Pancreatitis as a complication of endovascular aneurysm repair.

INTRODUCTION: We report a case of acute pancreatitis complicating an endovascular abdominal aortic aneurysm repair (EVAR). REPORT: A seventy three year old man underwent an EVAR and developed acute onset epigastric pain, followed by mottling of the upper abdominal wall. A raised amylase confirmed the diagnosis of acute pancreatitis. DISCUSSION: To our knowledge this is the first report of this complication of EVAR.

Cost-effective carotid endarterectomy.

BACKGROUND: Although carotid endarterectomy is increasing in the UK, there is evidence that the procedure is still underused. Methods of reducing cost in a single vascular unit have been assessed using a continuous audit including outcome measures. METHODS: A consecutive series of 333 patients admitted over 7 years under a single consultant surgeon were studied. Outcome measures included the rate of perioperative neurological complication of any kind, and death. The length of hospital stay and the number of readmissions within 30 days were recorded prospectively by computerized audit. RESULTS: Over the interval of the study, the number of preoperative investigations was reduced; angiography and cerebral computed tomography were reserved for specific indications. The median duration of hospital stay decreased from 7 to 2 days. There was no change in the stroke and death rate (3 per cent) during the study and only two patients required readmission within 30 days. CONCLUSION: Carotid endarterectomy can be performed cost-effectively using non-invasive preoperative investigations for the majority of patients. In-hospital stay has been reduced and the routine use of intensive care replaced by a 2-h stay in theatre recovery. These changes have been achieved without compromising patient safety.

The results of routine primary closure in carotid endarterectomy.

PURPOSE OF STUDY: The aims of this study were to determine the incidence of restenosis following carotid endarterectomy with primary closure of the arteriotomy and to observe the natural history of disease progression in the 1st postoperative year. METHODS: The study group consisted of a consecutive series of 126 patients undergoing carotid endarterectomy. Duplex imaging was performed preoperatively and at 8 weeks, 6 months and 1 year postoperatively. RESULTS: Five patients (4%) had a residual stenosis. At 12 months, the overall restenosis rate was 15%: 8.5% for males and 28.9% for females. None of these restenoses were symptomatic. There was no significant difference in the diameter of the internal carotid artery between male and female patients (U = 896, P = 0.60) and no significant difference in the diameter of the arteries that had restenosed at 12 months and those that had remained patent (U = 391, P = 0.33). CONCLUSIONS: Carotid endarterectomy with primary closure is associated with a low incidence of restenosis in men, but not in women. Criteria for selective patching should consider both gender and vessel calibre.

ICU protocol may affect the outcome of non-elective abdominal aortic aneurysm repair.

OBJECTIVES: To compare the outcome of patients undergoing non-elective abdominal aortic aneurysm repair at two hospitals under the care of a single vascular surgeon. DESIGN: Prospective and retrospective audit of 6 years of emergency and urgent infrarenal abdominal aortic aneurysm surgery. SETTING: Lewisham and North Southwark Health Authority. SUBJECTS: One hundred and forty-five patients who underwent emergency (46) or urgent (99) repair of an abdominal aortic aneurysm. PRIMARY OUTCOME MEASURE: Hospital mortality. SECONDARY OUTCOME MEASURES: Acute renal failure, intensive care and hospital length of stay distal ischaemia and return to theatre. RESULTS: Mortality was higher at hospital 2 than hospital 1 (28% vs. 9%, p = 0.0068). There was no significant difference in age, sex, cardiac history, hypertension, diabetes, smoking, renal impairment (all p > 0.05). There was no difference in operation time, blood loss and base excess at the end of surgery between the two groups (all p > 0.05). APACHE II scores on admission to ICU were similar in hospital 1 and hospital 2 (median 16 vs. 14, p > 0.03). Pulmonary artery catheters were placed in 18% of patients at hospital 1 compared with 96% at hospital 2. Patients at hospital 2 received more crystalloid (median 2990 vs. 2300 ml+, more colloid (median 4775 vs. 1500 ml), and more inotropes (median 1 vs. 0) than those at hospital 1 in their first 24 h on ICU (all p < 0.001). The volume of urine passed in the first 24 h was similar (median 2410 vs. 2000 ml, p = 0.12) yet the incidence of acute renal failure was higher at hospital 2 compared with hospital 1 (30% vs. 6%, p = 0.001). ICU length of stay of survivors was longer at hospital 2 (median 3 vs. 2 days, p = 0.0018) as was hospital length of stay (median 17.5 vs. 12 days, p = 0.0002). CONCLUSIONS: The outcome at both hospitals is at least as good as other reported series, but it is interesting to note that the hospital which used less pulmonary artery catheters and less intervention (in the form of colloid and inotropes) showed a reduced mortality. These data may be important in assessing the different therapeutic strategies employed postoperatively in the ICU.

Successful intraarterial thrombolysis of an ischemic limb four days after laparoscopic cholecystectomy.

Intraarterial thrombolysis is usually contraindicated after abdominal surgery because of the risk of bleeding. However, it is a highly effective treatment for embolic acute limb ischemia, particularly for clearing the distal vessels. We report a case in which intraarterial thrombolysis was safely used 4 days after laparoscopic cholecystectomy in a patient with an acutely ischemic leg due to embolus.

The medical treatment of patients presenting with intermittent claudication secondary to atherosclerosis.

Peripheral vascular disease affects a large number of elderly people but is symptomatic in only a few cases. Most of these will not be considered for surgical or radiological revascularisation procedures unless their disease affects the suprainguinal vessels. The traditional advice to stop smoking and keep walking is important but, in addition, thought should be given to the secondary prevention of cardiovascular disease in these patients. Thorough assessment and modification of their risk factors, including their lipid status, should be performed and aspirin should be prescribed to all patients who can tolerate it.

The impact of pre-clerking clinics on surgical operation cancellations: a prospective audit.

Pre-clerking of all patients undergoing elective general surgical operations was introduced at our hospital in an attempt to reduce an unacceptably high operation cancellation rate. A prospective audit has been performed on the effect of this policy on the cancellation rate. Before the introduction of pre-clerking there was a marked seasonal variation in the number of patients who failed to attend for surgery, which could be explained by absence on holiday. This seasonal variation disappeared after the start of pre-clerking clinics, but there has been no reduction in the number of cancellations for medical reasons.

A one-stop vascular clinic: a practical proposition with non-invasive assessment.

One-stop clinics are becoming increasingly popular with both patients and their general practitioners. Traditionally, vascular patients have needed to attend hospital two or three times for clinical examination and investigations. We have introduced a one-stop clinic for patients with lower limb arterial disease (LLAD) and aortic aneurysms. In 92 clinics over 2 years, 1194 new patients and 1409 follow-up patients were seen, with LLAD being the largest single category comprising 40% of the patients seen, followed by varicose veins (25%), carotid disease (12%), and aortic aneurysms (8%). Overall, 57% of patients had non-invasive imaging performed, either in the clinic or on a separate visit. Performing all LLAD and aortic scans in the clinic requires 1.9 h of imaging time per clinic. Extending in-clinic scanning to patients with varicose veins and carotid disease would increase this to 3.9 h of scanning per clinic and require a duplex scanner and an additional technologist in the clinic.

Endovascular repair of residual iliac artery aneurysms following surgery for ruptured abdominal aortic aneurysm.

Emergency repair of ruptured abdominal aortic aneurysm continues to have a high mortality. Such patients require expeditious operations to repair the ruptured segment rather than attempts to deal with all coexisting disease. The use of endovascular techniques obviates the need for open surgery to repair iliac aneurysms. We report two patients who, after successful repair of ruptured abdominal aortic aneurysms, had three iliac artery aneurysms treated successfully by embolisation in one case and percutaneous insertion of a self expandable stent graft in two cases. The issues that arise from such an approach are discussed with a review of the literature.

A 4-year prospective audit of the cause of death after infrarenal aortic aneurysm surgery.

This study was a 4-year prospective audit of abdominal aortic aneurysm surgery including 222 aneurysm repairs: 106 elective, 76 urgent and 40 emergency. Twenty-five patients died: four who underwent elective surgery, seven urgent and 14 emergency. The two major causes of death, multiple organ failure and colonic ischaemia, were responsible for 11 of the 25 deaths. The three deaths from myocardial infarction all occurred in patients with a leaking aneurysm. Blood loss was significantly higher in patients with multiple organ failure and in those with colonic ischaemia. Methods to identify patients at high risk of massive blood loss and colonic ischaemia may be a way to reduce mortality.

Breast conservation or mastectomy: treatment choice of women aged 70 years and older.

Fifty women aged 70 years and older with newly diagnosed carcinoma of the breast were prospectively studied after being offered a choice of four treatment options. Thirty-four of 38 patients who chose their own treatment had breast conservation; four opted for mastectomy. At 12-month follow-up only two women were unhappy with their choice of treatment. It is concluded that elderly women should be involved in deciding the treatment of their breast cancer.