Removing the need for crossmatched blood in elective EVAR.

OBJECTIVES: The unit cost for crossmatching blood is £137.22 (€158.94). A maximum surgical blood order schedule for elective EVAR does not exist. We studied the crossmatch to transfusion ratio in our series to establish this recommendation. MATERIALS AND METHODS: A single centre retrospective study of consecutive EVAR cases between October 2001 and December 2010. Blood loss, units transfused and indication for transfusion per case were analysed. RESULTS: 203 elective EVAR cases were studied. Median blood loss was 200 ml with a mean of 288 ml (range 50-8400 ml). A total of twelve patients (6%) required blood transfusion. Six cases (3%) for postoperative Hb <8 g/dL and three patients (1.5%) for medical complications. Three patients required a massive transfusion; two had peri-procedural haemorrhage and one patient developed a large groin haematoma. The crossmatch to transfusion ratio was 11.1. CONCLUSIONS: The maximum surgical blood order for elective EVAR should be a group and save (type and screen) sample because of the high crossmatch to transfusion ratio. Intraoperative transfusion is rarely required (<1%) but often necessitates large transfusion quantities. In this circumstance each hospital is required to have an emergency protocol to manage massive blood loss. Applying these principles across all surgical specialities may lead to significant financial savings, improve efficiency and reduce wastage.

Successful treatment of a chronically infected and necrotic tendo Achillis in a diabetic with excision, flexor hallucis longus transfer and split-skin grafting.

Chronic infections and ulceration around the tendo Achillis are difficult to manage. Split-skin grafts do not survive even on healthy exposed tendon. Refractory cases may require plastic surgical intervention with the use of free flaps. Patients with significant vascular disease are not suitable for such techniques. Flexor hallucis longus tendon transfer is an established treatment for chronic ruptures of the tendo Achillis. We report the successful treatment of an infected tendo Achillis with excision and reconstruction with flexor hallucis longus transfer. The muscle belly of this tendon allowed later skin grafting while the tendon transfer provided good functional recovery.

A novel approach to central venous catheter thrombosis in a patient with cystic fibrosis.

Catheter directed thrombolysis has been described as a treatment for large pulmonary emboli resistant to systemic therapy [Kelly P, Carroll N, Grant C, Barrett C, Kocka V. Successful treatment of massive pulmonary embolism with prolonged catheter-directed thrombolysis. Heart Vessels 2006;21:124?6]. We now describe a case in which local catheter directed thrombolysis, via a peripherally inserted central catheter (PICC), was used to treat a large thrombus surrounding the tip of an indwelling central venous line that was causing superior vena cava obstruction (SVCO), in a patient with cystic fibrosis.

Traumatic variation of popliteal artery entrapment syndrome.

Popliteal artery entrapment syndrome is a well recognised sequelae of anatomical variation in the origin of the medial head of gastrocnemius. It classically presents with distal ischaemia from progressive intimal fibrosis and eventual thrombosis. We present a unique case of acute lower limb ischaemia precipitated by trauma in a young man with undiagnosed popliteal artery entrapment. In this case sudden stress of the lower limb resulted in tearing of the tunica intima of the entrapped artery and exposure of the subendothelium with subsequent thrombus, distal embolisation and acute ischaemia. Successful limb salvage was achieved through endovascular thrombolysis and arterial reconstruction.

Does GH replacement therapy in adult GH-deficient patients result in recurrence or increase in size of pituitary tumours?

OBJECTIVE: Hypopituitary GH-deficient patients have an increased cardiovascular mortality and GH replacement in this population has resulted in considerable therapeutic benefit. GH replacement involves administration of a potentially mitogenic substance to patients with a previous or residual pituitary tumour. Our objective was to evaluate whether GH replacement results in an increase in the size of pituitary tumours. METHODS: This was a non-randomised observational study on patients recruited from the endocrine clinic. All subjects had GH deficiency, proven on an insulin tolerance test and were divided into those who were or were not receiving long-term GH replacement. Comparison of change in pituitary size was made with interval radiological imaging of the pituitary. RESULTS: Seventy-five patients (40 men and 35 women) were in the study, 47 were on long-term GH replacement and there were 28 controls. The average length of treatment for the treated group was 3.6 patient years. Thirty-nine patients in the treated group had at least 2 years of GH treatment between imaging studies of the pituitary. Two patients in the treated group had an increase in pituitary size (non-functioning adenomas) and two in the control group (one functioning and one non-functioning adenoma adenoma). None of these four patients required further treatment. There was no statistically significant difference between the two groups. CONCLUSION: Using a representative cohort of hypopituitary patients attending an endocrine clinic, GH replacement was not associated with an increased pituitary tumour recurrence rate. Although the results are not conclusive, in the period of observation GH had little adverse effect but longer studies are required to be certain.

Tracheobronchial stent insertions in the management of major airway obstruction in a patient with Hunter syndrome (type-II mucopolysaccharidosis).

We report a case of a 22-year-old male with Hunter syndrome who developed progressive major airway obstruction and was treated with insertion of plastic and metallic stents, with dramatic improvement in the patient's symptomatic and functional status. To the best of our knowledge, this is the first reported case of endoluminal stents being used in the management of major airway obstruction in a patient with Hunter syndrome.

Computed tomography findings in an inflamed meckel diverticulum.

Meckel diverticulum, the commonest congenital abnormality of the gastrointestinal tract, may be difficult to diagnose. Appearances on CT are often non-specific unless there is connection to the umbilicus or a complication has occurred. We report a case of an inflamed Meckel diverticulum seen on CT.

The role of CT and MR in imaging the complications of sickle cell disease.

Sickle cell disease is the most common inherited haemoglobinopathy described. Complications of sickle cell disease (SCD) are due to chronic haemolysis of fragile red cells or secondary to vascular occlusion by sickled red cells with subsequent tissue infarction. Traditionally plain film radiography has been the mainstay in the assessment of patients with SCD, but increasingly magnetic resonance (MR) imaging and computed tomography (CT) are being used. In this review the imaging features of a range of complications of SCD are demonstrated with particular emphasis on CT and MR.

Gadopentate dimeglumine as an alternative contrast agent for use in interventional procedures.

Renal failure due to iodinated contrast media is a serious complication of peripheral angiography in patients with impaired renal function. Gadolinium based agents which are widely used in magnetic resonance imaging have no adverse renal toxicity at recommended doses. These agents have sufficient radiographic density to be seen using digital subtraction equipment. We describe the use of undiluted gadopentate dimeglumine as the radiographic contrast agent in two patients who underwent complex interventional procedures.