A new "closed" in situ vein bypass technique results in a reduced wound complication rate.

OBJECTIVES: This prospective randomised multicentre trial was conducted to test whether a new "closed" technique for in situ vein bypass would result in a lower frequency of wound complications, without negative effects on patency rates and without an intolerable increase in residual arteriovenous fistulae compared to the conventional "open" technique. METHODS: We have developed a new "closed" technique using a co-axial catheter embolisation system for intra-operative coil embolisation of side branches, in order to avoid long incisions. PATIENTS: In four centres and 95 patients, 97 in situ bypasses were performed: 47 "closed" and 50 "open". Randomisation was stratified for below knee femoropopliteal bypasses (60) and femorocrural bypasses (37). Indications were disabling intermittent claudication (29), restpain (26) or ulcers and/or necrosis (42). RESULTS: Postoperative mortality was 2% (one in the "closed", one in the "open" group). A total number of 16 (34%) wound complications (grade 1, 2 and 3) occurred in the closed group compared to 36 (72%) in the open group (p < 0.05). Deep wound complications (grade 2) occurred in six patients (13%) of the "closed" group, compared to 15 (30%) in the "open" group. In both groups, three patients (6%) developed deep wound complications including the bypass area (grade 3). In the "closed" group, 20 patients needed additional treatment for arteriovenous fistulae, compared to four in the "open" group. One-year patency rates did not show a statistically significant difference: primary patency rates were 65% and 61% and secondary patency rates were 86% and 76% respectively for the "closed" and "open" group. CONCLUSION: These results indicate that a "closed" technique reduces wound complication rate, without negative effects on the short term patency rates. The "closed" technique results in an increased number of postoperative treatments for residual arteriovenous fistulae.

The transtibial route for femoral to anterior tibial artery bypass.

OBJECTIVE: To assess the applicability of the transtibial route, via a drilled hole in the tibia, for femoral to anterior tibial artery bypass surgery. DESIGN: in a pilot study of 10 patients the preoperative arm/ankle systolic blood pressure indices were compared with those after operation. Patients were followed for 2 years. RESULTS: of the 10 patients, one was lost to follow-up and two had occlusions of their bypasses. After two years the remaining seven still had patient bypasses, with arm/ankle systolic blood pressure indices that were significantly higher than those before operation (p < 0.05). CONCLUSION: The transtibial route, via a drilled hole in the tibia, is a viable alternative to other methods for femoral to anterior tibial artery bypass surgery.

Haemobilia: a report of 2 cases.

Although rare, haemobilia should be included in the differential diagnosis of obscure gastro-intestinal bleeding, particularly when accompanied by colic and jaundice. Case histories of 2 patients with haemobilia of different origin are presented. One had traumatic haemobilia after suture of a liver rupture; in the other patient an aneurysm of a branch of the right hepatic artery ruptured into the hepatic duct. The first patient recovered spontaneously; the second required ligation of the affected blood vessel. Diagnosis and treatment of the haemobilia syndrome are discussed, with reference to the liver blood supply.