Comparing surgeon- and nephrologist-inserted Tenckhoff catheters: experience from a metropolitan centre in Sydney.

BACKGROUND: Peritoneal dialysis (PD) is an effective home-based form of dialysis. Although several factors limit its use, the timely and successful insertion of a PD catheter is essential for increased uptake. AIMS: This retrospective observational study was performed at a tertiary teaching hospital in Sydney with the aim of comparing outcomes of PD catheter insertion using a percutaneous, modified Seldinger technique utilised by a trained nephrologist to the traditional surgical insertion using a mini-laparotomy. RESULTS: Over an 8-year period, 194 PD catheters were inserted. Aside from lower body mass indexes in the nephrologist-led interventions (P = 0.02), patient demographics were well matched. Time-to-insertion was significantly shorter with the percutaneous technique (P < 0.001). Univariant logistic regression noted no difference in the complication rate between the nephrologist-inserted and surgically inserted groups (likelihood ratio, 1.59; P = 0.08). There were differences in the type of adverse outcomes with each technique. Surgical procedures were more likely to have exit site leaks (P = 0.009) and peritonitis (P = 0.004), whereas procedure abandonment (P = 0.009) was more common in nephrologist-led procedures. CONCLUSIONS: The current study highlights that with careful patient selection, trained nephrologists in metropolitan areas can successfully insert PD catheters. Our experience noted fewer delays to catheter insertion, with similar total complication rates.

Rapid Formation and Rupture of Multiple Abdominal Pseudoaneurysms: A Life Threatening Case of Segmental Arterial Mediolysis.

We present a 62-year-old gentleman with rapidly forming abdominal pseudoaneurysms due to segmental arterial mediolysis (SAM). With rupture of his pseudoaneurysms, he underwent angiography and successful coil embolisation. In this case, we demonstrate the potential for rapid progression of pseudoaneurysms in SAM, with the need for prompt diagnosis and urgent endovascular intervention.

Durability of autogenous vein and polytetrafluoroethylene bypass grafts to the carotid arteries.

BACKGROUND: Bypass for extra-cranial arterial disease is infrequently carried out. We reviewed our experience to determine the outcome of carotid artery grafting using either an autogenous vein or polytetrafluoroethylene (PTFE). METHODS: Details of patients were recorded prospectively as part of a vascular surgical registry. Patients identified from the registry as having carotid artery bypass procedures were classified according to the type of conduit used. Comparison was made between patients with autogenous vein and PTFE grafts. RESULTS: Between 1978 and 2002, 24 patients (13 men and 11 women) mean age 60.0 +/- 13.4 years (range, 20-81 years) underwent 28 bypass procedures (three were bilateral and one was a reoperation). Symptomatic carotid disease was the clinical indication in 20 of 28 procedures (71.4%). Pathological indications included advanced atherosclerosis of the carotid arteries (15), past radiotherapy (4), failed stenting (3), resection of carotid body tumour (2), trauma (1), reoperation on a failed graft (1), carotid aneurysm (1) and iatrogenic carotid occlusion (1). An autogenous vein was used in 16, PTFE in 11 and autogenous artery in 1 of the patients. Using the Kaplan-Meier method, the overall patient cumulative 5-year survival was 84% and cumulative 5-year stroke-free survival was 93%. The combined perioperative stroke and mortality rate was 7.1%. Two patients had transient ischaemic attacks (7.1%), one had cranial nerve palsies (3.6%) and one required reoperation for bleeding (3.6%). Five-year cumulative graft primary patency using the Kaplan-Meier method was 74% for PTFE grafts and 92% for autogenous vein grafts (P = 0.37). CONCLUSION: Carotid artery bypass is a safe and a useful treatment option for complex extra-cranial arterial disease. Either PTFE or autogenous veins may be used as conduits.

A prospective study of subclinical myocardial damage in endovascular versus open repair of infrarenal abdominal aortic aneurysms.

BACKGROUND: Endovascular repair of abdominal aortic aneurysms (AAAs) is considered to be less invasive and better tolerated by the cardiovascular system than open repair. Our aim was to assess the true incidence of perioperative myocardial damage associated with endovascular vs open infrarenal AAA repair. METHODS: Between July 1999 and June 2001, preoperative and postoperative serum troponin T (TnT) levels were measured in all patients presenting for elective AAA repair at Royal Prince Alfred Hospital. The incidence of myocardial damage was recorded on the basis of standard clinical, biochemical, and electrocardiographic changes or a subclinical increase of 50% or more in serum TnT. Patients were excluded if the TnT increase was associated with a significant increase of serum creatinine (> or =50%) with no other evidence of myocardial ischemia. The differences between the two groups were analyzed with the chi 2 test and odds ratios. RESULTS: A total of 35 open and 112 endovascular AAA repairs were included in the study. There was no significant difference in age, sex, preoperative serum creatinine, or preoperative serum TnT between the two treatment groups. Seventeen patients had biochemical evidence of myocardial damage, which was clinically obvious in only one patient. Even though the incidence of previous myocardial infarction was significantly higher in patients undergoing endovascular repair (41%) than open repair (22%; P < .05), the overall incidence of myocardial damage (clinical or subclinical) was significantly higher in the open group compared with the endovascular group (8 [25%] of 32 vs 9 [8%] of 109, respectively; odds ratio, 3.7; 95% confidence interval, 1.28-10.49; P < .02). CONCLUSIONS: There is a previously underestimated incidence of subclinical myocardial damage associated with surgery for infrarenal AAA which is lower after endovascular than open repair.

Is bilateral duplex scanning necessary in patients with symptoms of deep venous thrombosis?

BACKGROUND: Venous duplex ultrasound scanning (VDUS) has been shown to be an accurate non-invasive means to diagnose symptomatic deep venous thrombosis (DVT). The aim of our study was to determine whether bilateral VDUS is necessary in patients who present with symptoms of DVT. METHODS: We retrospectively reviewed the results of bilateral lower extremity VDUS performed on 1029 inpatients at Royal Prince Alfred Hospital in the 24 months from 1 January 1998 to 31 December 1999. RESULTS: Of the 1029 patients, 705 (69%) presented with unilateral symptoms and 324 (31%) with bilateral symptoms. The overall incidence of DVT was 168 (16% of 1029 patients). In 705 patients with unilateral symptoms the diagnosis of DVT was confirmed in 120 (17.0%), of whom 20 (16.7%) had unsuspected bilateral DVT. There were 12 patients (1.7% of the 705 patients) who had DVT in the asymptomatic limb, without DVT identified in the symptomatic limb. Overall there were 32 (5% of 705) patients with unilateral symptoms who had unsuspected DVT in the asymptomatic limb. Of the 20 patients with bilateral DVT, only one patient had more extensive DVT in the asymptomatic limb than in the symptomatic limb, that was therefore likely to alter treatment. Bilateral symptoms of DVT were present in 324 (31.5%) patients, 48 (14.8%) of whom were found to have DVT. Nineteen (39.6%) of these DVTs were bilateral. CONCLUSION: Overall the diagnostic yield of VDUS was low in this study, with an incidence of 16% of DVT detected in symptomatic patients. Techniques that improve the diagnostic yield of VDUS in symptomatic patients are required. A significant proportion (23%) of the DVT detected in this study were bilateral, and a small but significant proportion (10%) of DVT found in patients presenting with unilateral symptoms were only in the asymptomatic contralateral limb. Our study supports bilateral VDUS in symptomatic inpatients, as the detection of DVT in asymptomatic limbs aids future patient management if symptoms develop in the asymptomatic limb.