Acute popliteal pseudoaneurysm rupture secondary to distal femoral osteochondroma in a patient with hereditary multiple exostoses.

A 21-year-old man with known hereditary multiple exostoses presented with a 24-hour history of atraumatic bruising and swelling of the posterior thigh. A leaking popliteal pseudoaneurysm was diagnosed on ultrasonography and an emergency saphenous vein bypass graft procedure performed. The patient required a post-operative blood transfusion but otherwise made a full recovery. Vascular complications from osteochondromas are rare and include vessel displacement, stenosis, occlusion, arteriovenous fistulas and pseudoaneurysm formation. Pseudoaneurysms usually present as an enlarging mass behind the knee. Acute rupture of an occult popliteal pseudoaneurysm caused by a distal femoral exostosis has not been reported previously.

The assessment of surgical skills and a simple knot-tying exercise.

Basic surgical skills courses are mandatory for all surgical trainees taking the MRCS examination. An important aspect of these courses is the level of practical skill achieved by junior surgeons attending them. We present a simple knot-tying exercise, which may be used to assess the baseline skill level of trainees at the outset of the course and against which their progress can be judged after tuition and practice.

Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins.

BACKGROUND: The aim of this study was to determine whether a polytetrafluoroethylene (PTFE) patch sutured over the religated saphenofemoral junction could reduce the rate of recurrence after operation for recurrent varicose veins. METHODS: Fifty patients who had surgery for recurrent long saphenous incompetence (81 legs had a small PTFE patch sutured over the religated saphenofemoral junction. There were no major complications following surgery. Three patients had a wound infection or delayed healing. All patients were invited for clinical examination and duplex imaging at a median of 19 (range 6-39) months after operation. RESULTS: Some 38 of 43 patients (70 legs) remained satisfied with the results of surgery; 16 (23 per cent) of 70 legs had visible veins on inspection and eight of these (11 per cent) involved symptomatic recurrence. Duplex imaging showed that recurrence was due to saphenofemoral junction incompetence in ten legs; two appeared to have a major groin connection but the other eight appeared to have neovascularization. Other causes were thigh perforator reflux (three legs) and cross-groin collaterals (three). Eleven of the 16 legs with recurrence had varicography but in two the procedure was a technical failure. Two legs had evidence of a significant connection (more than 3 mm) and two a minor connection (less than 3 mm) to the femoral vein at the level of the PTFE patch, but in the remainder recurrence was due to upper thigh perforating veins. There was good concordance between duplex imaging and varicography. CONCLUSION: PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch.

First year of a fast track carotid duplex service.

BACKGROUND: The risk of major stroke is highest in the first three months after a transient ischaemic attack (TIA). Urgent carotid endarterectomy can reduce the risk in patients with a severe carotid stenosis. An express carotid duplex service has been established and this study analyses the effect in the first year. METHODS: Local GPs were offered a new service whereby a carotid duplex scan would be guaranteed within 14 days of referral of any patient who had a recent clearly documented TIA or amaurosis fugax. Referral letters were faxed directly to the Vascular Office where the duplex scan was authorised by a consultant vascular surgeon. Patients with significant carotid disease on duplex were assessed in the out-patient clinic in preparation for surgery. RESULTS: In the first 12 months of the service, 90 fast track duplex scans were performed. In the same interval 490 routine carotid duplex scans were carried out. Some 13 carotid endarterectomies were carried out on patients from the fast track group (13/90, 14%), with a median delay between referral and surgery of 30 days (range 20-45) and median duration between onset of symptoms and surgery of 51 days (range 27-406). In the non fast track group 14/490 (2.8%) scans resulted in carotid intervention, a median 127 days (range 64-184) after referral. CONCLUSION: The fast track service significantly reduced the delay between referral and surgery. Timing of carotid surgery is critical. Performing the surgery at the time of greatest risk increases the benefit of carotid endarterectomy. Urgent and appropriate referral from the GPs is vital for the service to run effectively.