Unconventional Use of Balloon-Expandable Covered Stent in the Treatment of Iatrogenic Popliteal Pseudoaneurysm.

Popliteal artery pseudoaneurysm is a rare injury occurring in total knee replacement surgeries. The symptoms are usually pain and swelling on the affected side which prompts immediate investigations. Surgical and endovascular interventions are both available options for intervention with covered stents being the preferred choice. In this study, we report the case of a 72-year-old female diagnosed with right popliteal artery pseudoaneurysm following total knee replacement which was managed with the insertion of an Atrium Advanta V12 balloon-expandable covered stent (Atrium Medical Corp., Hudson, NH, USA).

Revacept, an Inhibitor of Platelet Adhesion in Symptomatic Carotid Stenosis: A Multicenter Randomized Phase II Trial.

BACKGROUND: Patients with symptomatic internal carotid artery (ICA) stenosis are at high risk of recurrent ischemic stroke and require early interventional treatment and antiplatelet therapy. Increased bleeding rates might counterbalance the periprocedural efficacy of intensified platelet inhibition. We aim to investigate, whether Revacept, a competitive antagonist of glycoprotein VI, adjunct to standard antiplatelet therapy reduces the occurrence of ischemic lesions in patients with symptomatic ICA stenosis. METHODS: International, multicenter (16 sites), 3-arm, randomized (1:1:1), double-blind, and placebo-controlled study with parallel groups, including patients with symptomatic ICA stenosis. A single infusion over 20 minutes of either placebo, 40 mg or 120 mg Revacept in addition to guideline-conform antiplatelet therapy was evaluated with regard to the exploratory efficacy end point: Number of new ischemic lesions on diffusion-weighted magnetic resonance imaging after treatment initiation. Main clinical outcome was the combined safety and efficacy end point including any stroke or death, transient ischemic attack, myocardial infarction, coronary intervention, and bleeding complications during follow-up. RESULTS: Out of 160 randomized patients, 158 patients (68±10.1 years, 24% female) received study medication (51 patients placebo, 54 patients 40 mg Revacept and 53 patients 120 mg Revacept) and were followed for 11.2±2.3 months. A total of 1.16 (95% CI, 0.88-1.53)/1.05 (95% CI, 0.78-1.42; P=0.629)/0.63 (95% CI, 0.43-0.93) new diffusion-weighted magnetic resonance imaging lesions per patient were detected in the placebo/40 mg/120 mg Revacept groups, without statistical evidence of a difference. A reduction of the combined safety and efficacy end point during the study period was observed in patients who received 120 mg (HR, 0.46 [95% CI, 0.21-0.99]; P=0.047), but not 40 mg Revacept compared with placebo (HR, 0.72 [95% CI, 0.37-1.42]; P=0.343). CONCLUSIONS: Revacept 120 mg reduced the combined safety and efficacy end point in patients with symptomatic ICA stenosis. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique Identifier: NCT01645306.

Resource use within a multidisciplinary foot team clinic.

OBJECTIVE: The establishment of multidisciplinary foot team clinics reduces the risk of amputation, but little is known about its resource requirement. This study evaluates the service's resource use for first visit attendees to an established multidisciplinary foot team clinic. METHOD: A retrospective evaluation was performed for new referrals to the clinic over six months, including demographics, resource use and clinical outcome. Data were extracted electronically with retrospective review of electronic clinical notes. RESULTS: A total of 240 first visit attendees were analysed. Mean age was 64±15years, 63% were male, 72% had type 2 diabetes, 16% had type 1 diabetes, 15% had a previous amputation, and 40% had a previous ulceration. Common presentations were ulcers (62%), osteomyelitis (11%), Charcot foot (19%), foot ischaemia (17%), post-surgical wounds (13%), and osteomyelitis (11%). At first attendance, 79% of patients required specialist services including diabetologist (45%), joint vascular review (23%), joint orthopaedics services (8%), dermatologist (2%), and orthotics services (1%). A total of 4% of patients had complex debridement, 0.4% total nail excision, 0.8% pus drainage, 3% cast-related procedures, and 1% vacuum-assisted dressing. Of the patients, 4% were admitted to hospital, 38% had vascular duplex investigations, 7% had a deep vein thrombosis scan, 16% had magnetic resonance imagine (MRI), and 5% had a bone scan. CONCLUSION: A functional multidisciplinary foot team clinic requires significant resources-both clinical and administrative-for prompt investigations and revascularisation to sustain low amputation rates. Regular appraisal of resource use helps with clinic and pathway planning.

Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study.

AIM: The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. METHODS: Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. RESULTS: Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. CONCLUSIONS: In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.

Peripheral Arterial Disease Located in the Feet of Patients With Diabetes and Foot Ulceration Demands a New Approach to the Assessment of Ischemia.

Peripheral arterial disease (PAD) is common below the knee in diabetes but arteries in the foot are controversially said to be spared of occlusive disease. This is relevant to the convenient site of vascular assessment that is recommended in guidelines. Should assessment be distal at toe/forefoot to detect foot disease or only proximal to detect disease at ankle level? The objective was to determine frequency of PAD at foot and ankle level. This was a cross-sectional observational study, evaluating arterial disease proximally by palpation of pedal pulses and Ankle Brachial Index (ABI), and distally by Toe Brachial Index (TBI), and forefoot transcutaneous oxygen tension (tcpO2), in consecutive patients presenting with foot ulceration. We assessed 301 limbs in 154 patients: 59% of limbs were ulcerated. PAD in the foot was detected in 70% and 74% of limbs by TBI and forefoot tcpO2, respectively, but PAD at ankle level only in 51% and 34% by pulse palpation and ABI, respectively. In limbs with "normal" ABI, PAD was present in the foot in 70% as indicated by low TBI, and in 73% by low tcpO2, with 70% to 64% having associated ulceration, respectively. When compared with arterial waveforms, as a measure of PAD, TBI gave an excellent AUC (area under the curve of the receiver operating characteristic curve) of 0.81 (95% confidence interval: 0.73-0.89), but ABI gave a poor AUC of 0.65 (95% confidence interval: 0.55-0.76). In conclusion, arterial disease is important in the foot and can be detected by TBI, which should be performed even when ABI is normal. Guidelines that recommend TBI only if ABI is artificially raised need updating.

Isolated low toe-brachial index is associated with increased mortality and morbidity: a retrospective cohort study.

OBJECTIVE: The aim was to assess the prognostic impact of perfusion assessments including ankle-brachial Index (ABI) and toe-brachial Index (TBI) on survival of patients who present with diabetic foot ulceration and to analyse clinical outcomes when patients are categorised into three levels of limb ischaemia. METHOD: This was a retrospective cohort analysis of consecutive patients presenting with foot ulceration. Patients continued with their standard of care, after having baseline assessments of limb perfusion. Patients were retrospectively categorised into three groups according to baseline ABI and TBI: Group 1 (n=31) non-ischaemic (TBI≥0.75, ABI≥0.9), Group 2 (n=67) isolated low TBI with foot ischaemia (TBI<0.75, ABI≥0.90) and Group 3 (n=30) foot-leg ischaemia (TBI<0.75, ABI<0.90). RESULTS: A total of 128 patients took part in the study. Low TBI was associated with a significant decrease in patient survival (42±20 versus 51±16 months, p=0.011). There was a progressive and significant decline in mean patient survival time (51±16 versus 44±20 versus 39±22 months, respectively, for ANOVA across the three groups, p=0.04). Patients with isolated low TBI had angioplasty and bypass at a rate similar to that of patients in Group 3 (low ABI and low TBI). The proportion of angioplasties was significantly higher in the isolated low TBI (19.4% (13/67) versus the non-ischaemic 3.2% (1/31), p=0.033). Such revascularisation resulted in ulcer healing within the foot ischaemic group that was similar to the non-ischaemic group (68% versus 60% over 12 months, p=0.454). CONCLUSION: Regardless of ABI level, measurement of TBI identifies patients with isolated low TBI who require specialised care pathways and revascularisation to achieve ulcer healing that is similar to non-ischaemic patients.

Novel Technique for Latero-anterior Approach to the Terminal Peroneal Artery for Bypass Surgery without Fibular Resection.

The peroneal artery (PeA) is often a vital target vessel for lower limb revascularization. Exploring the distal PeA can be challenging via the conventional approaches. We present a new, minimally invasive technique for a latero-anterior approach to the terminal PeA without fibular resection as either a target outflow vessel for open bypass revascularization surgery or, as in this report, the inflow for a crural-pedal bypass in a challenging case of critical limb-threatening ischemia.

Admission Time Deep Swab Specimens Compared With Surgical Bone Sampling in Hospitalized Individuals With Diabetic Foot Osteomyelitis and Soft Tissue Infection.

Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharging ulcer probing to the bone and the subsequent surgical bone sample (SBS) taken during surgical debridement was made. A total of 63 subjects (age 60.8 ± 13.5 years, 75% male, 80% Type 2 diabetes, HbA1C 8.9%±2.2%) were included. The proportion of Gram-positive (DWS 49% v SBS 52%) and Gram-negative (DWS 60% v SBS 60%) isolates was similar between the techniques. However, the overall concordance of isolates between the two techniques was only fair (κ=0.302). The best concordance was observed for Staphylococcus aureus (κ=0.571) and MRSA (κ=0.644). There was a correlation between number of isolates in SBS with prior antibiotic therapy of any duration (r= -0.358, p=0.005) and with the duration of ulceration (r=0.296, p=0.045); no clinical correlations were found for DWS. Prior antibiotic therapy (p=0.03) and duration of ulceration <8 weeks (p=0.025) were predictive of negative growth on SBS. In conclusion, we found only a fair concordance between deep wound swabs acquired at admission and surgical bone specimens in those presenting with a severe diabetic foot infection and features of osteomyelitis. Ensuring early surgical debridement of all infected tissue and obtaining bone specimens should be considered a clinical priority, which may also reduce the likelihood of negative growth on SBS.

Office Based Endovenous Radiofrequency Ablation of Truncal Veins: A Case for Moving Varicose Vein Treatment out of Operating Theatres.

OBJECTIVES: This study aims to assess the efficacy and outcomes at one year after office based endovenous radiofrequency ablation (OBEVRFA) as a standalone procedure for varicose veins under local anaesthesia. METHODS: A retrospective study of prospectively collected data of all OBEVRFAs done in the vascular unit from April 2014 to June 2016 was performed. The demographics, clinical findings, initial venous duplex ultrasound (DUS) findings, the vein ablated, and immediate complications were recorded. Patients were reviewed at six weeks and again if necessary with or without a repeat DUS. The follow up period ranged from 12 to 38 months. Patients undergoing further procedures for symptomatic residual veins within the follow up period were recorded. Average cost and income were obtained from the hospital Patient Level Information and Costing Systems data. RESULTS: A total of 523 limbs were listed for OBEVRFA during the study period. Ninety-four (18%) were cancelled on the day of surgery for various reasons. A total of 429 procedures in 394 patients were performed. There were 35 bilateral cases; each limb performed on separate occasions. The female to male ratio was 1.2:1. The median age was 54 years (range 17-88 years). The CEAP (Clinical, Etiologic, Anatomic and Pathophysiologic) classification was C2 to C3, 291 (68%); C4 to C5, 11 (26%), and C6, 26 (6%). Forty-seven (11%) recurrent varicose veins were treated. There were three recorded cases of endovenous heat induced thrombosis (EHIT). Sixty (14%) patients were lost to follow up. One hundred and five (29%) patients underwent repeat DUS for persistent symptoms. In the follow up period, only 86 patients (23%) needed further multiple avulsions. CONCLUSIONS: OBEVRFAs of the truncal veins for the treatment of varicose veins is safe and effective and could be performed in all suitable patients to free up theatre capacity.

The Diabetic Foot Attack: "'Tis Too Late to Retreat!"

The "diabetic foot attack" is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of "time is tissue" and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.

Recanalisation of Chronically Occluded Remote Superficial Femoral Artery Endarterectomy Through Angioplasty for Limb Salvage.

We report a novel application of balloon angioplasty to recanalise a chronically occluded remote endarterectomy superficial femoral artery. This patient previously had two occluded surgical bypass grafts in an attempt to revascularise the limb and presented with critical limb ischaemia and necrotic foot ulcerations. Following the angioplasty, the patient showed significant improvement in rest pain and healing of the ulcerations. This technique may be useful for limb salvage in patients where surgical options have been exhausted.

Carotid bypass using the Gore Hybrid Vascular Graft as a rescue technique for on-table failed carotid endarterectomy.

Carotid endarterectomy (CEA) remains the "gold standard" for atherosclerotic lesions involving the carotid bifurcation. Carotid bypass grafting using either polytetrafluoroethylene or long saphenous vein is a suitable alternative technique, especially in challenging endarterectomy and on-table failed CEA. We report our initial experience of using the Gore Hybrid Vascular Graft (W. L. Gore & Associates, Flagstaff, Ariz) in six patients as a rescue technique when standard CEA failed.

The diabetic foot: the importance of coordinated care.

Because of the severe morbidity and mortality associated with diabetes, diabetic foot care is an essential component of a peripheral vascular service. The goal of this article is to describe the vascular diabetic foot care pathway and how the coordinated foot care service for diabetic patients is delivered at King's College Hospital, London.

Transformation of the multidisciplinary diabetic foot clinic into a multidisciplinary diabetic foot day unit: results from a service evaluation.

The natural history of the diabetic foot is aggressive and complex. To counteract this, we describe the transformation of a Multidisciplinary Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit, which delivers an emergency open access system for patients, with a "one-stop," same day service in which investigations are performed, results reviewed and treatment implemented. It also provides joint clinics with vascular, orthopaedic, and plastic surgeons and specialized clinics for casting of complex neuropathic feet and for the administration of intravenous or intramuscular antibiotics on the same day. The aim was to document these increasingly wide-ranging facilities by undertaking a retrospective evaluation over a 6-week period, with analysis of notes, investigations, and an anonymous patient satisfaction survey. The clinic was visited by 597 patients who attended in 1076 appointments, of which 112 (10.4%) were emergency visits; these patients attended the clinic without a booked appointment but via an open access policy, 93 of whom were known to the clinic, but 19 were new self-referred patients to the service. Furthermore, 197 (18%) were seen in a Joint Vascular Diabetic Foot Clinic and 98 (9%) were seen in a Joint Orthopaedic Plastic Diabetic Foot Clinic, 570 (53%) were seen in an Active Ulcer Clinic and 97 (9%) in a Total Contact Casting Clinic. Forty-five percent of patients were prescribed antibiotics, including 188 (76%) as oral and 45(18%) as intravenous antibiotics and 15(6%) as intramuscular injections. Of the 1076 appointments, 150 (14%) patients were in the foot clinic for more than 4 hours. Sixty (10%) patients were reviewed 4 or more times over the 6-week period. Only 22 (2%) were admitted to hospital. Of the 125 survey responders, 98% were satisfied with this service, which has evolved from a Diabetic Foot Clinic into a Multidisciplinary Diabetic Foot Day Unit.

Multimodal intraoperative monitoring: an observational case series in high risk patients undergoing major peripheral vascular surgery.

Recent guidelines from the National Institute of Health and Care Excellence (NICE) and the UK National Health Service (NHS) have stipulated that intraoperative flow monitoring should be used in high-risk patients undergoing major surgery to improve outcomes and reduce costs. Depth of anaesthesia monitoring is also recommended for patients where excessive anaesthetic depth is poorly tolerated, along with cerebral oximetry in patients with proximal femoral fractures. The aims of this descriptive case series were to evaluate the impact of a multimodal intraoperative strategy and its effect on mortality and amputation rate for patients with critical leg ischaemia. In an observational case series, 120 elderly patients undergoing major infra-inguinal bypass between 2007 and 2012 were included in this retrospective analysis of prospectively collected data. Nominal cardiac output (nCO, LiDCOrapid, LiDCO Ltd, UK), bispectral index to monitor depth of anaesthesia (BIS, Covidien, USA) and cerebral oxygenation, rSO2 (Invos, Covidien, USA) readings were obtained before induction of general anaesthesia and throughout surgery. 30 day, 1-year mortality and amputation rates were analysed. Demographics and physiological parameters including correlation with V-POSSUM, age, gender and other co-morbidities were statistically analysed. Thirty-day mortality rate was 0.8% (n = 1). V-POSSUM scoring indicated a predicted mortality of 9%. Amputation rate was less than 2% at one year. Only 8% of patients (10 of 120) were admitted to a high dependency unit (HDU) postoperatively. 30-day mortality in our case series was lower than predicted by V-POSSUM scoring. Use of multimodal intraoperative monitoring with the specific aim of limiting build-up of oxygen debt should be subjected to a randomised controlled study to assess the reproducibility of these results.

The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome.

OBJECTIVE: This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI). METHODS: Between 2004 and 2011, patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. Angiography was used to divide the pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary end points were patency rates at 12 months, amputation-free survival at 48 months, and the rate of healing and time to healing of foot tissue loss. RESULTS: A total of 154 patients (75% men) with CLI underwent 167 infrapopliteal bypasses. Patients were a median age of 75 years (range, 46-96 years). Diabetic mellitus was present in 76%, chronic renal failure in 28%, and ischemic heart disease in 44%. The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264). CONCLUSIONS: The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.

Outcome of lower limb distal bypass in Afro-Caribbean populations.

There is little data on outcome following lower limb bypass surgery in ethnic minorities in the United Kingdom. We looked at the results of distal bypass surgery in Afro-Caribbeans (AFCs) and compared it to caucasians (CAs). Patients undergoing distal bypass between 2004 and 2009 were analyzed. Life table analyses and log rank were used to compare graft patency and amputation-free survival. A total of 86 CA and 39 AFC patients, with a median age of 78 years and 73 years, respectively (P = .01), underwent bypass. There were more women in AFC groups (41.1%) compared to CA group (19.2%, P = .01). Tissue loss as indication for surgery was more in AFC than in CA group (92.3% vs73.9%, P = .03). Primary, primary-assisted and secondary patency rates, and amputation-free survival at 12 months for AFCs compared to CAs (51.3 vs 44.6; 85.2 vs 80.9; 91.2 vs 84.4; and 84.9 vs 75.1). Graft patency after lower limb distal revascularization in AFCs is comparable to CAs.

Outcome of infra-inguinal bypass grafts using vein conduit with less than 3 millimeters diameter in critical leg ischemia.

OBJECTIVE: The purpose of this study was to evaluate the difference in amputation-free survival and patency rates of infra-inguinal bypass grafts in patients with critical leg ischemia (CLI) with vein conduits with an internal diameter <3 mm compared to those with vein conduits with a diameter of ≥ 3 mm. METHODS: Retrospective analysis of all consecutive patients with CLI undergoing infra-inguinal bypass. Preoperative duplex scan mapping and measurement of potential vein grafts were performed on all patients. Patients were recruited in a 1-year duplex scan graft surveillance program. Primary end points were amputation-free survival and patency rates at 1 year postoperatively. Kaplan-Meier and χ(2) test were used for statistical analysis. RESULTS: Between January 2004 and April 2010, 157 consecutive patients with CLI underwent 171 bypasses using vein conduits (111 men, 46 women; median age, 75 years; range, 45-96 years). Ninety-three bypasses (54.4%) were performed for tissue loss, 44 (25.7%) for gangrene, and for rest pain. Of the 157 patients, 113 (72.0%) had diabetes mellitus, 40 (25.5%) had renal impairment, 131 (83.4%) had hypertension, and 64 (40.8%) had ischemic heart disease. Femoro-popliteal bypass was performed in 38 cases (22.2%), whereas 133 (77.8%) of the bypasses were femoro-distal. Autogenous great saphenous vein (GSV) was used in all cases. All grafts were reversed. The diameter of 31 (18%) vein conduits measured <3 mm (range, 2-2.9 mm) on preoperative duplex scan. One hundred thirty-four grafts had at least 1-year follow-up. The primary, assisted primary, and secondary patency rates at 1 year for vein conduits <3 mm were 51.2%, 82.6%, and 82.6%, respectively, compared to 68.4%, 93.3%, and 95.2%, respectively, in the ≥ 3 mm group. This was only significant for the secondary patency (P = .0392). The amputation-free survival at 48 months was 70.8% for vein conduits <3 mm and 57.3 for vein conduits ≥ 3 mm. CONCLUSION: This series has shown that primary and assisted primary patency rates in small veins are not significantly different at 1 year but the secondary patency rates are better in the larger veins. Similarly, the amputation-free survival was also comparable. The authors would, therefore, advocate the use of small veins >2 mm in diameter in patients with CLI. Duplex scan surveillance followed by early salvage angioplasty for threatened grafts is needed to achieve good patency rates in both groups.

Cerebral monitoring in patients undergoing carotid endarterectomy using a triple assessment technique.

OBJECTIVES: Selective shunting during carotid endarterectomy (CEA) is advocated to reduce shunt related stroke. Cerebral monitoring is essential for temporary carotid shunting. Many techniques are available for cerebral monitoring, however, none is superior to monitoring the patient's neurological status (awake testing) while performing the procedure under local anaesthesia (LA). Cerebral oximetry (CO) and trans-cranial Doppler (TCD) has previously been used to show the adequacy of cerebral circulation in patients undergoing CEA. The aim of this study is to assess the reliability of CO and TCD in predicting the need for shunting compared to the awake testing. METHODS: Patients scheduled for CEA under LA were included. Patients converted to general anaesthesia (GA) and patients with no TCD window were excluded from the study. The Somanetics INVOS(®) CO was used for ipsilateral cerebral monitoring in all patients, in addition to TCD and awake testing. The percentage fall in CO regional oxygen saturation (rSO(2)), and decline in the mean flow velocity (FVm) in TCD following carotid artery clamping recorded. A drop in rSO(2) of ≥20% or FVm of ≥50% was considered an indicator of cerebral ischaemia that may predict the need for carotid shunting. Patients only shunted based on awake testing. RESULTS: Forty-nine patients underwent triple assessment. The median clamp time was 24 min. 8/49 patients (16.3%) needed carotid shunting based on awake testing. In this group, six patients had ≥20% drop in rSO(2), and ≥50% drop in FVm. However, two patients had a non-significant drop in both rSO(2) and FVm (false negative). In the non-shunted group (41/49), one patient had a significant drop in rSO(2) (false positive) while 10/41 patients had a >50% drop in FVm. This represents sensitivity of 75%, and specificity of 97.5% for CO compared to sensitivity of 75% and specificity of 75% for TCD in prediction of shunting. The positive predictive value and negative predictive value were 85.7 and 95.2%, respectively for CO, compared to 37.5 and 93.9% for TCD. CONCLUSIONS: TCD is less accurate than CO in predicting the need for carotid shunting during CEA. A combination of both methods does not add to the accuracy of detecting the need for carotid shunting.