Radiotherapy-related axillary artery occlusive disease: percutaneous transluminal angioplasty and stenting. Two case reports and review of the literature.

Radiotherapy-related axillary artery occlusive disease is a relatively rare condition. This complication is usually encountered in patients with breast carcinoma treated by radiotherapy and might be frequently concealed by the presence of lymphoedema. We discuss this rare complication of radiotherapy treatment for breast cancer and present two cases and their successful treatment by a modified percutaneous transluminal angioplasty and stenting technique. A review of literature on the subject is also presented.

10-year experience of injuries sustained during clearance of anti-personnel mines.

Clearance of anti-personnel mines and unexploded ordnance in countries recovering from war usually continues long after conflict has ceased. We prospectively recorded 92 traumatic injuries sustained by 73 mineclearers working in seven countries over a period of 10 years. 15% of injuries were fatal, with an incidence of 116 injuries per 100000 workers per year. Limb injury occurred in 59% of cases, with an overall amputation rate of 30%. 44% of injuries were sustained by workers handling a mine, resulting in severe upper limb and facial injuries. The incidence of facial injuries fell after the introduction of visors.

Open access carotid duplex scanning: throughput and resultant surgical workload.

It is now generally accepted that high-quality duplex scanning obviates the need for pre-operative angiography in the assessment of most cases of carotid disease. An information leaflet was circulated to all general practitioners and hospital doctors in early 1996. Indications, results of treatment and details of the open access service were described. This paper outlines the workload that followed, for both imaging and surgical departments.

Effect of left renal vein division during aortic surgery on renal function.

A total of 398 consecutive patients underwent surgery for an aneurysm or occlusive disease of the aorta at Norfolk and Norwich Hospital between December 1994 and October 1998. It was necessary to divide the left renal vein in 58 (14.6%) cases. We examined the effect of this division on the mortality rate and renal function. Renal function was assessed by measuring serum creatinine pre-operatively, peri-operatively and long-term postoperatively. There was no significant difference in the mortality rate between patients who had the left renal vein divided (LRVD) and in whom the left renal vein remained intact (LRVI)--31% versus 32%, P = 0.83. There was no significant difference in the pre-operative serum creatinine level between both groups (107 +/- 21 mumol/l in LRVD versus 103 +/- 29 mumol/l in LRVI, P = 0.14). There was an insignificant rise in the mean serum creatinine 7 days postoperatively (111 +/- 21 mumol/l in LRVD versus 107 +/- 31 mumol/l in LRVI, P = 0.05). The mean serum creatinine returned back to the pre-operative level at 30 days postoperatively (106 +/- 16 mumol/l in LRVD and 105 +/- 29 mumol/l, P = 0.20). After 1 month, there was no significant difference in the number of patients who had a sustained elevation of serum creatinine level (7.5% in LRVD versus 2.7% in LRVI, P = 0.11). We feel that division of the left renal vein is a safe and helpful procedure during juxtarenal aortic surgery.

The case against a national screening programme for aortic aneurysms.

This review examines the assumptions underlying the calls for a national screening programme for aneurysms. It concludes that on the basis of published evidence, many of the necessary criteria for any putative screening programme are not met for this disease. Although the disease is an important cause of death, and a screening method is available, we lack basic knowledge about the natural history of the disease, especially small aneurysms, and about the cost-effectiveness of a screening programme. In particular, the treatment is an operation which, nationwide, carries a high mortality and is likely to be unacceptable to many patients. The consequences of such a programme would be to diagnose many small aneurysms, for which the best treatment remains unclear, and which will engender much unnecessary anxiety among patients so diagnosed.

Venous valve repair: early results in fifty-two cases.

PURPOSE: Chronic deep venous insufficiency, usually secondary to the postthrombotic syndrome, is due to primary valve failure in approximately 15% of cases. In these cases surgical repair of the valvular mechanism may be indicated. METHODS: Fifty-two limbs in 42 patients were treated with superficial femoral vein valvuloplasty after appropriate investigation. Adjunctive operations on the superficial or perforating veins were performed on 49 limbs during the same hospital admission. RESULTS: Of the 27 patients who have completed one year of follow-up, 85% are free of reflux on duplex scanning and 68% have had normalization of venous refilling times. Of 11 limbs with venous ulceration followed up for more than 1 year, only one has had a recurrent ulcer (9%). In patients without ulceration the procedure has been successful in alleviating symptoms of venous insufficiency. CONCLUSIONS: We conclude that the procedure, in conjunction with appropriate superficial venous operation, is effective in selected patients with deep vein reflux whose conditions remain uncontrolled by conservative measures. At 1 year, 85% of valvuloplasties in this series remained competent.

Effects of intermittent pneumatic compression of the foot on the microcirculatory function in arterial disease.

OBJECTIVE: The venous pump of the foot assists blood returning to the heart. The aim of this study was to evaluate the effect of mechanical activation of the foot pump on the microcirculation of the skin in patients with peripheral occlusive arterial disease. DESIGN: Single parallel group comparing patients with arterial disease to normal control subjects. SETTING: Department of Surgery, the University College and Middlesex Hospital, London, U.K. SUBJECTS AND MATERIALS: 15 patients with peripheral occlusive arterial disease and 15 control subjects. A pneumatic impulse foot pump was applied to the foot. OUTCOME MEASURES: The Laser Doppler flux (LDF) and transcutaneous oxygen tension (tcPO2) were measured on the big toe with the subject supine, before, during and after a 10 min period of foot pumping. The study was repeated with the subject sitting. RESULTS: On sitting there is a fall in LDF and rise in tcPO2. Application of intermittent pneumatic compression of the foot in the sitting position resulted in an increase in LDF. In patients, the median percentage increase was 57% and the median difference was 82 arbitrary units (AU) (95% CI 60-130, p < 0.001). In controls, the median percentage increase was 66% and the median difference was 124 AU (95% CI 73-275 p < 0.001). There was a corresponding "further" increase in tcPO2 in both groups of subjects. In patients, the median percentage increase was 8%, in controls the median percentage increase was 10% p < 0.01). CONCLUSION: We conclude that intermittent pneumatic compression of the foot in the dependent position increases LDF and tcPO2.

Hyperaemic response in the skin microcirculation of patients with chronic venous insufficiency.

The capacity of the microcirculation in the liposclerotic skin of patients with chronic venous insufficiency to vasodilate in response to pilocarpine electrophoresis was assessed using laser Doppler fluxmetry. Pilocarpine induces vasodilation by direct action on capillaries; other methods of vasodilatation, such as heating of the skin, act by a number of pathways including a neurogenic one. Thirty patients with lipodermatosclerosis and chronic venous insufficiency and 20 control subjects were studied. There was no difference in peak vasodilatation following pilocarpine electrophoresis in the two groups. The median (interquartile range) peak flux in patients was 665 (382-1025) units and in controls 765 (452-975) units (95 per cent confidence interval of difference--270 to 150 units, P = 0.5). This suggests that the capillaries in the liposclerotic skin of patients with chronic venous insufficiency have a normal capacity to vasodilate.

Venous ulcers and the superficial venous system.

PURPOSE: The purpose of this study is to identify the anatomic location of venous disease in patients with venous ulceration and chronic venous insufficiency. METHODS: Both limbs of 59 consecutive patients attending the Middlesex Hospital Vascular Laboratory (London, U.K.) with venous ulceration were assessed by color duplex ultrasound scanning to determine the location of venous disease. RESULTS: Isolated deep venous reflux was present in only 12 limbs (15%). A combination of deep and superficial venous reflux was found in 25 limbs (32%), and in 42 limbs (53%) there was only superficial venous reflux. CONCLUSION: In just over half the patients with venous ulceration, the disease is confined to the superficial venous system. This group of patients may benefit from surgical treatment. This study emphasizes the need for vascular laboratory investigation of patients with leg ulceration.

When do vascular surgeons prescribe antiplatelet therapy? Current attitudes.

A large number of studies have addressed the efficacy of antiplatelet agents in the prevention of primary and secondary atherosclerotic events. We have undertaken to review the literature and conclude that there is good evidence for the routine prescription of antiplatelet therapy in the prevention of secondary atherosclerotic events in patients with unstable angina, myocardial infarction, transient ischaemic attacks and post-arterial reconstruction. The evidence for any benefit in the prevention of vascular graft occlusion is less clear cut. We therefore conducted a postal survey of Vascular Surgeons in Britain and Ireland, receiving 112 responses to 134 questionnaires. Forty-seven percent of surgeons used antiplatelet therapy following any vascular procedure that they undertook. The rest were more selective in their use of these drugs, reserving them for specific vascular reconstruction, e.g. with synthetic grafts. Five percent of surgeons used anti-platelet aggregating prophylaxis only in patients following transluminal balloon angioplasty. In view of extensive evidence of reduction in long-term vascular mortality and non-fatal vascular events by the use of these drugs in patients who have had a primary vascular event, we would suggest that there is a strong argument for the routine use of anti-platelet drugs in patients presenting with arterial disease to a Vascular Surgeon, regardless of vascular reconstruction, angioplasty or type of graft used.

Vasomotion in the leg skin of patients with chronic venous insufficiency.

The characteristics of vasomotor activity in patients with lipodermatosclerosis (LDS) were studied using Laser Doppler fluxmetry and frequency analysis. Laser Doppler flux in the skin was recorded in the goiter region in 17 patients with LDS due to venous disease and in 16 normal control subjects. The Laser Doppler signals were analysed to give mean levels of flux and the frequency and amplitude of vasomotion were found using a fast Fourier transform (FFT). The results show significantly greater basal flow (p less than .001), and vasomotor frequency (p less than .001) and amplitude (p less than .001) in venous disease. The altered vasomotor activity is not due simply to the increased flow in LDS since increasing the flow in normal skin using the vasodilator pilocarpine does not produce as noticeable a difference.

Drug treatment of chronic venous insufficiency and venous ulceration: a review.

Treatment of venous insufficiency and venous ulceration has for many years relied on established principles of compression and limb elevation. Drug treatment has been of little benefit. In recent years, a better understanding of the pathological mechanisms underlying skin damage in venous disease has allowed more rational pharmacotherapeutic approaches to be made. This review examines these, with special reference to current theories of the cause of venous ulceration.

Disease mechanisms in venous ulceration.

Disease mechanisms in venous ulceration are poorly understood. Recent hypotheses have postulated two separate mechanisms to explain the extensive microcirculatory damage which leads, eventually, to ulceration. A number of treatments, based on the suggested pathogenesis, have been undertaken and this review critically examines these theories in the light of the results of these treatments.

Vasodilatory capacity of the skin in venous disease and its relationship to transcutaneous oxygen tension.

Low transcutaneous oxygen tension (Ptc,O2) values in the supramalleolar skin of patients with venous disease are often reported. This measurement involves heating the skin to 43 degrees C to cause maximum vasodilatation and is valid only if liposclerotic and normal skin can vasodilate to the same degree. Forty-four limbs were studied, 15 with lipodermatosclerosis (LDS), 14 with uncomplicated varicose veins, and 15 controls. A Ptc,O2 electrode was modified to incorporate a laser Doppler probe. Laser Doppler flux was measured in the supramalleolar skin before and after local heating to 43 degrees C and the relative increase in flux was measured. The Ptc,O2 was then measured at the same site and on the chest. Vasodilatory capacity was expressed as the ratio of peak:basal laser Doppler flow, and the Ptc,O2 was expressed as a leg:chest ratio. Median laser Doppler flow was higher in limbs with LDS (median 67 mV) than in normal limbs (median 40 mV) (P less than 0.03). Ptc,O2 was higher in control limbs (median ratio 0.94) than in limbs with LDS (median 0.53) (P less than 0.006). The microcirculation in LDS had less capacity to vasodilate after heating (median factor of increase 5.4) than normal skin (median factor of increase 12.3) (P less than 0.001). A simple regression analysis was performed on all pairs of data, and revealed a correlation between Ptc,O2 and vasodilatory capacity (r = 0.524, P less than 0.001). The results indicate that low Ptc,O2 levels in venous disease reflect an inability of the microcirculation to increase its flow in response to local heating; inferences about the oxygen content of liposclerotic skin at normal temperatures cannot be drawn using this technique.