Successful non operative management of late infrainguinal polytetrafluoroethylene vascular graft infection with antibiotics alone: a report of two cases.

Polytetrafluoroethylene (PTFE) prosthetic vascular graft infection is a serious complication of arterial reconstructive surgery. Traditional management is primarily surgical and may result in long hospital stay with significant morbidity and mortality. The authors describe two cases of infected femoropoliteal PTFE grafts which were managed non operatively with antibiotic therapy alone, resulting in early return to normal activities and excellent resolution of infection on Indium labelled leucocyte scanning. The authors suggest that in selected cases antibiotic therapy alone is a valuable tool in the management of infrainguinal PTFE prosthetic sepsis.

Results of independent medical interview and examination in the diagnosis and assessment of hand-arm vibration syndrome.

In the UK the use of the Stockholm Classification has been recommended by the Health and Safety Executive and by the Working Party of the Faculty of Occupational Medicine. The Stockholm Workshop 1994 did not recommend any changes to the existing classification but considered the variety of screening and diagnostic tests suitable for the staging of HAVS. Thirty one males claiming to be suffering from HAVS were interviewed and examined by each of the authors independently. The examination of each patient included detailed occupational and medical histories, standard physical examination with the additional tests of the rewarm time and aesthesiometry. Thermal neutral zone test (TNZ), vibrotactile thresholds and grip strength were also performed by McGeoch. All patients were classified by the Taylor/Pelmear and Stockholm Classifications. Both authors agreed that all the patients were suffering from HAVS. Agreement to within one stage was high for both the vascular and neurological elements. The additional neurological tests used by McGeoch appeared to result the raising of the neurological staging. The results indicate that independent interview plus objective tests performed by experienced physicians allow for reliable diagnosis and staging of claimants. Standardisation of tests is urgently required.

Mesenteric angioplasty for chronic intestinal ischaemia.

Mesenteric angina is a difficult diagnosis and surgical treatment carries a significant morbidity and mortality. In patients with stenotic mesenteric vascular disease angioplasty offers an alternative method of treatment. In six patients who underwent mesenteric angioplasty relief of symptoms was achieved in five. Recurrence of symptoms associated with recurrent stenosis occurred in two patients and was remedied by re-dilation in one. Mesenteric angioplasty is a safe alternative to surgical revascularisation for mesenteric stenosis causing chronic intestinal ischaemia.

Follow-up of conventional angioplasty versus laser thermal angioplasty for total femoropopliteal artery occlusions: results of a randomized trial.

Sixty-eight patients with 68 femoropopliteal occlusions were entered into a randomized trial of conventional guide-wire and catheter percutaneous angioplasty versus laser thermal angioplasty. Thirty-four occlusions were randomized to conventional angioplasty and 34 to laser thermal angioplasty. After successful recanalization and balloon dilation, the patients were followed up for 1 year. Follow-up consisted of obtaining measurements of the ankle-arm indexes at 1, 3, 6, and 12 months. The increase in the mean resting ankle-arm index 1 year after conventional angioplasty (0.26) was greater than that after laser angioplasty (0.12). At 1-year follow-up, the cumulative success rate was 47% for patients treated with conventional angioplasty versus 39% for those treated with laser angioplasty. Statistical analysis showed no significant difference in clinical success between the two treatment groups.

Total peripheral artery occlusions: conventional versus laser thermal recanalization with a hybrid probe in percutaneous angioplasty--results of a randomized trial.

Increasing the primary success rate in recanalization of peripheral vascular occlusions is one aim of using laser techniques in the treatment of peripheral vascular disease. Although reports of lasers enabling recanalization after failure of guide wires have been numerous, direct comparisons of the success of the two techniques in a randomized trial have been few. The results of a randomized trial showed no statistical difference in recanalization of femoropopliteal occlusions between the conventional guide wire and hybrid laser probe. The number of patients with iliac occlusions was small and comparisons are difficult to make, but the findings suggest that the hybrid laser probe has little to offer. Immediate crossover to the alternative method allowed investigation of the relationship between the two methods in practice. Combining the two methods improved the primary success rate from 82% to 91% for femoropopliteal occlusions randomized to laser thermal recanalization and from 74% to 91% for those randomized to conventional recanalization.

The role of percutaneous transluminal angioplasty in the treatment of critical ischaemia.

In an attempt to establish the overall role played by percutaneous transluminal angioplasty in the treatment of critical ischaemia we studied 101 consecutive patients (110 limbs) who presented to one vascular unit over an 18 month period with this diagnosis. All patients underwent assessment with Doppler waveform analysis and arteriography and decisions about further management were made jointly by the surgical team and vascular radiologist. Results showed that only 24/110 limbs (22%) had lesions that were suitable for treatment with angioplasty alone. In addition one patient underwent angioplasty in conjunction with a distal bypass. Forty-one of the 110 limbs (37%) underwent reconstructive surgery, 18/110 (16%) primary amputation and 26/110 (24%) conservative treatment. Of those 24 limbs undergoing angioplasty, four were technically unsuccessful, and six were technically successful but without clinical improvement and all required alternative treatment. Only 12/110 limbs (11%) showed clinical improvement during their admission following angioplasty. We conclude that although angioplasty can be used successfully to treat critical ischaemia the overall numbers of patients who are suitable for treatment and who gain benefit from it is small.

The complication rate of percutaneous peripheral balloon angioplasty.

One thousand six hundred and forty-two vessel segments (46% iliac, 54% femoro-distal) in 1141 patients have undergone percutaneous peripheral balloon dilatation at the Northern General Hospital, Sheffield over a 9 year period. Forty-two significant complications were encountered in all; 28 of these were occlusive and half of these were treated by angioplasty itself, either by thrombolysis or catheter suction. There was one case of distal ischaemia attributed to cholesterol embolisation which led to death (Gaines et al., 1988). There were two cases of perforation and haematoma requiring surgery, one retroperitoneal haemorrhage and one false aneurysm. One diabetic patient developed septicaemia following successful PTA for an ischaemic foot and died. One case each of bowel ischaemia, cerebrovascular accident and myocardial infarction occurred within 24 h of the angioplasty procedure, but there was no clear causal relationship. Arterial wall dissection or perforation per se was not considered a complication unless it progressed to haemorrhage or vessel occlusion. There were three cases of femoral nerve damage causing sensory loss in the thigh, two of which were permanent. Four hundred and thirty-five procedures were performed in patients with rest ischaemia. Of these, 2.8% developed complications requiring surgery, but only 0.9% required reconstructive bypass surgery. For intermittent claudication 1207 procedures were performed, 0.7% of these developed complications requiring surgery but only 0.5% required reconstructive surgery. These results justify the use of angioplasty in the treatment of intermittent claudication and in poor risk patients with threatened limb loss.

Percutaneous transluminal angioplasty of the distal abdominal aorta.

Percutaneous Transluminal Angioplasty (PTA) has become widely practised and is a significant advance in the treatment of arterial disease. Its use in the treatment of atheromatous abdominal aortic stenoses in thirteen patients is described. Technical success was achieved in all with no complications. In a follow-up period from 7 to 70 months all patients have benefitted and 85% remain symptom free.

Percutaneous laser thermal angioplasty: initial results and 1-year follow-up in 129 femoropopliteal lesions.

Percutaneous peripheral laser thermal angioplasty with a laser-heated metallic-capped fiber was used as an adjunct to conventional balloon angioplasty. Initial angiographic and clinical success was achieved in 99 of 129 (77%) femoropopliteal stenoses and occlusions (21 of 22 [95%] stenoses, 17 of 17 [100%] short [1-3-cm] occlusions, 26 of 37 [70%] medium-length [4-7-cm] occlusions, and 35 of 53 [66%] long [greater than 7 cm] occlusions). There was a 4% frequency of vessel perforation without clinical sequelae and no necessity for emergency bypass surgery. The 1-year cumulative clinical patency was 77% for the 99 lesions with an initial clinical success. In the 21 stenoses and 17 short occlusions, the cumulative clinical patency rates were 95% and 93%, respectively. In the longer occlusions (4-7 cm and greater than 7 cm), the clinical patency rates were 76% and 58%, respectively. The initial angiographic and clinical success, as well as the 1-year cumulative clinical patency, for stenoses and short occlusions after laser-assisted balloon angioplasty may be greater than after conventional balloon angioplasty alone.

Cholesterol embolisation: a lethal complication of vascular catheterisation.

Cholesterol embolisation after vascular catheterisation occurred in 5 patients. It tended to be associated with difficult manipulation of the catheter within a severely diseased aorta, and a common feature is leg pain with livedo reticularis despite palpable pulses. Confusion, renal failure, and death ultimately ensue.

Percutaneous laser thermal angioplasty: initial clinical results with a laser probe in total peripheral artery occlusions.

A metal-tipped laser fibre was used during percutaneous angioplasty of femoral/popliteal or iliac artery occlusions in 56 patients. Primary success was achieved in 50 (89%) of these total occlusions, providing a channel for subsequent balloon dilatation. Before the procedure, 18 lesions had been judged untreatable by conventional angioplasty and four of the six failures were in these. Complications directly attributable to the laser probe were one case of vessel perforation and two cases of entry into vessel walls; these had no sequelae. Other acute complications were a distal thrombosis in a non-heparinised patient, requiring local streptokinase treatment, and two reocclusions and one transient peripheral embolic episode in the first 24 hours. The laser probe technique has potential for increasing the proportion of patients suitable for angioplasty.

Parathyroid surgery in chronic renal failure: subtotal parathyroidectomy or autotransplantation?

In the period 1970-1983, 27 patients with end stage renal failure underwent neck exploration for hyperparathyroidism. In 1977 the operative policy changed from subtotal parathyroidectomy to total parathyroidectomy and autotransplantation. Eight patients underwent subtotal parathyroidectomy while fifteen patients underwent total parathyroidectomy and autotransplantation. All were cured of their symptoms and hypercalcaemia was resolved. There was no significant difference in the requirement for postoperative calcium and vitamin D supplements between the two groups. Recurrent hypercalcaemia developed in one patient who had undergone total parathyroidectomy and autotransplantation. Resolution followed removal of approximately half the transplant. There were four deviations from the operative policy.

The effect of vibration on digital blood flow.

The effect on digital blood flow of an acute exposure to vibration has been assessed. Vibration in the frequency range 40-200 Hz reduces digital blood flow, the effect being maximal at 120 Hz. Increasing the amplitude of vibration reduces digital blood flow. The results have implications in the formulation of industrial vibration standards and in the pathophysiology of vibration-induced white finger.

Prophylactic use of metronidazole in preventing wound sepsis after elective cholecystectomy.

The effect of intravenous metronidazole as prophylaxis against postoperative wound infection was studied in a prospective, randomized, double-blind controlled trial of 116 patients undergoing elective cholecystectomy. No significant difference was found in the infection rate between the treated and the control groups.