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The purpose of this study was to determine whether surgeons without formal radiological training are able to assess suitability of patients with ruptured abdominal aortic aneurysms (AAA) for EVAR. The CT scans of 20 patients with AAA were reviewed under timed conditions by six vascular surgeons. Twenty minutes was allocated per scan. They were asked to determine if each aneurysm would be treatable by EVAR in the emergency setting and, if so, to measure for device selection. The results were then compared with those of a vascular radiologist. Six surgeons agreed on the suitability of endovascular repair in 45% of cases (95% CI, 23.1-68.5%; 9/20 scans; kappa = 0.41 [p = 0.01]) and concurred with the radiologist in eight of these. Individually, agreement ranged from 13 to 16 of the 20 scans, 65-80% between surgeons. The kappa value for agreement between all the surgeons and the radiologist was 0.47 (p = 0.01, moderate agreement). For the individual surgeons, this ranged from 0.3 to 0.6 (p = 0.01). In conclusion, while overall agreement was moderate between the surgeons and the radiologist, it is clear that if surgeons are to assess patients for ruptured EVAR in the future, focused training of surgical trainees is required.

Background: Because subintimal angioplasty (SA) is a technique that can achieve recanalization of long arterial occlusions, it is considered an alternative to lower limb bypass operations. The aim of this prospective study was to identify the risk factors that affect patency of SA in patients suffering from critical limb ischemia (CLI)., Methods and Results: 51 consecutive infrainguinal SA were done in 46 patients suffered from CLI. The patients were followed-up with regular duplex scans up to 12 months post-intervention. Sex, atherosclerosis risk factors, and some technical details of the procedure (number of patent run-off vessels after the procedure, length and re-entry point of angioplasty) were examined as potential risk factors of patency, using survival analysis statistical techniques. The overall patency rate at 12 months post-intervention was 50%. According to Cox-regression analysis, the factors that affect patency were the number of run-off vessels and the length of occlusion. Patients with two or three run-off vessels had a hazard of occlusion of 0.30 (P = .027) compared to those who had one run-off vessel. The 12-months patency in patients with more than one run-off vessels was 81% vs. 25% in patients with one run-off vessel. Regarding the length of angioplasty, the hazard of reocclusion was 1.02 for every centimeter of occlusion (P = .049)., Conclusions: The number of patent run-off crural vessels after the angioplasty and the length of occlusion are significant risk factors for reocclusion of infrainguinal SA in patients with CLI. Trying to recanalize more than one run-off vessels could raise the SA patency.

Objectives: To describe our experience with iatrogenic arterio-venous fistula (AVF) occurring during lower limb subintimal angioplasty, their management and the final clinical, radiological outcome., Design: Retrospective review of case series from two centres, from a computerised database over a period of five years., Material: Twelve patients whose lower limb subintimal angioplasty was complicated by Iatrogenic AVF., Results: The Majority of AVF occurred at the popliteal trifurcation vessels. And the incidence of this complication in our case series was 0.8%. This was managed with a variety of techniques-Coil embolisation, balloon tamponade, alternative dissection and stent placement. In one patient, the fistula was left open intentionally. All twelve patients had a successful angioplasty. The overall technical success rate for AVF ablation was eighty percent., Conclusions: AVF is a potential complication of angioplasty. The majority can be managed by endovascular means during the angioplasty procedure with good technical success.

Objective: To investigate the value of duplex ultrasound scanning (DUSS) in the routine follow up of patients following EVAR., Methods: Imaging was reviewed for 310 consecutive patients undergoing EVAR at a single centre. Concurrent ultrasound and CT scans were defined as having occurred within 6 months of each other. There were 244 paired concurrent DUSS and CT scans which were used for further analysis. These modalities were compared with respect to sensitivity, specificity, positive and negative predictive values and level of agreement (by Kappa statistics) using CT as the 'gold standard'., Results: DUSS failed to detect a number of endoleaks which were seen on CT and the sensitivity of this test was therefore poor (67%). However, the specificity of DUSS compared more favourably with a value of 91%. Positive predictive values ranged from 33-100% but negative predictive values were more reliable with values of 91-100% at all time points post operatively. There were no type I leaks, or endoleaks requiring intervention which were missed on DUSS. Overall, there was a 'fair' level of agreement between the two imaging modalities using Kappa statistics., Conclusion: Although DUSS is not as sensitive as CT scanning in the detection of endoleak, no leaks requiring intervention were missed on DUSS in this study. DUSS is much cheaper than CT and avoids high doses of radiation. DUSS therefore remains a valuable method of follow up after EVAR and can reduce the need for repeated CT scans.

Background: This was a retrospective study of the effectiveness of open, retrograde angioplasty/stenting of supra-aortic arterial stenoses combined with transcranial Doppler-directed dextran therapy in preventing perioperative embolization., Methods: Eight patients underwent angioplasty/stenting of the proximal common carotid (synchronous carotid endarterectomy (CEA) in six), while four underwent angioplasty/stenting of the innominate artery (synchronous CEA in one). Open exposure of the carotid bifurcation enabled temporary carotid clamping to protect the brain from procedural embolization. Dextran was administered to patients with a high rate of embolization on transcranial Doppler after the operation., Results: No emboli were recorded in the cerebral circulation during the actual angioplasty procedure when the internal carotid artery was clamped. After operation three patients developed high-rate embolization and received dextran. No strokes or deaths occurred within 30 days of treatment. One patient developed symptoms and a recurrent stenosis greater than 50 per cent during follow-up and was treated by redo angioplasty., Conclusion: Retrograde angioplasty/stenting with or without synchronous CEA offers an alternative approach to treating patients with supra-aortic inflow disease., (Copyright (c) 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Purpose: To determine the feasibility of synchronous superficial venous surgery and on-table subintimal angioplasty in the treatment of venous ulcers with arterial compromise., Methods: Between January 1992 and December 2004, 9 patients (8 women; median age 83 years, range 72-92) underwent the synchronous procedure. No patient had deep venous reflux; 4 patients presented with rest pain and 2 were diabetic. Their medical records were retrospectively reviewed to gather data on clinical assessment, ankle-brachial index (ABI), lower limb arterial and venous duplex scans, and treatment variables., Results: Angioplasty was technically successful (median ABI improvement 0.31, range 0.23-0.34) in all procedures, which lasted a median 85 minutes (range 60-160). The procedure was performed under general anesthesia in 7 patients, local in 1, and spinal in 1. Superficial venous surgery was performed first in 8 patients: 6 had great saphenous vein (GSV) ligation without stripping, followed by subintimal angioplasty, and 1 also had small saphenous vein (SSV) ligation. One patient underwent SSV ligation first, followed by angioplasty; another had GSV disconnection and stripping, followed by angioplasty. In 1 patient, angioplasty preceded GSV surgery. One patient required repeat angioplasty 1 week later for re-occlusion. All ulcers healed (median 4 months, range 1-36). Five patients died during a median 32-month follow-up (range 4-82) from unrelated causes; there was 1 ulcer recurrence at 3 years in a patient who declined further investigation and treatment., Conclusions: Simultaneous superficial venous surgery and on-table subintimal angioplasty is a safe and novel strategy in the management of a select subgroup of patients with venous ulcers and coexistent arterial compromise.

Purpose: To evaluate the clinical outcome of subintimal angioplasty in diabetic patients with critical limb ischemia (CLI) compared to nondiabetics irrespective of the patency status of the treated arteries., Methods: The records of 99 consecutive patients (53 men; median age 78.5 years, range 42-92) suffering from CLI who underwent primary infrainguinal subintimal angioplasty in 112 limbs within a 6-month period were studied retrospectively. A third of the patients (n=33) were diabetic. The technical success, perioperative morbidity/mortality, and clinical success were compared between the diabetic and nondiabetic patients. Kaplan-Meier life-table analysis was used to analyze clinical success, limb salvage, and survival for both groups., Results: The overall technical success was 89% (81% in diabetics, 93% in nondiabetics, p=0.05). Perioperative morbidity was 8% (16.7% in diabetics, 3.9% in nondiabetics, p=0.03). The perioperative mortality was zero. The clinical success at 12, 24, and 36 months was 74%, 72%, and 65% in nondiabetics and 69%, 63%, and 54% in diabetics, respectively (p=0.17). The limb salvage rate at 36 months was 88% overall (90% in nondiabetics, 82% among diabetics, p=0.20). The 36-month survival rate was 61% in nondiabetics and 57% in diabetics (p=0.29)., Conclusions: In terms of clinical outcome, infrainguinal subintimal angioplasty is almost equally effective in diabetics as in nondiabetics suffering from CLI.

Objectives: to determine the incidence of early complications following percutaneous transluminal angioplasty and to describe their management and outcome., Materials: five hundred and fifty consecutive patients undergoing angioplasty of 648 limbs, containing 1053 anatomical segments during a two year period were reviewed retrospectively., Results: early complications affected 109 segments (10%) in 92 limbs (14%) of 84 patients (15%). Of the 109 segments affected by early complications, 106 (97%) were managed by endovascular techniques with surgery being required on only three (3%) occasions. There were no deaths attributable to angioplasty., Conclusions: although early complications occur in 14% of limbs undergoing percutaneous transfemoral angioplasty, the majority (97%) can be managed by endovascular techniques.

Background: Peripheral angioplasty is increasingly the first choice intervention in patients with peripheral vascular disease. The aim of the current study was to audit prospectively all major complications, especially the requirement for emergency surgical intervention., Patients and Methods: A prospective audit of outcome after peripheral angioplasty in 988 patients undergoing 1377 interventional procedures between 1 October 1995 and 30 September 1998 at which 1619 vessel segments were angioplastied., Results: Major medical morbidity (bronchopneumonia, stroke, renal failure, myocardial infarction) complicated 33/1377 procedures (2.4%). Emergency surgical intervention was required after 31/1377 procedures (2.3%) with the commonest aetiologies being acute limb ischaemia and haemorrhagic complications. The amputation rate following angioplasty was 0.6% and no patient presenting with claudication or graft complications underwent amputation. The amputation rate following angioplasty for critical limb ischaemia was 2.2%. Overall, the risk of death and/or major medical complication and/or requiring emergency surgical intervention was 3.5%. The rate of complications was no different for subintimal as opposed to transluminal angioplasties., Conclusions: Peripheral angioplasty is associated with a low risk of major medical and surgical complications.

In peripheral vascular disease, iliac occlusions are one of the most difficult lesions to treat, because of the frequency with which dissection occurs from an ipsilateral approach. We describe a technique of subintimal recanalization of iliac occlusions by a combined ipsilateral and contralateral approach.

Examines the complication of percutaneous transluminal angioplasty in the legs. Indications for angioplasty; Percentage of patient having renal failure; Incidence of retroperitoneal bleeding.

SummaryBackground: The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA). Methods: Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters. Results: Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle : brachial pressure index was 0·86 (0·52–1·10) before dilatation and 1·00 (0·83–1·40) immediately after dilatation (P = 0·0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures. Conclusion: It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone. [ABSTRACT FROM AUTHOR]

Aims: Primary angioplasty (PTA), stenting and surgical revascularization have all been advocated for the treatment of iliac occlusions. The aim of the study was to review the long-term outcome of a policy of primary angioplasty with salvage stenting as the first-line treatment for iliac occlusions. Methods: Between 1996 and 2000, 90 patients underwent PTA for iliac occlusions in 94 limbs (median age 65 (43–88) years). Presenting symptoms were claudication in 79 and critical limb ischaemia in 15. There were 16 diabetics. Short-term complications and long-term outcome for the patient cohort were defined by clinical follow-up. Results were quantified by life table analysis, and groups were compared by the Kaplan–Meier test. Results: Technical success was obtained in 77 per cent of the patient group. Salvage stent placement was utilized in 17 per cent of the cases. There were five immediate complications that required surgical intervention (5 per cent) and one death within 30 days (1 per cent). Cumulative limb salvage, patient survival and symptom recurrence rates at 1 and 4 years were 99, 89 and 39, and 99, 64 and 41 per cent, respectively. There was a significant difference in symptom recurrence between those patients having PTA of the CIA when compared to the EIA (12-month symptom recurrence rates, 27 per cent CIA versus 47 per cent EIA, P = 0.025). Mode of presentation, run off and presence of diabetes did not affect symptom recurrence (P > 0.05). Conclusion: Recurrent symptoms are common following PTA of external iliac occlusions. These lesions may be better treated with surgical revascularization. [ABSTRACT FROM AUTHOR]

Examines the role of subintimal angioplasty in treating arterial disease with severe lower limb ischaemia. Risk factors in the treatment of arterial disease; Exhibition of complications by angioplasty; Effectiveness of the procedure for treating crural vessels.