Outcome of the external carotid artery following carotid endarterectomy with added external carotid artery eversion endarterectomy.

OBJECTIVE: To study the results of eversion endarteterctomy of the external carotid artery (ECA) performed as part of standard CEA at a tertiary referral center using duplex ultrasonography. MATERIALS AND METHODS: Sixty patients (18 women and 42 men) who underwent 65 carotid endarterectomies at Waikato Hospital between January 2006 and July 2007 for significant internal carotid artery (ICA) disease were studied. The procedure also included eversion endarterectomy of the ECA with sharp transection at eversion end point. Preoperative and postoperative duplex scans were performed for all patients using Acuson (USA) ultrasound machine and by one sonographer. Postoperative follow-up scans at periods between 6 weeks and 18 months were reviewed and analyzed with Ascer et al. Doppler ultrasound-scan peak systolic velocity (PSV) criteria. RESULTS: Preoperative scans revealed significant bifurcation disease involving both ICA and ECA in all patients. The first post operative scan, done six weeks post-operatively, revealed one incomplete ECA endarterectomy, resulting in moderate (50%-74%) stenosis, while the rest had no evidence of residual ECA disease at the site of ECA endarterectomy. Over the post-operative period, sixteen (24.6%) ECA lesions and no occlusions were reported. The degree of ECA stenosis ranged from moderate to severe with PSVs ranging from 120 to 461 cm per second. All ECA lesions were ostial. Only 3 (18.7%) lesions were detected in the first nine months post operatively. Fifteen lesions were smooth and regular on duplex, while one had features of irregular residual stenosis. Eight (50%) were isolated ECA lesions, while the rest was associated with either ICA restenosis or occlusion. CONCLUSION: ECA disease progression detected by Duplex ultrasound following eversion endarterectomy, as a part of CEA, commonly happens after 9 months and results in recurrent ECA stenosis, in most cases. Timing and features of the lesions suggest an intimal reaction as the aetiology in most cases. Eversion endarterectomy of the ECA does not predispose to ECA occlusion.

Spontaneous arterial thrombosis in association with pancreatic carcinoma: diagnosis and interventional management.

A 58-year-old woman presented with bilateral upper limb ischaemia. Digital subtraction angiography demonstrated upper limb arterial thrombosis, extensive on the left. This was initially treated with catheter-directed thrombolysis which cleared the thrombus on the right, although the left upper limb required supplementary surgical embolectomy. Subsequently, biopsy-proven pancreatic adenocarcinoma was detected. The upper limb arterial thrombosis appeared to be spontaneous in association with the malignancy because there was no obvious embolic source.

Twelve years experience of vena cava filtration.

Fourteen patients have required vena caval interruption in a period of 12 years at St Thomas' Hospital. Half of these patients had an underlying malignancy. None of these patients have had clinical or lung scan evidence of recurrent emboli. There were no deaths related to filter insertion and no patient died of a pulmonary embolism. Vena caval interruption is a procedure that is rarely necessary but may be valuable in carefully selected patients.

Putting a finger on the deep inguinal ring.

The clinical distinction between direct and indirect inguinal hernias is often made by determining whether digital pressure over the deep inguinal ring is able to control the hernia. In 25 consecutive patients having inguinal hernia operations, the positions of the mid-inguinal point and the mid-point of the inguinal ligament were determined pre-operatively and compared with the position of the deep inguinal ring measured at operation. Neither the mid-inguinal point nor the mid-point of the inguinal ligament correctly predicted the position of the deep inguinal ring (the mean position of the deep inguinal ring was found to be 0.52 cm lateral to the mid-inguinal point and 0.46 cm medial to the mid-point of the inguinal ligament). If the position of the deep inguinal ring cannot be accurately determined using fixed landmarks, it is unlikely that direct and indirect inguinal hernias can be distinguished by clinical examination.

Lymphangiomatosis of the limbs. Clinicopathologic analysis of a series with a good prognosis.

Six cases of a distinctive but poorly recognized variant of lymphangiomatosis with predominant or exclusive involvement of the soft tissues of the limb/limb girdle are described. The six patients were male and presented with slowly progressive swelling of the involved limb. The age of onset was at birth (three cases), 3 months (one case), 11 years (one case) and 12 years (one case). Five patients had involvement of the lower extremity and one of the right upper extremity. Three patients had concomitant asymptomatic bone involvement either in the affected limb (two cases) or in distant bones (one case). Only one patient had visceral involvement that was limited to the ipsilateral thorax and was associated with chylothorax. Diagnosis was confirmed in all but one patient by lymphangiography. Treatment consisted principally of surgical reduction with significant clinical improvement. No patient later developed systemic involvement and the clinical course was benign. The bone lesions did not progress in any patient. Histologically, each case was characterised by interconnecting, dilated lymphatic spaces, lined by a single, attenuated layer of endothelial cells, involving the dermis, subcutis, and occasionally, underlying fascia and skeletal muscle with characteristic and extensive "dissection" of collagen and surrounding normal adnexal structures. Despite the absence of red blood cells in the vascular spaces, interstitial hemosiderin deposition was prominent in four cases. As opposed to most cases of lymphangiomatosis, which usually have extensive visceral involvement associated with a very poor prognosis, involvement in this variant is limited almost exclusively to soft tissues of the limb and bone and is associated with good prognosis.