Outpatient angioplasty: 4-year experience in one practice.

Angioplasty is often performed as an inpatient procedure after preliminary angiography. In order to increase efficiency and patient comfort we introduced a policy of performing angioplasty for chronic leg ischaemia as an outpatient whenever possible, using duplex scanning to select suitable lesions. This paper examines the safety and feasibility of this policy over a 4-year period. We prospectively assessed 168 consecutive cases which were planned for outpatient angioplasty from a total of 190 cases undergoing angioplasty and found full agreement between duplex scanning and angiography in 92%. Six patients (4%) developed complications of angioplasty requiring admission and another five were admitted for unexpected organisational reasons. Thus, the complication rate of outpatient angioplasty was 4%. All complications were noted at the time of angioplasty with no unexpected readmissions. Angioplasty for leg ischaemia is feasible and safe to perform as an outpatient using duplex scanning to select appropriate cases.

Ambulatory venous pressure: correlation with skin condition and role in identifying surgically correctible disease.

OBJECTIVES: (1) To evaluate the full spectrum of venous skin damage with respect to ambulatory venous pressure. (2) To determine whether the ambulatory venous pressure/tourniquet test can be used to select patients for superficial venous surgery (eg. long or short saphenous stripping). DESIGN: Prospective study. SETTING: Vascular studies unit. MATERIALS AND METHODS: Ambulatory venous pressure was measured in a larger sample of limbs (360) with a wide spectrum of venous disease. In addition the effect of a tourniquet placed below the knee on ambulatory venous pressure and venous refilling time was assessed in 234 limbs. This was compared with Duplex assessment of deep and superficial venous reflux at this site. RESULTS: There was a linear trend towards more severe skin damage with increasing ambulatory venous pressure. Ulceration was associated with more severe calf muscle pump dysfunction (higher ambulatory venous pressure) than were lipodermatosclerosis, eczema or pigmentation. The tourniquet test was not able to distinguish between deep and superficial reflux as determined by Duplex scanning. CONCLUSIONS: Ambulatory venous pressure should be used to quantify venous insufficiency and remains the reference standard test of the venous calf muscle pump. The tourniquet test should not be used to select patients for surgery since it cannot distinguish deep from superficial venous incompetence. Venous reflux is best localised using Duplex ultrasound.

A survey of methods used for cardiac risk assessment prior to major vascular surgery.

OBJECTIVES: To assess the frequency with which various methods of cardiac risk assessment are used prior to major vascular surgery and the way in which patients considered to the "high" risk are managed. DESIGN: Questionnaire survey. SETTING: Great Britain and Northern Ireland. MATERIALS: Vascular Surgeons who are current members of the Vascular Surgical Society of Great Britain and Northern Ireland. CHIEF OUTCOME MEASURES: Number of respondents reporting routine or frequent use of particular investigations and methods of management. MAIN RESULTS: Of 246 respondents, 52% had access to a high dependency unit and 77% used intensive therapy units routinely following aortic reconstruction. Some measure of ejection fraction was the most common investigation and was used routinely prior to aortic reconstruction by 35% and often by 33% of respondents, this being more frequent in respondents from teaching hospitals and those carrying out a greater number of reconstructions. Calculated clinical risk indices were rarely used. The identification of high risk patients led to referral to a cardiologist for 90% of respondents and influenced the choice of anaesthetist for 50%. CONCLUSIONS: It is concluded that there is considerable variation in practice, but that those who carry out more vascular surgery are more aggressive in their assessment of cardiac risk prior to reconstruction.

Does the limb swell after revascularisation by percutaneous transluminal angioplasty?

OBJECTIVE: To discover if limb swelling occurs after successful revascularisation by percutaneous transluminal angioplasty (PTA). DESIGN: Prospective Study. SETTING: Vascular Laboratory. MATERIALS: Twenty-five patients with occlusive arterial disease of the lower limb revascularised by percutaneous transluminal angioplasty were studied. CHIEF OUTCOME MEASURES: The ankle/brachial pressure index and foot volumes measured by water displacement plethysmography were measured before and after PTA. MAIN RESULTS: The volume of the revascularised limb increased by 2% on the first day postangioplasty (p = 0.009) and 4% on the 7th day (p < 0.001) compared with the contralateral leg. CONCLUSIONS: Leg swelling is a consequence of revascularisation of the ischaemic limb and occurs in the absence of damage to the lymphatic drainage of the limb.

The use of a simple clinical cardiac risk index predictive of long-term outcome after infrarenal aortic reconstruction.

OBJECTIVE: Assessment of the value of preoperative clinical cardiac risk score (Detsky) in predicting long-term outcome in terms of survival and quality of life after elective aortic reconstruction. DESIGN: Prospective assessment of cardiac risk factors using Detsky's modification of Goldman's Index. SETTING: District General Hospital. MATERIALS: Ninety-three consecutive patients undergoing elective infrarenal aortic reconstruction. CHIEF OUTCOME MEASURES: After a median follow-up of 50.5 months, surviving patients were interviewed to assess quality of life using a standard Rosser classification. MAIN RESULTS: A high pre-operative cardiac risk score (Detsky > 10) was associated with decreased probability of survival, increased likelihood of suffering a non-fatal cardiovascular event, and diminished quality of life at the time of assessment. CONCLUSIONS: Preoperative cardiac risk assessment is helpful in predicting long-term outcome.

Unrecognised arterial injury of the forearm: a secondary bleed presenting as acute compartment syndrome.

This case describes an arterial injury that remained unrecognised for 3 days, when a sudden secondary bleed caused acute compartment syndrome of the forearm. We have been unable to find another case of compartment syndrome presenting in this manner. The importance of thorough wound exploration is highlighted and the diagnosis and treatment of the syndrome discussed.

Clinical significance of venous reflux detected by duplex scanning.

Duplex scanning was used to determine the presence of valvular incompetence in the major veins of 274 legs with venous disease. Using multivariate logistic regression analysis the significance of valvular function in each vein in relation to the clinical condition of the limb was calculated. Superficial femoral, profunda femoris and short saphenous vein function did not correlate with the clinical state of the limb; common femoral, popliteal and long saphenous vein function did. A table was constructed from the statistical model such that the relative contribution made by each vein could be estimated for limbs with different patterns of venous insufficiency. This model should now be tested in a prospective study and, if validated, could be used to improve decision making in venous surgery.

Investigation and significance of short saphenous vein incompetence.

In this study, 186 limbs with varicose veins or venous skin changes were examined using duplex ultrasonography. Limbs were classified on the basis of short saphenous or popliteal venous incompetence and the number of limbs with venous ulceration (active or healed) recorded. Short saphenous incompetence did not produce a significant increase in the incidence of ulceration, whereas popliteal reflux produced an increase in the risk of ulceration which was statistically significant when compared with limbs without reflux in these two veins (chi 2 = 4.55, P = 0.003). There was no significant difference in the proportion of limbs with concomitant long saphenous reflux between these two groups. Short saphenous reflux is not important in the pathogenesis of venous ulceration. Popliteal reflux is an important factor in the pathogenesis of venous ulceration. More attention should be paid to the surgical correction of popliteal reflux when present in limbs with venous ulceration that fail to heal by conservative measures.

Venous assessment using air plethysmography: a comparison with clinical examination, ambulatory venous pressure measurement and duplex scanning.

Air plethysmography was compared with clinical assessment, ambulatory venous pressure measurement and duplex ultrasonography in 103 unselected limbs with venous disease and ten normal control limbs without such disease. Measurements of venous function obtained by air plethysmography showed considerable overlap between groups of limbs classified on the basis of clinical condition or by the presence of popliteal incompetence detected by duplex scanning. The measurement of venous refilling time using air plethysmography correlated poorly with that obtained by venous cannulation (rs = 0.58). The residual volume fraction did not correlate with ambulatory venous pressure measurement (rs = 0.04). Air plethysmography was not found to be as useful as previously reported. The residual volume fraction should not be accepted as a substitute for ambulatory venous pressure measurement, which remains the 'gold standard' test of venous function.

Isolated endometriosis of the small bowel presenting as acute small bowel obstruction.

Although endometriosis is a common disease, small bowel involvement is unusual. We recently treated a patient in whom the diagnosis of endometriosis was made only after histological examination of a solitary lesion, which was obstructing the distal ileum and had the clinical appearance of a malignant tumour.