Aortic graft preservation by debridement and omental wrapping.

BACKGROUND: Aortic graft infection is a rare, but grave, complication in vascular surgery. Graft removal together with extra-anatomical bypass or in situ graft replacement is usually advocated, but these procedures are associated with significant morbidity and mortality. METHODS AND RESULTS: Two cases of aortic graft infection in high-risk surgical candidates managed by open debridement and omental wrapping with graft preservation are described. Both remain well at 3 years without any adjunctive procedures. CONCLUSION: Debridement and omental wrapping may offer an alternative to graft removal and revascularization in selected patients. This relatively low-risk procedure may allow long-term survival.

Isolated right testicular pain for six days: an unusual presentation of occult abdominal aortic aneurysm leak.

Abdominal aortic aneurysm (AAA) rupture commonly presents with abdominal or lower back pain and haemodynamic instability. There have been case reports of co-existing left testicular pain;(1) however, very few cases describe right testicular pain as the sentinel symptom. We discuss the case of a 75-year-old man who presented to the on-call urologists with a 6-day history of right testicular pain. On examination, a painless AAA was detected. The patient was stable and a CT scan demonstrated a large AAA extending into the right iliac vessels, with suggestion of leakage. Attempted emergency repair was unsuccessful and the patient died in theatre. This atypical presentation of occult aneurysm leak highlights the need for clinical vigilance in the older patient with seemingly benign groin symptoms, including isolated right testicular pain.

Risk factors for chronic ulceration in patients with varicose veins: a case control study.

BACKGROUND/OBJECTIVE: Identifying which patients with varicose veins are at risk of progressing to more severe forms of chronic venous disease could help in assigning clinical priorities and targeting appropriate treatments. The aim of this study was to determine, in subjects with varicose veins, the characteristics of venous disease and other factors associated with an increased risk of ulceration. METHODS: One hundred twenty subjects with varicose veins and an open or healed venous leg ulcer were compared with 120 controls with varicose veins and no history of venous ulcer on this case control study. Subjects were recruited from hospital settings and primary care. Each subject completed a questionnaire on lifestyle and medical history and underwent an examination comprising of clinical classification of venous disease (CEAP), duplex scanning, quantitative digital photoplethysmography, and measurement of dorsiflexion. Multiple logistic regression analyses and calculation of receiver operating characteristic (ROC) curves were performed to identify the combination of factors which most accurately predicted which patients with varicose veins will develop leg ulcers. RESULTS: An increased risk of ulceration was associated with the severity of clinical venous disease, especially with the presence of skin changes (P < .0001). Other significant risk factors included history of deep vein thrombosis (DVT) (P = .001), higher body mass index (BMI) (P = .006), smoking (P = .009), and reflux in the deep veins (P = .0001). Ulceration was associated with reduced volume of blood displaced as reflected by photoplethysmography and a limited range of ankle movement (not wholly due to the effects of an active ulcer) (both P < .05). Multivariate analyses showed that skin changes including lipodermatosclerosis (odds ratio [OR] 8.90, 95% confidence interval [CI] 1.44-54.8), corona phlebectatica (OR 4.52, 95% CI 1.81-11.3) and eczema (OR 2.87, 95% CI 1.12-7.07), higher BMI (OR 1.08, 95% CI 1.01-1.15), and popliteal vein reflux (OR 2.82, 95% CI 1.03-7.75) remained independently associated with increased risk of ulceration while good dorsiflexion of the ankle (OR 0.88, 95% CI 0.81-0.97) and an effective calf muscle pump (OR 0.96, 95% CI 0.92-0.99) remained protective factors. ROC curve analyses indicated that a model based on clinical observation of skin changes, duplex scanning for popliteal reflux, and calf muscle pump tests would be the most accurate in determining which patients with varicose veins develop leg ulcers. CONCLUSIONS: The results of this study confirm that, in patients with varicose veins, those with skin changes of chronic venous insufficiency and deep vein incompetence are at greatly increased risk of ulceration. However, the risks may also be increased in those who smoke, are obese, and have restricted ankle movement and reduced calf muscle pump power.

One-stage repair of an aortic dissection and aortic coarctation.

Ascending aortic dissection with aortic coarctation has a high mortality. There are few reports of successful surgical management of the combined condition. We report a case of a successful one-stage repair of type A aortic dissection with aortic coarctation, using an extra-anatomic bypass to connect the ascending to the abdominal aorta.

Functional outcome after open repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Outcome after operative repair of ruptured abdominal aortic aneurysm (AAA) has traditionally been assessed in terms of survival. This study examines the functional outcome of patients who survive operation. METHODS: Consecutive patients who survived open repair over an 18-month period were entered into a prospective case-control study. Age- and sex-matched controls were identified from patients undergoing elective AAA repair. The Short Form-36 health survey was administered to both groups of patients at 6 months after operation. Results were compared with the expected scores for an age- and sex-matched normal UK population. RESULTS: Fifty-seven patients underwent open repair of a ruptured AAA, and 30 survived; no patient was lost to follow-up. There were no significant differences in quality of life between patients who had an emergency repair and those who had an elective repair. Both of these groups had poorer health-related quality of life outcomes than the matched normal population. Surprisingly, compared with the normal population, patients after elective repair had poorer outcomes in more health domains than patients who survived emergency operation. CONCLUSIONS: Survivors of ruptured AAA repair have a good functional outcome within 6 months of operation.