Transarterial Embolisation of Abdominal Aortic Type II Endoleaks Accessed via the Deep Circumflex Iliac Artery: A Case Series and Literature Review.

We report our technique and experience treating 3 patients with native abdominal aortic aneurysm (AAA) sac expansion following EVAR, who were managed with transarterial embolisation via the deep circumflex iliac artery (DCIA). In this case series, we demonstrate that transarterial embolisation via the DCIA is a feasible and safe treatment option. The DCIA should be routinely interrogated with angiography as not only a cause of possible Type II endoleak, but also to identify a potential access route to the abdominal aortic sac for interventional treatment.

Intra-operative duplex ultrasound scanning in renal transplantation: protocol and service requirements.

Intra-operative duplex ultrasound in renal transplantation was first described in 1998 and whilst reported in problematic cases, there are few reports of its routine use and no current published protocols. Since 2013, we have used intra-operative ultrasound in all renal transplants. The formal protocol used since August 2020 is presented as a reference document for other transplant centres. A Canon Aplio 800 ultrasound system with an i22LH8 hockey-stick transducer is used to image the renal cortex and major vessels, and an i8CX1 matrix transducer to image the graft during and after fascial closure. These transducers are fully sterilised with Sterrad and no sheathing of transducers is required. The transplant surgeon scans within the sterile field with the sonographer guiding imaging and adjusting machine settings. Ultrasound findings are discussed between team members including any requirement for interventions. Ultrasound is performed at three stages of the operation: Stage 1: after clamp release identifying issues of graft vascularity including otherwise unrecognised major vessel and anastomotic abnormalities. Stage 2: following ureteric implantation identifying compromised perfusion due to graft rotation or vessel kinking. Stage 3: after fascial closure identifying compromised perfusion due to external compression. Post-operative scanning, including assessment of the collecting system and bladder, is performed routinely on days 1, 3, 7 and 30. The intervention is effective with no early graft losses or peri-operative vascular thromboses. The requirements for service provision are significant including the availability of additional transducers, and sonographers with expertise in intra-operative scanning able to attend after-hours for extended periods.

Is There a Role for Heli-FX Endoanchors in Treating Type 1B Common Iliac Artery Endoleaks?

OBJECTIVES: The management of type 1B endoleaks following endovascular aortic aneurysm repair (EVAR) can be challenging. The Heli-FX Endoanchor system effectively treats proximal type 1A endoleaks but has not been used for type 1B common iliac artery endoleaks. This study demonstrates that it is both safe and effective in being used in the common iliac artery (CIA) limb of an EVAR. METHODS: A retrospective review of patients identified through coding and medical records was performed to extract information on demographics, aneurysmal features, operative features, and postoperative outcomes. This was then collated and analysed thoroughly and compared to existing research. RESULTS: Four patients with six type 1B CIA endoleaks were treated with Heli-FX Endoanchors in the CIA limbs of EVAR grafts. There was 100% technical success rate with complete exclusion of the endoleaks at 6 months. With mean follow up of 714 days, there were no Endoanchor-specific complications. One patient required explantation of the aortic endograft due to contralateral limb fracture, where it was found that an Endoanchor had penetrated the common iliac vein, requiring primary closure. CONCLUSIONS: Heli-FX Endoanchors were effective within this cohort of patients, though key risks were identified. Adjacent anatomy to the CIA must be considered, which also have nearly half the arterial thickness compared to the aorta. Pre-operative planning is essential given the theoretical risk of placing Endoanchors.

A sex-based analysis of 5-year outcomes following stenting for the treatment of aorto-iliac occlusive disease.

OBJECTIVES: The aim of this study was to evaluate the impact of sex on mid-term outcomes following stenting for aorto-iliac occlusive disease (AIOD). METHODS: The Covered versus Balloon Expandable Stent Trial (COBEST) compared the safety and efficacy of the covered stent (CS) with those of the bare metal stent (BMS) in the treatment of hemodynamically significant AIOD. It was identified that CS provided a significant benefit. The primary endpoint of our analysis was the rate of primary patency 5 years following stenting for AIOD (inclusive of both CS and BMS) in both sexes. RESULTS: Of the 168 lesions treated, 103 (61%) were present in men and 65 (39%) were present in women. Of the concomitant comorbidities, diabetes mellitus was significantly more common in women (17.5% vs 41.5%, p = .006). Although chronic limb threatening ischemia (CLTI) at the time of intervention was more common in women, the difference was not significant (16.5% vs 24.6%, p = .395). Sex was not associated with the primary patency rate (male; 0.70, 95% confidence interval [CI]: 0.23-2.19, p = .543). When considering both male sex and the utilization of BMS, no significant impact was found on the primary patency rate (hazard ratio [HR]: 3.43, 95% CI: 0.69-17.10, p = .133). All-cause mortality at 60 months was 22.6% in men compared to 19.4% in women (p = .695). CONCLUSIONS: No significant difference was identified in the primary patency rate between the sexes. Further investigation is warranted to ascertain whether sex-specific interventional guidelines are required in this regard.

Ex vivo repair and autotransplantation for a complex renal artery aneurysm.

Renal artery aneurysms (RAA) are rare, occurring with an incidence of <0.1%. Open repair remains the mainstay of treatment for anatomically complex aneurysms. Here, we present a case of a large hilar RAA managed with ex vivo reconstruction and heterotopic renal autotransplantation. In this case, the complex anatomy and location of the aneurysm precluded the use of an endovascular approach. In situ repair was deemed unfavorable because of the technical difficulty of the repair with the numerous arterial branches involved, risk of parenchymal injury from prolonged warm ischemic time, restricted surgical field and risk of aneurysm rupture. This case contributes to the literature on laparoscopic nephrectomy, ex vivo repair and autotransplantation as a safe and viable treatment strategy for patients with complex RAA.

AFX unibody stent graft: Effective and safe for the treatment of severe aorto-iliac occlusive disease.

OBJECTIVES: The primary objective of this study was to determine the primary, assisted primary and secondary patency rates of the Endologix AFX stent-graft in patients considered high risk for open surgery with complex aorto-iliac occlusive disease. The secondary objective was to determine 30-day major adverse cardiovascular and cerebrovascular events. METHODS: A retrospective review was undertaken of clinical records of 38 patients who underwent AFX stent-graft placement for aorto-iliac occlusive disease from 2016 to 2019. Patient data was de-identified and entered into a REDcap secure database. Descriptive statistical analysis (means and standard deviations) and Kaplan-Meier survival curves were created to determine the duration of patency of the AFX stent-graft system. RESULTS: Primary patency rates at 6, 12 and 24 months were 92%, 92% and 84%, respectively. Assisted primary patency rates at these times were 100%, 100% and 93% with secondary patency of 100% maintained throughout. The incidence of 30-day major adverse cardiovascular and cerebrovascular events was 8% and major adverse limb events was 3%. One death unrelated to the AFX device occurred during the study period though outside of the 30-day peri-operative period. CONCLUSIONS: Primary, assisted primary and secondary patency rates of AFX stent-grafts, when used to treat aorto-iliac occlusive disease, are high. This study supports the use of the AFX stent-graft for the endovascular treatment of complex aorto-iliac occlusive disease as an alternative to other endovascular options as well as a safe alternative to open aorto-iliac or aorto-femoral bypass in patients who are at high risk for open procedures.

Editor's Choice - Optimal Timing of Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection: A Systematic Review and Meta-Analysis.

OBJECTIVE: Type B aortic dissections (TBAD) have a high mortality rate and are challenging to both classify and manage. There is significant evidence supporting the use of early intervention in complicated TBAD with thoracic endovascular aortic repair (TEVAR). Currently, there is equipoise regarding the optimal timing for TEVAR in TBAD. This systematic review answers whether early TEVAR in the hyperacute or acute phase of the disease has improved aorta related events in the one year follow up period with no change in mortality rate when compared with TEVAR in the subacute or chronic phase. DATA SOURCES: A systematic review and meta-analysis was performed with Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search guidelines for MEDLINE, Embase, and Cochrane Reviews until 12 April 2021. Inclusion and exclusion criteria targeting the review objective and high quality research were employed by separate authors. REVIEW METHODS: These studies were then reviewed for suitability, risk of bias, and heterogeneity using the ROBINS-I tool. Results were extracted for the meta-analysis with RevMan using odds ratios with 95% confidence intervals with I2 used to assess heterogeneity. RESULTS: Twenty articles were included. A meta-analysis showed no significant difference between acute phase TEVAR (excluding the hyperacute phase) and subacute or chronic phase TEVAR for the all cause 30 day and one year mortality rates. Aorta related events in the 30 day post-operative period were unaffected by the timing of intervention but had significant improvement in aorta related events in the one year follow up favouring TEVAR in the acute phase compared with subacute or chronic phase. Risk of confounding was high but with low heterogeneity. CONCLUSION: Without prospective randomised controlled studies, it is evident that there is improved aortic remodelling in long term follow up with intervention in the acute setting from three to 14 days after symptom onset. This suggests that TEVAR in the acute period of TBAD is both safe and beneficial, and can be considered for early stent grafting based on clinical, anatomical and patient factors.

Early Outcomes in Renal Transplantation With Routine Intraoperative Duplex Ultrasound.

BACKGROUND: While intra-operative duplex ultrasound scanning can be readily performed in renal transplantation, the value of this intervention in routine practice is not established. METHODS: Three hundred thirty-one consecutive single renal transplants in adult recipients underwent intraoperative scanning at implantation. Early graft losses were compared with those recorded in the ANZDATA Registry. RESULTS: Nine overt vascular abnormalities were corrected prior to scanning. Four further suspected venous outflow restrictions were confirmed by ultrasound and revised. Another 11 major vascular revisions were performed following intraoperative ultrasound consisting of 7 otherwise unsuspected inflow abnormalities, all corrected, and 4 anastomoses redone to reposition the graft. Thirty-two (9.7%) grafts were repositioned under ultrasound guidance to improve cortical perfusion but without vascular revision. One graft with hyperacute rejection was explanted 4 days postimplantation and one graft with primary nonfunction remained well perfused. Two patients died within 90 days, both with functioning grafts. Twenty-three grafts were re-explored within 7 days, including 9 solely for graft hypoperfusion. There were no postoperative arterial thromboses and, at re-exploration, no arterial anastomoses required revision. There were no postoperative venous thromboses, although one venous anastomosis was revised. No grafts were lost within 90 days for surgical or technical reasons compared with 76 (1.0%) of 7603 contemporaneous grafts in the ANZDATA Registry (P = .077 Fisher's exact test, P = .069 χ2 test). CONCLUSIONS: The routine use of intraoperative ultrasound appears to be of benefit by identifying otherwise unrecognized vascular abnormalities, leading to a reduction in early graft losses because of surgical factors.

Successful endovascular exclusion of Mycobacterium bovis mycotic aneurysm following intravesical bacille Calmette-Guerin therapy.

Bacille Calmette-Guerin (BCG) is a live-attenuated strain of Mycobacterium bovis. It is routinely used in the treatment of early-stage transitional cell carcinoma. The development of mycotic aneurysm in the context of prior intra-vesical BCG treatment has not been reported. This case demonstrates a rare but potentially catastrophic vascular complication of BCG. A high index of suspicion is required for any patient presenting with new aneurysmal disease in the context of previous BCG therapy. The value of endovascular surgery as a bridge to definitive surgical repair and diagnostic considerations is discussed.

Involvement of Kommerell's diverticulae-a new anatomical risk factor for acute aortic syndrome progression and technical considerations.

We present two cases of acute aortic syndromes (AAS), involving an aberrant right subclavian artery (ARSA) with associated Kommerell's diverticulae (KD). One of the cases involves a penetrating aortic ulcer in patients with an ARSA and KD and represents the first reported such case in the literature. Both cases progressed despite optimal medical therapy suggesting AAS with this anomalous anatomy needs a more aggressive operative approach. The involvement of KD in a patient with AAS appears to increase aortic disease progression and this anatomical variation should be considered another anatomical criterion that may place these patients at higher risk of complication. Progression during conservative management and waiting for the patient to be in the traditional safer 'sub-acute' time frame after presentation increased the eventual difficulty of the hybrid repair. A hybrid open-endovascular repair was utilized in all cases and is a safe and effective strategy for managing patients with ARSA and KD presenting with AAS.

Complex thoracic aortic dissection treated by aorto-biiliac bypass and juxta-renal removal of aortic fenestrations.

Thoracic aortic dissections are a life-threatening pathology. They occur when there is an intimal tear causing separation of the layers of the aorta. Thoracic aortic dissections can be acute or chronic and depending on the pattern of the dissection can be difficult to treat. No acute dissections are the same, and herein we describe a case of a 62-male presenting with an acute thoracic aortic dissection requiring acute aorto-biiliac bypass and juxta-renal removal of aortic fenestrations.

Systematic review of intra-operative duplex scanning during renal transplantation.

INTRODUCTION: A systematic review of the value of intra-operative duplex scanning during renal transplantation was undertaken. METHODS: Studies assessing intra-operative renal cortical flow in the arcuate vessels with outcomes of ultrasound directed interventions during the initial procedure, delayed graft function, post-operative resistive indices, graft losses and early returns to theatre for graft hypoperfusion were reviewed. PROSPERO registration: (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020203873). RESULTS: Literature searching identified 2069 articles for screening, with 131 reviewed and 12 selected for analysis comprising 5 individual case reports, one case series of 11 patients and 6 non-randomised controlled trials. Studies with similar methodologies were pooled because of the low number of studies and outcomes. Outcomes of interest were not reported for all patients. Intra-operative interventions comprising graft repositioning in 18 (16%) and vascular revision in 2 (2%) were performed in 115 patients undergoing intra-operative scans. There were no graft losses or returns to theatre for graft hypoperfusion (0 of 108 cases) compared to 7 of 71 (10%) without intraoperative scanning (P = 0.003). Three of 8 (38%) patients with high intra-operative resistive indices (RIs) were returned to theatre for hypoperfusion compared to 1 of 110 (1%) patients with normal resistive indices (P = <0.001). Ten of 13 (77%) patients with high RIs had delayed graft function compared to 10 of 40 (25%) with normal RIs (P = 0.001). CONCLUSION: Despite the absence of randomised controlled trials, and heterogeneous small studies, adverse outcomes were reduced with intra-operative scanning. High intraoperative RIs were predictive of both delayed graft function and return to theatre for hypoperfusion.

Protocol for the Stimulating ß3-Adrenergic Receptors for Peripheral Artery Disease (STAR-PAD) trial: a double-blinded, randomised, placebo-controlled study evaluating the effects of mirabegron on functional performance in patients with peripheral arterial disease.

INTRODUCTION: There is currently only one approved medication effective at improving walking distance in people with intermittent claudication. Preclinical data suggest that the ß3-adrenergic receptor agonist (mirabegron) could be repurposed to treat intermittent claudication associated with peripheral artery disease. The aim of the Stimulating ß3-Adrenergic Receptors for Peripheral Artery Disease (STAR-PAD) trial is to test whether mirabegron improves walking distance in people with intermittent claudication. METHODS AND ANALYSIS: The STAR-PAD trial is a Phase II, multicentre, double-blind, randomised, placebo-controlled trial of mirabegron versus placebo on walking distance in patients with PAD. A total of 120 patients aged ≥40 years with stable PAD and intermittent claudication will be randomly assigned (1:1 ratio) to receive either mirabegron (50 mg orally once a day) or matched placebo, for 12 weeks. The primary endpoint is change in peak walking distance as assessed by a graded treadmill test. Secondary endpoints will include: (i) initial claudication distance; (ii) average daily step count and total step count and (iii) functional status and quality of life assessment. Mechanistic substudies will examine potential effects of mirabegron on vascular function, including brachial artery flow-mediate dilatation; MRI assessment of lower limb blood flow, tissue perfusion and arterial stiffness and numbers and angiogenesis potential of endothelial progenitor cells. Given that mirabegron is safe and clinically available for alternative purposes, a positive study is positioned to immediately impact patient care. ETHICS AND DISSEMINATION: The STAR-PAD trial is approved by the Northern Sydney Local Health District Human Research Ethics Committee (HREC/18/HAWKE/50). The study results will be published in peer-reviewed medical or scientific journals and presented at scientific meetings, regardless of the study outcomes. TRIAL REGISTRATION NUMBER: ACTRN12619000423112; Results.

A Novel Approach to a Patient with both Aortoiliac and Venous Occlusive Disease.

Radiation-induced arteritis is a well-recognized complication of radiotherapy; however, radiation-induced venous stenosis is very rare (Zhou W, Bush RL, Lin PH, et al. Radiation-associated venous stenosis: endovascular treatment options. J Vasc Surg 2004;40:179-182). We describe a case of mixed aortoiliac arterial occlusive disease and iliac venous outflow obstruction secondary to radiation-induced vascular disease. Several endovascular procedures were undertaken to treat aortoiliac occlusive disease, which was followed by stenting for venous occlusive disease.

Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity.

BACKGROUND: People undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (e.g. heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT), but is associated with an increased risk of bleeding. Mechanical prophylaxis (e.g. antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has minimal side effects. However, mechanical prophylaxis is not always appropriate for people with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis for people undergoing major amputation and whether this is one treatment alone or in combination with another. This is an update of the review first published in 2013. OBJECTIVES: To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2019. We planned to undertake reference checking of identified trials to identify additional studies. We did not apply any language restrictions. SELECTION CRITERIA: We included randomised controlled trials and quasi-randomised controlled trials which allocated people undergoing a major unilateral or bilateral amputation (e.g. hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We resolved any disagreements by discussion. Outcomes of interest were VTE (DVT and pulmonary embolism (PE)), mortality, adverse events and bleeding. We used GRADE criteria to assess the certainty of the evidence. The two included studies compared different treatments, so we could not pool the data in a meta-analysis. MAIN RESULTS: We did not identify any eligible new studies for this update. Two studies with a combined total of 288 participants met the inclusion criteria for this review. Unfractionated heparin compared to low molecular weight heparin One study compared unfractionated heparin with low molecular weight heparin and found no evidence of a difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35; 75 participants; very low-certainty evidence). No bleeding events occurred in either group. Deaths and adverse events were not reported. This study was open-label and therefore at a high risk of performance bias. Additionally, the study did not report the method of randomisation, so the risk of selection bias was unclear. Heparin compared to placebo In the second study, there was no evidence of a benefit from heparin use in preventing PE when compared to placebo (OR 0.84, 95% CI 0.35 to 2.01; 134 participants; low-certainty evidence). Similarly, no evidence of improvement was detected when the level of amputation was considered, with a similar incidence of PE between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97; 94 participants; low-certainty evidence); and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43; 40 participants; low-certainty evidence). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent PE, all of whom had been on placebo (low-certainty evidence). Bleeding events were reported in less than 10% of participants in both treatment groups, but the study did not present specific data (low-certainty evidence). There were no reports of other adverse events. This study did not report the methods used to conceal allocation of treatment, so it was unclear whether selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis. AUTHORS' CONCLUSIONS: We did not identify any eligible new studies for this update. As we only included two studies in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in people undergoing lower limb amputation. Further large-scale studies of good quality are required.

Grafts for mesenterico-portal vein resections can be avoided during pancreatoduodenectomy.

BACKGROUND: The aim of this study was to assess whether pancreatoduodenectomy (PD) and en bloc mesenterico-portal resection (PD+VR) could be performed with primary venous reconstruction, avoiding a vascular graft. In addition, the short-term surgical outcomes of this approach were compared with a standard PD (PD-VR). STUDY DESIGN: Two hundred twelve patients underwent PD between January 2004 and June 2011. Clinical data, operative results, pathologic findings, and postoperative outcomes were collected prospectively and analyzed. RESULTS: One hundred fifty patients (71%) had PD-VR and 62 patients underwent PD+VR. The majority (82%) of the venous reconstructions were performed with primary end-to-end anastomosis. Only 1 patient had synthetic interposition graft repair. The volume of intraoperative blood loss and the perioperative blood transfusion requirements were significantly greater, and the duration of the operation was significantly longer in the PD+VR group compared with the PD-VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, or grades of complications between the 2 groups. Multivariate logistic regression identified American Society of Anesthesiologists score as the only predictor of postoperative morbidity. Fifty percent of patients with pancreatic adenocarcinoma (n = 101) required VR. A significantly higher rate of positive resection margins (p < 0.001) was noted in the PD+VR subgroup compared with PD-VR subgroup. Furthermore, high intraoperative blood loss and neural invasion were predictive of a positive resection margin. CONCLUSIONS: Pancreatoduodenectomy with VR and primary venous anastomosis avoids the need for a graft and has comparable postoperative morbidity with PD-VR. However, it is associated with an increased operative time, higher intraoperative blood loss, and, for pancreatic ductal adenocarcinoma, a higher rate of positive resection margins compared with PD-VR.

One hundred and seventy-eight consecutive pancreatoduodenectomies without mortality: role of the multidisciplinary approach.

BACKGROUND: Pancreatoduodenectomy offers the only chance of cure for patients with periampullary cancers. This, however, is a major undertaking in most patients and is associated with a significant morbidity and mortality. A multidisciplinary approach to the workup and follow-up of patients undergoing pancreatoduodenectomy was initiated at our institution to improve the diagnosis, resection rate, mortality and morbidity. We undertook the study to assess the effect of this approach on diagnosis, resection rates and short-term outcomes such as morbidity and mortality. METHODS: A prospective database of patients presenting with periampullary cancers to a single surgeon between April 2004 and April 2010 was reviewed. All cases were discussed at a multidisciplinary meeting comprising surgeons, gastroenterologists, radiologists, oncologists, radiation oncologists, pathologists and nursing staff. A standardized investigation and management algorithm was followed. Complications were graded according to the Clavien-Dindo classification. RESULTS: A total of 295 patients with a periampullary lesion were discussed and 178 underwent pancreatoduodenectomy (resection rate 60%). Sixty-one patients (34%) required either a vascular or an additional organ resection. Eighty-nine patients experienced complications, of which the commonest was blood transfusion (12%). Thirty-four patients (19%) had major complications, i.e. grade 3 or above. There was no in-hospital, 30-day or 60-day mortality. CONCLUSIONS: Pancreatoduodenectomy can safely be performed in high-volume centers with very low mortality. The surgeon's role should be careful patient selection, intensive preoperative investigations, use of a team approach, and an unbiased discussion at a multidisciplinary meeting to optimize the outcome in these patients.

Clinical efficacy of metal stents for the treatment of focal abdominal aortic stenosis.

Seven patients (four women and three men) who underwent primary stenting of infrarenal abdominal aortic stenosis over a 4-year period are reported. The patients ranged between 44 and 77 years of age. All were referred for treatment of disabling claudication. Self-expanding stents with balloon assistance were used. A single complication, a retroperitoneal haematoma, requiring surgical intervention occurred in one patient. Patients had either complete resolution of symptoms (five of seven) or a substantial decrease in their claudication symptoms. Primary stenting is a safe and effective treatment for severe abdominal aortic stenosis.

Pattern of equestrian injuries presenting to a Sydney teaching hospital.

BACKGROUND: Equestrian activities are associated with a high rate of injury. Attempts to reduce the incidence and severity of injury require accurate characterization of risk factors and pattern of injury. The present study was performed to analyse the injuries seen at an Australian centre where a large number of equestrian injuries present. METHODS: Data were collected prospectively over a 3 year period on all equestrian injuries presenting to the Prince of Wales -Hospital complex. These data were compared against and combined with retrospectively collected data over the preceding 3 years at the same centre. RESULTS: Two hundred and twenty-one injured equestrians presented (181 consented) in the prospective period of the study, and 208 presented in the retrospective period. Overall, 81% of riders were wearing a helmet at the time of their injury. Helmet use was associated with a significantly lower admission rate (27% vs 55%; P < 0.0001, from combined data). Recreational equestrians had a higher admission rate than professional equestrians, and had a significantly higher head and spine injury rate than the professional group. Rate of helmet use increased from 72% in the retrospective group to 91% in the more recent prospective group, and total admissions decreased from 43% to 14%. CONCLUSION: Significant and serious injuries are associated with equestrian activities, with the higher risk group being recreational equestrians, and riders not using a helmet. The pattern of injury favours head and spine in recreational and non-helmeted riders, and extremities for professional and helmeted riders. Helmet use is still not universal among riders, although an increase in its use may be contributing to an overall reduction in admission rate. Facial and spinal injuries still occurred in helmeted patients.