aortic aneurysm (AAA). Linear multilevel modelling estimated that PAA growth was 2·4 (95 per cent c.i. 1·6 to 3·7) mm a year. Growth was estimated at 0·8 (0·1 to 1·5) mm per year in patients without an AAA and 3·5 (2·9 to 4·2) mm per year in those with a known AAA (previous open repair, previous endovascular aneurysm repair or AAA under surveillance) (P < 0·001). CONCLUSION: Growth rates of PAA were heterogeneous but were optimally predicted by multilevel modelling. Patients with an existing AAA may have faster PAA progression than those without.

Renal extracellular vesicles: from physiology to clinical application.

Urinary extracellular vesicles (uEVs) are released from all regions of the kidney's nephron and from other cells that line the urinary tract. Extracellular vesicles retain proteomic and transcriptomic markers specific to their cell of origin and so represent a potential reservoir for kidney disease biomarker discovery. Exosomes, a subtype of uEVs, are distinguished from other vesicles by features related to their biogenesis within cells: mature multi-vesicular bodies fuse with the cellular membrane to liberate exosomes into the extracellular space. uEVs represent a novel cell signalling mechanism because they can be shuttled to a recipient cell and, through a number of proposed mechanisms, affect the recipient cell's proteome and function. Here we review the current evidence for uEV signalling along the nephron, their role in health and disease of the kidney, and their potential for clinical translation as biomarkers and therapeutics.

Comprehensive microRNA profiling in acetaminophen toxicity identifies novel circulating biomarkers for human liver and kidney injury.

Our objective was to identify microRNA (miRNA) biomarkers of drug-induced liver and kidney injury by profiling the circulating miRNome in patients with acetaminophen overdose. Plasma miRNAs were quantified in age- and sex-matched overdose patients with (N = 27) and without (N = 27) organ injury (APAP-TOX and APAP-no TOX, respectively). Classifier miRNAs were tested in a separate cohort (N = 81). miRNA specificity was determined in non-acetaminophen liver injury and murine models. Sensitivity was tested by stratification of patients at hospital presentation (N = 67). From 1809 miRNAs, 75 were 3-fold or more increased and 46 were 3-fold or more decreased with APAP-TOX. A 16 miRNA classifier model accurately diagnosed APAP-TOX in the test cohort. In humans, the miRNAs with the largest increase (miR-122-5p, miR-885-5p, miR-151a-3p) and the highest rank in the classifier model (miR-382-5p) accurately reported non-acetaminophen liver injury and were unaffected by kidney injury. miR-122-5p was more sensitive than ALT for reporting liver injury at hospital presentation, especially combined with miR-483-3p. A miRNA panel was associated with human kidney dysfunction. In mice, miR-122-5p, miR-151a-3p and miR-382-5p specifically reported APAP toxicity - being unaffected by drug-induced kidney injury. Profiling of acetaminophen toxicity identified multiple miRNAs that report acute liver injury and potential biomarkers of drug-induced kidney injury.

Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss.

INTRODUCTION: Small bowel obstruction (SBO) in pregnancy is rare and is most commonly caused by adhesions from previous abdominal surgery. Previous literature reviews have emphasised the need for prompt laparotomy in all cases of SBO because of the significant risks of fetal loss and maternal mortality. We undertook a review of the contemporary literature to determine the optimum management strategy for SBO in pregnancy. METHODS: The MEDLINE® and PubMed databases were searched for cases of SBO in pregnancy between 1992 and 2014. Two cases from our own institution were also reviewed. RESULTS: Forty-six cases of SBO in pregnancy were identified, with adhesions being the most common aetiology (50%). The overall risk of fetal loss was 17% and the maternal mortality rate was 2%. In cases of adhesional SBO, 91% of cases were managed surgically, with 14% fetal loss. Two cases (9%) were managed conservatively with no complications. Magnetic resonance imaging (MRI) was used to diagnose SBO in 11% of cases. CONCLUSIONS: Based on our experience and the contemporary literature, we recommend that urgent MRI of the abdomen should be undertaken to diagnose the aetiology of SBO in pregnancy. In cases of adhesional SBO, conservative treatment may be safely commenced, with a low threshold for laparotomy. In other causes, such as volvulus or internal hernia, laparotomy remains the treatment of choice.

Low Prevalence of netB and tpeL in Historical Clostridium perfringens Isolates from Broiler Farms in Alabama.

The discovery of novel Clostridium perfringens toxins NetB and TpeL has initiated questions regarding their role in the pathogenesis of disease. However, data showing the prevalence of these genes in C. perfringens populations are limited to certain geographical areas. If netB and tpeL are important virulence factors for disease worldwide, one would expect to find these genes in isolates from other regions as well. To address this hypothesis, C. perfringens isolates collected from Alabama broiler farms over 15 yr ago were toxin genotyped using PCR. Each isolate was screened for netB and tpeL; the major lethal toxin genes cpa, cpb, etx, and ia; and the enterotoxin gene cpe. Results of the assay showed all isolates presumed to be C. perfringens were genotypically type A, cpe negative except for one broiler litter isolate, which was genotypically type C. Only two isolates were positive for netB. Similarly, only two isolates were positive for tpeL, one of which was also netB positive. The low incidence observed for netB and tpeL indicates that these genes are not significant virulence factors for the sampled population.

Aspirin therapy is associated with less compact fibrin networks and enhanced fibrinolysis in patients with abdominal aortic aneurysm.

OBJECTIVE: Thrombotic changes in fibrin networks contribute to increased cardiovascular risk in patients with abdominal aortic aneurysm (AAA). Given that aspirin modulates the fibrin network, we aimed to determine if aspirin therapy is associated with changes in ex-vivo fibrin clot characteristics in AAA patients and also conducted an exploratory analysis of 5-year mortality in these individuals. METHODS: We recruited 145 male patients, divided into controls (aortic diameter < 3 cm, n = 49), AAA not taking aspirin (AAA-Asp, n = 50) and AAA on 75 mg day(-1) aspirin (AAA+Asp, n = 46), matched for aneurysm size. Characteristics of clots made from plasma and plasma-purified fibrinogen were investigated using turbidimetric analysis, permeation studies, and confocal and electron microscopy. Plasma fibrinogen, D-dimer and inflammatory marker levels were also measured. RESULTS: Maximum absorbance (MA) of plasma clots from controls was lower than that of AAA patients not on aspirin (AAA-Asp) at 0.30 ± 0.01 and 0.38 ± 0.02 au, respectively (P = 0.002), whereas aspirin-treated subjects had MA similar to controls (0.31 ± 0.02 P = 0.9). Plasma clot lysis time displayed an identical pattern at 482 ± 15, 597 ± 24 and 517 ± 27 s for control, AAA-Asp and AAA+Asp (P = 0.001 and P = 0.8). The lysis time of clots made from purified fibrinogen of AAA-Asp was longer than that of AAA+Asp patients (756 ± 47 and 592 ± 52 s, respectively; P = 0.041). Permeation studies and confocal and electron microscopy showed increased clot density in AAA-Asp compared with the AAA+Asp group. Mortality in AAA-Asp and AAA+Asp was similar, despite increased cardiovascular risk in the latter group, and both exhibited higher mortality than controls. CONCLUSION: Aspirin improves fibrin clot characteristics in patients with AAA, which may have important clinical implications.

Renal P2 receptors and hypertension.

The regulation of extracellular fluid volume is a key component of blood pressure homeostasis. Long-term blood pressure is stabilized by the acute pressure natriuresis response by which changes in renal perfusion pressure evoke corresponding changes in renal sodium excretion. A wealth of experimental evidence suggests that a defect in the pressure natriuresis response contributes to the development and maintenance of hypertension. The mechanisms underlying the relationship between renal perfusion pressure and sodium excretion are incompletely understood. Increased blood flow through the vasa recta increases renal interstitial hydrostatic pressure, thereby reducing the driving force for transepithelial sodium reabsorption. Paracrine signalling also contributes to the overall natriuretic response by inhibiting tubular sodium reabsorption in several nephron segments. In this brief review, we discuss the role of purinergic signalling in the renal control of blood pressure. ATP is released from renal tubule and vascular cells in response to increased flow and can activate P2 receptor subtypes expressed in both epithelial and vascular endothelial/smooth muscle cells. In concert, these effects integrate the vascular and tubular responses to increased perfusion pressure and targeting P2 receptors, particularly P2X7, may prove beneficial for treatment of hypertension.

Cardiovascular risk in patients with small and medium abdominal aortic aneurysms, and no history of cardiovascular disease.

BACKGROUND: Cardiovascular disease (CVD) is the main cause of death in people with abdominal aortic aneurysm (AAA). There is little evidence that screening for AAA reduces all-cause or cardiovascular mortality. The aim of the study was to assess whether subjects with a small or medium AAA (3·0-5·4 cm), without previous history of clinical CVD, had raised levels of CVD biomarkers or increased total mortality. METHODS: This prospective study included subjects with a small or medium AAA and controls, all without a history of clinical CVD. CVD biomarkers (high-sensitivity C-reactive protein, hs-CRP; heart-type fatty acid-binding protein, H-FABP) were measured, and survival was recorded. RESULTS: Of a total of 815 people, 476 with an AAA and 339 controls, a cohort of 86 with small or medium AAA (3-5·4 cm) and 158 controls, all with no clinical history of CVD, were identified. The groups were matched for age and sex. The AAA group had higher median (i.q.r.) levels of hs-CRP (2·8 (1·2-6·0) versus 1·3 (0·5-3·5) mg/l; P < 0·001) and H-FABP (4·6 (3·5-6·0) versus 4·0 (3·3-5·1) µg/l; P = 0·011) than controls. Smoking was more common in the AAA group; however, hs-CRP and H-FABP levels were not related to smoking. Mean survival was lower in the AAA group: 6·3 (95 per cent confidence interval (c·i.) 5·6 to 6·9) years versus 8·0 (7·6 to 8·1) years in controls (P < 0·001). Adjusted mortality was higher in the AAA group (hazard ratio 3·41, 95 per cent c·i. 2·11 to 9·19; P < 0·001). CONCLUSION: People with small or medium AAA and no clinical symptoms of CVD have higher levels of hs-CRP and H-FABP, and higher mortality compared with controls. They should continue to receive secondary prevention against CVD.

Early re-presentations and the potential role of catheter-directed thrombolysis in patients diagnosed with a lower limb deep vein thrombosis: a single-centre experience.

INTRODUCTION: Catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (DVT) restores venous patency, reduces the risk of the post-thrombotic syndrome and may reduce longer term treatment costs. This study assessed the potential role of CDT in patients with DVT with regard to representation following the index event. METHODS: A retrospective review of all patients with a positive lower limb DVT scan. Potential suitability of each patient to undergo CDT was based on well-recognized inclusion/exclusion criteria. RESULTS: In total, 1689 patients underwent a DVT-specific lower limb venous duplex. A total of 269 were found to have a DVT. Fifty-three of these patients met the inclusion criteria for CDT (only 2 underwent CDT). Fifty-nine of the 269 patients with an index DVT re-presented to our institution with a venous thromboembolism-related clinical event. These patients were significantly younger than those who did not reattend. A higher proportion of patients who represented were deemed suitable for CDT for the index DVT compared with those who did not represent (17/59 versus 36/210; P = 0.04). CONCLUSION: This pragmatic study highlights the fact that significant number of patients return to secondary care with actual/perceived complications following initial diagnosis and treatment of a DVT which may have been amenable to CDT.

Meta-analysis of prospective trials determining the short- and mid-term effect of elective open and endovascular repair of abdominal aortic aneurysms on quality of life.

BACKGROUND: Repair of an abdominal aortic aneurysm (AAA) is undertaken to prevent rupture. Intervention is by either open repair (OR) or a more minimally invasive endovascular repair (EVAR). Quality-of-life (QoL) analysis is an important health outcome and a number of single studies have assessed QoL following OR and EVAR. This was a meta-analysis of published studies to assess the effect of an intervention on QoL in patients with an AAA. METHODS: A systematic literature search was undertaken for studies prospectively reporting QoL analysis in patients with an AAA undergoing elective intervention. A multivariable meta-analysis model was developed in which the outcomes were mean changes in QoL scores over time, both for all AAA repairs (OR and EVAR) and comparing OR with EVAR. RESULTS: Data were collated from 16 studies (14 OR, 12 EVAR). The results suggested that treating an AAA had an effect on patient-reported QoL, evident from the statistically significant changes predominantly in domains assessing physical ability and pain. QoL was affected most within the first 3 months after any form of intervention, and was more pronounced following OR. Furthermore, a deterioration in the Physical Component Summary score following an AAA repair (either OR or EVAR) was evident at 12 months after intervention. CONCLUSION: Treating an AAA deleteriously affects patient-reported QoL over the first year following intervention.

Ovarian mass causing paradoxical MI and leg ischaemia.

Paradoxical embolus through a patent foramen ovale is a well-reported phenomenon. Clinical consequences include stroke, intestinal infarction, lower limb ischaemia, and even acute myocardial infarction (MI), via embolisation to the coronary arteries. We present a case of acute MI, cardiogenic shock, and cardiac arrest caused not by this mechanism, but by embolisation of thrombotic material to the aortic root with transient complete occlusion of the left main stem (LMS) coronary artery. During percutaneous coronary intervention to treat this occlusion the thrombus became lodged at the aortic bifurcation causing lower limb ischaemia. Despite successful treatment of this via bilateral groin exploration and thromboembolectomy the patient became increasingly acidotic and an abdominal and pelvic CT scan was performed. This revealed the source of the thrombus to be the patient's congested and compressed pelvic veins which were the result of a large, previously undiagnosed ovarian malignancy with metastatic spread. Although very unusual we feel this case highlights an important differential in the diagnosis of anterolateral MI and images similar to those presented here are previously unreported in the literature.

Aberrant medial sural artery causing popliteal vein entrapment syndrome.

Isolated popliteal venous entrapment is unusual and often caused by variation or aberrant origins of the gastrocnemius muscle, thickened perivenous fascia or an abnormal vascular bundle. We report a unique case of a fit and well 35-year-old man with popliteal venous entrapment after presenting to the vascular unit with symptomatic varicose veins. The cause of the entrapment was found to be an aberrant medial sural artery on operative exploration. The artery was ligated, releasing the entrapped vein. The patient made an uneventful recovery with resolution of symptoms of venous insufficiency without evidence of muscle ischaemia.