Mid-term Outcomes of Renal Branches Versus Renal Fenestrations for Thoraco-abdominal Aneurysm Repair.

OBJECTIVE/BACKGROUND: The objective was to investigate renal outcomes following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) comparing fenestrations with branches for the renal arteries. METHODS: Renal outcomes following TAAA endovascular repair performed with renal branches were collected from five high volume European centers and compared with renal outcomes following TAAA endovascular repair performed with renal fenestrations at one center. Renal re-intervention and occlusion rates, and freedom from any renal outcome and death were analyzed by patient and target vessel. Estimated glomerular filtration rate (eGFR) was calculated and collected pre-operatively and at the last available follow up. RESULTS: In total, 449 patients were included in this retrospective study (235 treated with branched devices [BEVAR] and 214 with fenestrated devices [FEVAR]). Altogether, 856 renal vessels were analyzed (445 perfused by branches and 411 by fenestrations). Both groups were comparable except for sex and smoking habits. Technical success rates were 95% and 99%, respectively. Mean ± SD follow up was 19 ± 18 months after BEVAR and 24 ± 20 months after FEVAR. During follow up, renal re-intervention rates were similar in both groups (4.7% vs. 5.2%). The renal occlusion rate was significantly higher following BEVAR (9.6% vs. 2.3%; p < .01), and the 2 year freedom for renal occlusion rate was 90.4% (SE 85.8-95.3%) following BEVAR and 97.1% (SE 94.6-99.7%) following FEVAR (p < .01). During follow up, a 12% median decrease in eGFR was observed following BEVAR versus 9% following FEVAR (non-significant). The 2 year survival rates were 73.4% (SE 66.6-80.9%) and 81.8% (SE 76.1-87.9%) following BEVAR and FEVAR, respectively. CONCLUSION: Mid-term renal outcomes following endovascular repair of TAAA are satisfactory. Endograft designs incorporating renal fenestrations rather than renal branches are associated with significantly lower occlusion rates. A prospective trial is now required to confirm these results.

Editor's Choice - Effect of Branch Stent Choice on Branch-related Outcomes in Complex Aortic Repair.

OBJECTIVES: The use of branched stent grafts for the treatment of thoracoabdominal aneurysms [TAAA] is increasing, but mating stent graft choice has not been studied. This study combined experience of five high volume centres to assess a preferred mating stent. METHODS: Data from five centres were retrospectively combined. Patients were included if they underwent stent graft for treatment of TAAA that used only branches to mate with visceral and renal vessels. All patients with fenestrations in their device were excluded. Perioperative details, reintervention, occlusion, and death were recorded. Outcome of occlusion or reintervention, as well as a composite outcome of any death, occlusion, or reintervention was planned using a per-patient, and per-branch analysis. RESULTS: In 235 included patients, there were 940 vessels available for placement of mating stent. The average age of included patients was 70 years (SD 7.9), and 179 of the 235 were male. Medical comorbidities included diabetes in 29/234 (12.4%), current smoker in 81/233 (34.8%), and COPD in 77/234 (32.9%). The primary stent deployed was self-expanding in 556 branches, balloon expandable in 231 branches, and was unknown in 92 branches. After a mean of 20.7 months (SD 25) follow-up, there have been 44 incidents of occlusion or reintervention, of which 40 culprit stents are known. Where the stent placed is known, the event rate in renal branches (35/437, 8%) is higher than that of visceral branches (8/443, 1.8%). There is no difference in occlusion or reintervention between self-expanding and balloon expandable stents (HR 0.95, p = .91) but there is a statistically significant difference between renal and visceral artery occlusions (HR 3.51, p = 0.001). CONCLUSION: There appears to be no difference in occlusion or reintervention rate for branch vessels mated with balloon expandable compared with self-expanding stents. Renal events appear to outnumber visceral events in this population.

Neuroprotective Strategies Can Prevent Permanent Paraplegia in the Majority of Patients Who Develop Spinal Cord Ischaemia After Endovascular Repair of Thoracoabdominal Aortic Aneurysms.

OBJECTIVES: Spinal cord ischaemia (SCI) following endovascular thoracoabdominal aortic aneurysm (TAAA) repair is a devastating and unpredictable complication. This study describes a single unit's experience of SCI in patients who have had endovascular TAAA repair. METHODS: A prospectively maintained database of patients having endovascular TAAA repair using branched and fenestrated stent grafts between 2008 and 2014 at a single high volume centre was reviewed. Patients who developed neurological symptoms and signs related to SCI were identified and factors associated with onset and recovery of neurology were analysed. RESULTS: Sixty-nine patients (median age 73 years, 52 male; Crawford classification type I [n = 4], type II [n = 11], type III [n = 33], type IV [n = 14], type V [n = 7]) underwent endovascular TAAA repair. Twelve patients developed neurological symptoms/signs related to SCI but this was successfully reversed in eight patients, leaving four (5.8%) with permanent paraplegia. The median length of aorta covered was not significantly different in the 12 patients who developed SCI compared with the cohort that did not. Eleven of the patients who developed SCI had an intraoperative mean arterial pressure (MAP) below 80 mmHg. Cutaneous atheroemboli were noted in half of the patients in the SCI group compared with 11% of the non-SCI group (p < .05). Strategies used to reverse SCI included raising MAP, cerebrospinal fluid drainage, angioplasty of stenosed internal iliac arteries, and restoring perfusion to the aneurysm sac. CONCLUSIONS: This series highlights some of the risk factors associated with the development of SCI after endovascular repair of TAAAs. It also illustrates the importance of a dedicated institutional protocol aimed at ensuring the early diagnosis of SCI and prompt intervention to reverse permanent paraplegia in the majority of cases.

Editor's choice--Angulation of the C-arm during complex endovascular aortic procedures increases radiation exposure to the head.

OBJECTIVES/BACKGROUND: The increased complexity of endovascular aortic repair necessitates longer procedural time and higher radiation exposure to the operator, particularly to exposed body parts. The aims were to measure directly exposure to radiation of the bodies and heads of the operating team during endovascular repair of thoracoabdominal aortic aneurysms (TAAA), and to identify factors that may increase exposure. METHODS: This was a single-centre prospective study. Between October 2013 and July 2014, consecutive elective branched and fenestrated TAAA repairs performed in a hybrid operating room were studied. Electronic dosimeters were used to measure directly radiation exposure to the primary (PO) and assistant (AO) operator in three different areas (under-lead, over-lead, and head). Fluoroscopy and digital subtraction angiography (DSA) acquisition times, C-arm angulation, and PO/AO height were recorded. RESULTS: Seventeen cases were analysed (Crawford II-IV), with a median operating time of 280 minutes (interquartile range 200-330 minutes). Median age was 76 years (range 71-81 years); median body mass index was 28 kg/m(2) (25-32 kg/m(2)). Stent-grafts incorporated branches only, fenestrations only, or a mixture of branches and fenestrations. A total of 21 branches and 38 fenestrations were cannulated and stented. Head dose was significantly higher in the PO compared with the AO (median 54 µSv [range 24-130 µSv] vs. 15 µSv [range 7-43 µSv], respectively; p = .022), as was over-lead body dose (median 80 µSv [range 37-163 µSv] vs. 32 µSv [range 6-48 µSv], respectively; p = .003). Corresponding under-lead doses were similar between operators (median 4 µSv [range 1-17 µSv] vs. 1 µSv [range 1-3 µSv], respectively; p = .222). Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05). CONCLUSIONS: The head is an unprotected area receiving a significant radiation dose during complex endovascular aortic repair. The deleterious effects of exposure to this area are not fully understood. Vascular interventionalists should be cognisant of head exposure increasing with C-arm angulation, and limit this manoeuvre.

Pathology specific early outcome after thoracic endovascular aortic repair.

OBJECTIVES: Endovascular intervention is established for treatment of thoracic aortic dissection and aneurysm. The aim of this study was to compare the incidence of all-cause and aortic-related in-hospital mortality, stroke, spinal cord ischaemia, and major adverse event rate for patients undergoing thoracic aortic endovascular intervention to see if there is a pathology-specific effect. METHODS: Data were collected prospectively and analysed retrospectively for a cohort of 309 consecutive patients with either thoracic aortic dissection or aneurysm over a 14-year period. RESULTS: There were 209 men and 100 women with a median age of 72 years (interquartile range [IQR] 63-78 years). Aneurysm affected 62% (193/309) of patients and 37% (116/309) had complicated type B aortic dissection, of whom 43% (50/116) had acute and 57% (66/116) chronic presentations. In patients with aortic dissection compared to aneurysm, there was no significant difference in all-cause in-hospital mortality (6.9% vs. 8.3% respectively, p = 0.827, relative risk [RR] 0.83, 95% confidence interval [CI] 0.37-1.88), stroke (6.0% vs 6.2%, p = 1.00, RR 0.971, CI 0.39-2.39), spinal cord ischaemia (6.0% vs 6.2%, p = 1.00, RR 1.030, CI 0.42-2.54), or major adverse event rate (16.4% vs. 16.6%, p = 1.00, RR 0.988, CI 0.59-1.66). The rate of aortic related death was four times greater in the dissection than in the aneurysm group (4/8 = 50% vs 2/16 = 12.5%, p = 0.06, RR 6.99, CI 0.92-52.5) although this did not reach statistical significance. CONCLUSIONS: There was no difference in the incidence of in-hospital mortality, stroke, and spinal cord ischaemia between aneurysm and dissection. The higher rate of aortic related death in the dissection group may indicate the need to refine the clinical management of these patients, including procedural planning, endograft design, and operative technique.

Occupational radiation exposure during endovascular aortic procedures.

OBJECTIVES: To measure the radiation exposure of the operating team during endovascular aortic procedures, and to determine factors that predict high exposures. MATERIALS AND METHODS: Electronic dosimeters placed over and under protective lead garments, were used to prospectively record radiation exposure during endovascular aortic repairs performed in a designated interventional radiology suite. Univariate and multivariate linear regression analyses of predictors of radiation exposure were performed. RESULTS: A total of 26 infra-renal and 10 thoracic endovascular cases were studied. Median (IQR) patient age and body mass index were 76.0 (70.0-81.8) years and 26.2 (23.9-28.9) kg/m(2) respectively. Over-lead exposure to the operator was higher for thoracic than for infra-renal procedures (421.0 [233.8-597.8] µSv vs. 52.5 [27.8-179.8] µSv, p = .0003), reflecting a significant exposure to unprotected parts of the body. Under-lead exposures for operator and assistant were 5.5 (2.0-14.2) µSv and 1.0 (0.0-2.3) µSv respectively, which for an average caseload would comply with total body effective dose limits. Type of case and percentage of digital subtraction angiography (DSA) time in left anterior oblique angulations predicted dose to the operator (p < .0001). CONCLUSIONS: Thoracic procedures, DSA runs and obliquity of the C-arm are strong predictors of radiation exposure during endovascular aortic repairs. Understanding scatter radiation dynamics and instigating measures to minimise radiation exposure should be mandatory.

A novel reverse thermosensitive polymer to achieve temporary atraumatic vessel occlusion in infra-popliteal bypasses.

OBJECTIVE: The study aims to assess a novel thermosensitive polymer (LeGoo(®)) for distal vessel control during infra-popliteal (crural/pedal) bypass surgery in severe leg ischaemia. METHOD: Retrospective analysis of all distal bypasses from October 2009 to February 2012. Technical success, patency, limb salvage and amputation-free survival rates were analysed. RESULTS: Fifty-four infra-popliteal bypasses using the polymer were performed in 46 patients. The distal anastomosis was at the anterior tibial (n = 15, 28%), posterior tibial (n = 12, 22%), peroneal (n = 8, 15%), tibio-peroneal trunk (n = 8, 15%) and dorsalis pedis arteries (n = 11, 20%). Technical success was achieved in 51/54 (94.4%; failures: two inadequate haemostasis, one un-dissolved polymer). In-hospital duplex of the distal anastomosis showed a significant stenosis in two cases (4.3%). Outflow angioplasty was performed in three cases (two distal anastomotic, one run-off vessel, 5.6%). The 1-year patency rate was 76.2% (standard error (SE) 6.7%), limb salvage rate 79.3% (SE 6.7%). Amputation-free survival was 93.5% at 30 days (SE 3.6%) and 67.5% at 1 year (SE 7.5%). CONCLUSION: This thermosensitive polymer is a potentially safe and useful atraumatic device to achieve a blood-less distal anastomotic field in infra-popliteal bypasses. The technique avoids other potentially traumatic methods of vessel control, which may be particularly important in patients with calcified distal vessels.

Quality improvement framework for major amputation: are we getting it right?

INTRODUCTION: The quality improvement framework for major amputation was developed with the aim of improving outcomes and reducing the perioperartive mortality to less than 5% by 2015. The aim of the study was to assess our compliance with the framework guidelines and look for the reasons for non-compliance. METHOD: All major amputations performed between 2008 and 2010 were included. The following data were collected: presence of infection ± tissue loss, status of arterial supply, revascularisation attempts, time to surgery, type of amputation, morbidity and mortality. RESULTS: A total of 81 patients were included (42 BKAs, 39 AKAs). Ninety percentage had formal preoperative arterial investigations and 84% had an attempted revascularisation procedure. Patients who were transferred late from non-vascular units (n = 12) had a 30-day mortality of 50% whereas patients who presented directly to our unit had a 30-day mortality of 7.2%. The number of amputations has decreased over the last 3 years from 34 to 21 per year, coinciding with the doubling of crural revascularisation procedures performed (from 60 to 120 per year). Ten patients underwent a revision from BKA to AKA because of an inadequate profunda femoris artery (PFA), whereas all those with a healed BKA stump either had a good PFA or a named crural vessel. CONCLUSION: The overall number of amputations is decreasing from year to year. By doubling our crural revascularisation procedures we are saving more limbs. Thirty-day mortality is higher than expected, particularly in patients who present late. Expeditious referral may potentially improve the mortality rate among this group of patients.

Predictors of outcome after endovascular repair for chronic type B dissection.

OBJECTIVES: To assess the durability of endovascular repair (TEVAR) in chronic type B dissection (CD) and identify factors predictive of outcome. DESIGN: Retrospective analysis of a prospective database. MATERIALS: Patients undergoing TEVAR for CD at a tertiary referral centre 2000-2010. METHODS: Analysis of pre-operative characteristics, operative outcome, false lumen thrombosis, aortic diameter and survival. RESULTS: 58 consecutive patients were included (49 elective, 9 urgent, mean age 66 years). Mean aortic diameter was 6.4 cm (Standard deviation SD 1.3 cm). Three patients died perioperatively (5%, 1 urgent, 2 elective). Complications included retrograde type A dissection (n = 3), paraplegia (1), and transient ischaemic attack (1). Estimated survival (Kaplan-Meier) was 89% (1-year) and 64% (3-years). Forty-seven patients had mid-term imaging follow-up at mean 38 months. Reintervention rate was 15% at 1-year and 29% at 3-years. Aortic diameter decreased in 24, was stable in 15 and increased in 8. Mid-term survival was higher in patients with aortic remodelling (reduction of aortic diameter >0.5 cm; 3-year 89%) than without (54%; Log Rank p = 0.005). Remodelling occurred with extensive false lumen thrombosis. CONCLUSION: Satisfactory mid-term outcome after TEVAR for CD remains a challenge. Survival is associated with aortic remodelling, which is related to persistence of flow in the false lumen.

Imaging vascular trauma.

BACKGROUND: Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. METHODS: A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000-2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. RESULTS: Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. CONCLUSION: Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.

Total endovascular repair of thoracoabdominal aortic aneurysms.

BACKGROUND: Endovascular graft designs incorporating sidebranches, fenestrations and scallops offer a minimally-invasive alternative to open surgery and hybrid approaches for thoracoabdominal aortic aneurysms (TAAA). Our unit has offered total endovascular TAAA repair to selected higher-risk patients since 2008. We report the largest UK series to date of total endovascular TAAA repair. METHODS: Retrospective analysis of a prospectively-maintained operative database. RESULTS: 31 patients (21 male, 10 female) median age 71 years (range 58-84), with TAAA (12 Crawford type I, 13 type III, 6 type IV), median diameter 6.4 (4.3 (mycotic)- 9.9) underwent endovascular TAAA repair (total 48 sidebranches, 26 fenestrations, 13 scallops) between July 2008 and January 2011. Median operating time 225 min (65-540 min), X-ray screening time 58 min (4-212 min), contrast dose 175 ml (70-500 ml), blood loss 325 ml (100-400 ml). Median post-operative length of hospital stay 6 days (2-22 days). Three patients (3/31, 9.7%) died within 30 days of operation: multisystem organ failure (1) acute renal failure and paraplegia (1) and paraplegia (1). There were no other cases of in-hospital organ failure, paraplegia or major complications. The median change in pre-discharge from pre-operative renal function was 3.4% deterioration in eGFR (range: 32.7% deterioration to 73.0% improvement) One patient presented with late-onset paraparesis, a second developed acute renal failure 8 months after repair. One early high-pressure endoleak (type 3) required correction. Three patients had died by median follow-up 12 months (1-36), 2 from heart disease and one from haemopericardium secondary to acute dissection of the ascending aorta (the dissection did not involve, nor extend close to, the endovascular graft). CONCLUSIONS: Total endovascular repair of TAAA offers patients a minimally-invasive alternative to open surgery with early results at least comparable to those seen with open or hybrid surgical approaches.

Predictors of stroke and paraplegia in thoracic aortic endovascular intervention.

BACKGROUND: Endoluminal repair of thoracic aortic pathology has become established in clinical practice, but is associated with significant neurological complications. The aim of this study was to identify factors that were predictive of stroke and paraplegia. METHODS: Prospective data was collected for a cohort of 293 consecutive patients having thoracic aortic endovascular repair between August 1997 and September 2009. Patient and procedural characteristics were related to the incidence of stroke and paraplegia using multivariate logistic regression analysis. RESULTS: The median age was 68 years (18-87), there were 191 men and 102 women. Mortality was 5.1% for 195 elective and 13.4% for 98 urgent patients. Stroke affected 16 (5.5%) patients: 11 affected the anterior and 5 the posterior circulation. Coverage of the left subclavian artery with no revascularisation was the only significant factor predictive of stroke (OR 5.34 (1.42-20.40) P = 0.01). Paraplegia affected 16 patients (5.5%) but no independent risk factor was identified: 12 were identified perioperatively and 4 were delayed by up to 6 months. CONCLUSION: Covering the left subclavian artery without revascularisation increases the risk of stroke following endoluminal repair of thoracic pathology. Paraplegia appears to be more complex and no independent precipitating factor was identified.

Long-term surveillance with computed tomography after endovascular aneurysm repair may not be justified.

BACKGROUND: There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair. METHODS: Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed. RESULTS: The male : female ratio was 11 : 1, median age 76 (range 40-93) years and median aneurysm diameter 6.1 (5.3-11) cm. The overall 30-day mortality rate was 1.7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7.4 per cent), of which six (1.4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2.9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4.1 per cent); extra-anatomical bypass was needed in 15 patients (3.6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0.5 per cent). CONCLUSION: Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.

Is endovascular repair of mycotic aortic aneurysms a durable treatment option?

OBJECTIVE: Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. METHOD: A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. RESULTS: Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. CONCLUSION: Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.

Mobile phones, in combination with a computer locator system, improve the response times of emergency medical services in central London.

INTRODUCTION: The aim of this study was to determine whether mobile phones and mobile phone locating devices are associated with improved ambulance response times in central London. PATIENTS AND METHODS: All calls from the London Ambulance Service database since 1999 were analysed. In addition, 100 consecutive patients completed a questionnaire on mobile phone use whilst attending the St Thomas's Hospital Emergency Department in central London. RESULTS: Mobile phone use for emergencies in central London has increased from 4007 (5% of total) calls in January 1999 to 21,585 (29%) in August 2004. Ambulance response times for mobile phone calls were reduced after the introduction of the mobile phone locating system (mean 469 s versus 444 s; P = 0.0195). The proportion of mobile phone calls made from mobile phones for life-threatening emergencies was higher after injury than for medical emergencies (41% versus 16%, P = 0.0063). Of patients transported to the accident and emergency department by ambulance, 44% contacted the ambulance service by mobile phone. Three-quarters of calls made from outside the home or work-place were by mobile phone and 72% of patients indicated that it would have taken longer to contact the emergency services if they had not used a mobile. CONCLUSIONS: Since the introduction of the mobile phone locating system, there has been an improvement in ambulance response times. Mobile locating systems in urban areas across the UK may lead to faster response times and, potentially, improved patient outcomes.

Neurological complications following endoluminal repair of thoracic aortic disease.

Open surgery for thoracic aortic disease is associated with significant morbidity and the reported rates for paraplegia and stroke are 3%-19% and 6%-11%, respectively. Spinal cord ischemia and stroke have also been reported following endoluminal repair. This study reviews the incidence of paraplegia and stroke in a series of 186 patients treated with thoracic stent grafts. From July 1997 to September 2006, 186 patients (125 men) underwent endoluminal repair of thoracic aortic pathology. Mean age was 71 years (range, 17-90 years). One hundred twenty-eight patients were treated electively and 58 patients had urgent procedures. Anesthesia was epidural in 131, general in 50, and local in 5 patients. Seven patients developed paraplegia (3.8%; two urgent and five elective). All occurred in-hospital apart from one associated with severe hypotension after a myocardial infarction at 3 weeks. Four of these recovered with cerebrospinal fluid (CSF) drainage. One patient with paraplegia died and two had permanent neurological deficit. The rate of permanent paraplegia and death was 1.6%. There were seven strokes (3.8%; four urgent and three elective). Three patients made a complete recovery, one had permanent expressive dysphasia, and three died. The rate of permanent stroke and death was 2.1%. Endoluminal treatment of thoracic aortic disease is an attractive alternative to open surgery; however, there is still a risk of paraplegia and stroke. Permanent neurological deficits and death occurred in 3.7% of the patients in this series. We conclude that prompt recognition of paraplegia and immediate insertion of a CSF drain can be an effective way of recovering spinal cord function and improving the prognosis.

Hybrid repair of type B dissecting aneurysm with associated Kommerell's diverticulum.

Endovascular therapy has revolutionised vascular surgery. Complex open surgical procedures may be replaced with a combination of extra-anatomical reconstruction and endovascular treatment. This minimally invasive approach is associated with a lower peri-operative morbidity and mortality than open repair. We describe a novel 2-stage treatment in a patient with Type B thoracic aortic dissection with subsequent aneurysmal dilatation and the added difficulty of a concomitant aneurysmal aberrant right subclavian artery (Kommerell's diverticulum).

Large infra-renal abdominal aortic aneurysms: endovascular vs. open repair--single centre experience.

Endovascular aneurysm repair (EVAR) has become an established alternative to open repair (OR). We present a consecutive series of 486 elective patients with large infra-renal aortic abdominal aneurysm, comparing OR with EVAR. Prospective data collected during an 8-year period from January 1997 to October 2005 was reviewed. Statistical analysis performed using SPSS data editor with chi(2) tests and Mann-Whitney U-tests. There were 486 patients with 329 OR (293 males, 36 females) with median age of 72 years with median diameter 6.3 cm and 157 EVAR (148 males, 9 females) with median age 75 years with median diameter 6.1 cm. Mortality was 13 (4%) for OR and 5 (3.2%) for EVAR (three of whom were in the UK EVAR 2 trial). Blood loss was significantly less for EVAR 500 ml vs. 1500 ml for OR. Sixty-five (19.8%) patients with OR had significantly more peri-operative complications compared with 14 (8.9%) with EVAR. The length of stay in hospital was significantly less for EVAR. This non-randomised study shows that although EVAR does not have a statistically significantly lower mortality, it does have statistically significantly lower complication rates compared with OR. EVAR can be achieved with good primary success, but long-term follow-up is essential to assess durability.

Critical limb ischemia in the dialysis-dependent patient: infrainguinal vein bypass is justified.

The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.