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Abstract: Objective: To compare 1-year potencies’ of heparin-bonded PTFE [(Hb-PTFE) (Propaten®)] grafts with those of ordinary polytetraflouroethylene (PTFE) grafts in a blinded, randomised, clinically controlled, multi-centre study. Materials and methods: Eleven Scandinavian centres enrolled 569 patients with chronic functional or critical lower limb ischaemia who were scheduled to undergo femoro–femoral bypass or femoro–poplitaeal bypass. The patients were randomised 1:1 stratified by centre. Patency was assessed by duplex ultrasound scanning. A total of 546 patients (96%) completed the study with adequate follow-up. Results: Perioperative bleeding was, on average, 370 ml with PTFE grafts and 399 ml with Heparin-bonded PTFE grafts (p = 0.32). Overall, primary patency after 1 year was 86.4% for Hb-PTFE grafts and 79.9% for PTFE grafts (OR = 0.627, 95% CI: 0.398; 0.989, p = 0.043). Secondary patency was 88% in Hb-PTFE grafts and 81% in PTFE grafts (OR = 0.569 (0.353; 0.917, p = 0.020)). Subgroup analyses revealed that significant reduction in risk (50%) was observed when Hb-PTFE was used for femoro–poplitaeal bypass (OR = 0.515 (0.281; 0.944, p = 0.030)), and a significant reduction in risk (50%) was observed with Hb-PTFE in cases with critical ischaemia (OR = 0.490 (0.249; 0.962, p = 0.036)). Conclusion: The Hb-PTFE graft significantly reduced the overall risk of primary graft failure by 37%. Risk reduction was 50% in femoro–poplitaeal bypass cases and in cases with critical ischaemia. [Copyright &y& Elsevier]

Aim: Background: The aim of this study was to estimate the cost effectiveness of screening for abdominal aortic aneurysm (AAA). Material and methods: All 12,639 men born in the years 1921–1933 (aged 64–73) living in Viborg County, Denmark, were randomly allocated either to receive an invitation to abdominal ultrasound scanning for AAA or to be controls. Costs for screening and surveillance were assessed prospectively. Diagnosis Related Group (DRG) costs from 1999 were used concerning admissions with uncomplicated and complicated operations. Admissions for AAA surgery were retrospectively classified according to complications in patient records. Results: Mean follow-up time was 52 months. 76.6% of invited men attended screening, and 191 (4.0%) had an AAA. As previously reported, the cumulative 5-year AAA-specific mortality in the invited group was significantly reduced by 67% compared to the control group (P=0.003). The costs were estimated to be €11.23 per scan. The costs per life-year saved were €9057 (€5872–20,063) after 5 years, and were expected to decrease to €2708 (€1758–6031) after 10 years and to €1825 (€1185–4063) after 15 years. Conclusion: Screening of 64–73 years old males in Denmark seems cost effective. [Copyright &y& Elsevier]

The article reports that in Danish men 64-73 years of age, screening for abdominal aortic aneurysm (AAA) reduced specific mortality caused by AAA but not all cause morality. In men 64-73 years of age, about 3 AAA related deaths were averted for every 1000 men invited for screening. However, the 75% reduction in emergency surgery among the screened population was offset by a 3-4 fold increase in the total number of aneurysm procedures. Because the cost effectiveness of screening is highly dependent on the underlying prevalence, screening a population with a low level of opportunistic identification of AAA and high prevalence will be most cost effective.

The lethality of ruptured abdominal aortic aneurysm (AAA) is 80-95% compared to 5-6% after elective surgery. However, AAA seldom causes symptoms before rupture. From 1994 to 1998, 12,639 men aged 64-73, from Viborg County, were randomised 1:1 for an invitation to an ultrasonographic scan or for controls. There were 75% fewer emergency operations (P < 0.001), and 67% lower AAA-specific mortality in the screening group (P = 0.002). The costs were 6,221 pounds sterling (4,034-13,782) per saved living year, expected to decrease to about 1,860 pounds sterling after 10 years. Screening of Danish men, aged 65-73, is recommended.

Introduction: The hospital costs and benefits of screening older males for abdominal aortic aneurysms (AAA) are unknown., Material and Methods: In 1994, a hospital-based screening trial of 12,658 65-73-year-old males in the County of Viborg, Denmark, was started. AAA > 5 cm were referred for surgery. The remaining AAA were offered annual control scans. Those with aortic ectasia (def.: 2.5-2.9 cm) were rescreened at 5-year intervals. AAA-operations and deaths of AAA at hospital were registered. Finally, costs of screening, surveillance, and treatment were registered. Data on causes of death outside hospitals could not be obtained., Results: The attendance rate was 76%, of whom 191 (4.0%) had AAA. The average observation time was 5.13 years. 60 in the screened and 41 in the control group were operated (P = 0.06), 7 and 27 were operated as an emergency (P < 0.001), and 6 and 19 died at the hospitals due to AAA (p = 0.009). The costs per scan were 83.50 DKK, 81,400 DKK per elective operation (71,485 DKK after screening), and 117,000 DKK for an emergency operation. The costs per prevented hospital death were 67,855 DKK or approx. 7,540 DKK per life year saved (1 GBP = 12 DKK)., Discussion: Screening older males for AAA in Denmark seems very cost-effective and reduces hospital mortality of AAA by 68% and probably the overall AAA-specific mortality by 73%.

Introduction: Macrolide treatment has been reported to reduce the risk of recurrent ischaemic heart disease. The influence of a macrolide on the expansion rate of small abdominal aortic aneurysms (AAA) is unknown at present. The aim of this study was to investigate the effect of roxithromycin on the expansion rate of small AAA., Materials and Methods: A total of 92 patients with a small AAA were recruited from two populations. One population consisted of 6.339 men aged 65-73 years who were offered participation in a mass screening programme for AAA at the local hospital. From this population 66 subjects were recruited. The remaining 26 were recruited from among 49 subjects diagnosed at interval screening for an initial aortic diameter between 25 mm and 29 mm. The patients were randomized to receive either oral roxithromycin 300 mg once daily for 28 days or matching placebo, and followed for a mean of 1.5 years., Results: During the first year the mean annual expansion rate of AAA was reduced by 44% in the macrolid group (1.56 mm/year) compared to 2.80 mm/year after placebo (p = 0.02). During the second year the difference was only 5%. Multiple linear regression analysis showed that roxithromycin treatment and initial AAA size were significantly related to AAA expansion when adjusted for smoking, diastolic blood pressure, and IgA level > or = 20. The logistic regression analysis confirmed a significant difference in expansion rates above 2 mm annually between the intervention and placebo groups, OR = 0.09 (95% CI: 0.01-0.83)., Discussion: In comparison to placebo, roxithromycin 300 mg daily for four weeks reduced the expansion rate of AAA.

Objective: Three proteolytic systems seem involved in the aneurysmal degradation of the aortic wall. Plasmin is a common activator of the systems and could thus be predictive for the progression of abdominal aortic aneurysms (AAAs)., Methods and Materials: In 1994, 112 of 141 male patients with AAA diagnosed through population screening (defined as 3 cm or more) were interviewed and examined and had blood samples taken. One hundred twelve cases were scanned annually for 1 to 5 years (mean, 2.5 years) and referred for surgery if the AAA exceeded 5 cm in diameter. A random sample of 70 of the 112 cases had P-plasmin-antiplasmin-complexes (PAPs), P-plasminogen, and S-elastin-peptides (SEPs)., Results: PAP was positively correlated with annual expansion rate (r = 0.39, 0.16-0.56), persisting after adjustment for initial AAA size, SEP, age, and smoking. However, PAP levels did not correlate with the initial AAA size or SEP. Furthermore, PAP levels were significantly predictive for cases expanding to operation-recommendable AAA sizes. Combined with the initial AAA size, both optimal sensitivity and specificity were 82%, increasing to 95% and 96%, respectively, excluding those lost to follow-up and accepting 2 mm of interobserver variation., Conclusion: The progression of AAA is correlated with the PAP level, which seems to have a predictive value similar to the best serologic predictor known, serum-elastin-peptides.

Introduction: The aim of the study was to estimate the direct cost of an abdominal aortic aneurysm (AAA) repair and to validate it against the national Diagnostic Related Group (DRG) costs., Material: Over a three-year period, between January 1996 and December 1998, a total of 100 men were selected at random from a series of 197 patients treated with open surgery for (AAA) at the Department of Vascular Surgery, Viborg Hospital., Results: The total cost of an AAA operation without complications was estimated to be 70,000 DKK, compared to the DRG price of 79,000 DKK. Complications were significantly more frequent after emergency repair (odds ratio = 4.3 (95% CI; 1.9-10.1)). A statistically significant difference was seen in the cost of AAA repair between elective and emergency operations with rupture (p < 0.05), mainly because of the longer stay in hospital., Discussion: The estimated cost is sufficiently reliable to be used in analysis of cost-effectiveness.

Introduction: Screening and observation of abdominal aortic aneurysms (AAA) produce psychological stress. Consequently, safe and optimal intervals of rescreening and observation must be developed., Method: In a randomised, mass screening trial of 6,339 men aged, 65-73 years from 1994 to 1998, 76% attended, and 191 (4%) had AAA > or = 3 cm. Twenty-four (0.5%) had AAA above 5 cm in diameter and were referred for surgery, while the rest were offered annual control. Later, all 348 (7.5%) men who, 3 to 5 years before, had had an ectatic aorta (an infrarenal aortic diameter of 25-29 mm or a distal/renal aortic diameter ratio of > 1.2) were offered rescreening, together with a control group of 380 men., Results: None of the controls had developed AAA. Of those who initially had an aortic diameter of 25-29 mm aorta, 28.5% had developed AAA (size range 30-48 mm), whereas only 3.5% with a ratio > 1.2 developed AAA (size range 30-34 mm). During the fourth year of surveillance some AAA initially sized below 3.5 cm expanded to above 5 cm, whereas this occurred in some sized 3.5-3.9 cm during the second year and in most above 4 cm did during the first year of observation., Conclusion: Rescreening for AAA can be restricted to initially ectatic aortas sized 25-29 mm at five-year intervals. Observation of small AAA can be restricted to 1-4 year intervals.

Background: The aim of the paper is to compare the epidemiology, risk factors and manifestations of iliac and abdominal aortic aneurysms., Methods: Two studies were used: 1. 5,470 65-73-year-old men invited for screening for abdominal aortic aneurysms. 2. Review of all 350 patients operated on for central aneurysms in the county of Viborg, Denmark from 1989-1997., Results: 4,176 attended for screening. One hundred and seventy (4.0%) had an abdominal aortic aneurysm. Twenty-one (0.56%) needed operation. The proportion of patients with common iliac aneurysms requiring surgery was 0.17%. The operative incidence of iliac aneurysm was 18.4 per million per year, and 92.4 per million per year were operated on for abdominal aortic aneurysm. The mean serum cholesterol level for isolated iliac aneurysm and combined aneurysms was significantly lower compared to isolated abdominal aortic aneurysm (p<0.05). Urological symptoms were present in 42% of cases with isolated iliac aneurysm, and 25% of combined aneurysms compared to 8% of isolated abdominal aortic aneurysms. Fifty-eight percent of the isolated iliac aneurysms were ruptured, as against 27% of the abdominal aortic aneurysms. The peri- and postoperative mortality was 57% in ruptured isolated iliac aneurysms, 47% in ruptured combined aneurysms, and 31% in ruptured isolated aortic aneurysms., Conclusions: Iliac aneurysms seem to be more underdiagnosed than abdominal aortic aneurysms, and are often diagnosed because of clinical manifestations, especially urological, or rupture. Iliac aneurysms seem more lethal than those of the abdominal aorta in cases of rupture.

The objective of the study was to compare emergency operations for ruptured abdominal aortic aneurysm (RAAA) by a mobile operation team, with operation for RAAA carried out at our vascular unit. During a five year period (1993-1998), 18 emergency operations were carried out for abdominal aortic aneurysm (AAA) with rupture at the primary receiving hospital with assistance from a mobile operation team. In the same period 82 aneurysms with rupture were resected at our vascular surgical unit. Preoperatively, patients operated at the primary receiving hospitals had significantly lower blood pressure (P < 0.05) and an intraoperative higher blood loss (P < 0.05). Furthermore, postoperative complications tended to be higher among patients operated at hospitals without a vascular unit. consequently, the mortality was 67% compared to 47% in the department. However, 1/3 of the patients operated by the mobile operation team survived. Consequently, haemodynamically unstable non-transportable patients with an RAAA should be considered for surgery by a mobile operation team.

The relationship between abdominal aortic aneurysms (AAA) and chronical obstructive pulmonary disease (COPD), and in particular the suggested common elastin degradation caused by elastase and smoking was analysed by a cross sectional population mass screening study for AAA, and a prospective cohort study of small AAA. All previous computer-hospital-recorded diagnoses were received concerning 4,404 men invited to screening for AAA. One hundred and forty-one had AAA (4.2%). They were asked for an interview, a clinical examination, and a blood sample. Men with an AAA of 3-5 cm were offered annual control-scans to check for expansion. Of COPD-patients, 7.7% had AAA (crude OR = 2.05), however the adjusted OR was only 1.53 after adjusting for other co-existing diseases (p = 0.13). The mean annual expansion was 2.74 mm per year in COPD patients and 2.72 in non-COPD patients, and 4.7 mm in oral steroid-users compared to 2.6 in non-steroid-users (p < 0.05). S-elastin-peptides (SEP) and P-elastase-alpha1-antitrypsin-complexes (PEAC) were negatively correlated to FEV1 in COPD-patients. However, SEP, beta-agonist-treatment, and FEV1 was positively correlated to expansion by multivariate regression analysis, while PEAC and S-alpha1-antitrypsin did not influence expansion, suggesting elastase plays a major role in the pathogenesis of COPD but not in AAA. The high prevalence of AAA among patients with COPD is more likely to be caused by medication and coexisting diseases rather than a common pathway of pathogenesis.

BACKGROUND: The potential correlation between chronic infection with Chlamydia pneumoniae and the progression of small abdominal aortic aneurysms (AAAs) and lower limb atherosclerosis was studied. METHODS: Mass screening for AAA was carried out in outdoor clinics at all hospitals in the county. Some 139 men (aged 65-73 years) with a 3.0-4.9-cm AAA were followed prospectively for 1-3 (mean 2.7) years. Initially, an interview and examination was performed, and blood samples were taken. RESULTS: Some 62 per cent (53-71 per cent) had an immunoglobulin (Ig) A level of 40 or more, or an IgG level of 64 or above. Some 83 per cent (74-93 per cent) had an IgA level of 20 or more, or an IgG level of 32 or more. Men with an IgA level of 20 or more had 51 per cent greater AAA expansion and men with an IgA level of 40 or above had 24 per cent more expansion. An IgA level of 20 or more, or IgA of 40 or greater, were significant independent predictors of AAA expansion adjusted for age, smoking, initial AAA size, steroid treatment, diastolic blood pressure, pulmonary function and other plasma factors. The ankle blood pressure index (ABI) of the IgA-seropositive men decreased 11 per cent, while the ABI decreased by 5 per cent among IgA-seronegative men (P < 0.05). The significant difference persisted after adjusting for age, smoking, initial systolic ankle blood pressure, initial brachial systolic or diastolic blood pressure, but disappeared after adjusting for low-density lipoprotein (LDL) levels. CONCLUSION: A high proportion of men with a small AAA have signs of chronic C. pneumoniae infection. The progression of AAAs and lower limb atherosclerosis seems to be correlated to chronic infection with C. pneumoniae.

Background: To study the propranolol treatment of small abdominal aortic aneurysms (AAA) concerning intention to treat, side effects, and inhibition of expansion., Design: Two-year lasting prospective randomised double-blinded intervention trial., Setting: Hospital-based mass screening for AAA with annual ambulatory control of small AAA., Participants: Of 122 screening-diagnosed small AAA, 51 (42%) were excluded because of contraindications or present beta-blockage, and 17 refused participation. Thus, 54 (44.3%) were included., Intervention: Participants were randomised to 40 mg propranolol twice a day or placebo., Measures: The same observed was used to follow-up AAA-expansion, side effects, quality of life (QL), branchial and ankle blood pressure (ABI), and pulmonary function (FEV1 and FVC)., Results: Sixty percent in the propranolol group, and 25% in the placebo group dropped out, mainly caused by dyspnoea in the propranolol group (RR=1.74, 95% C.I.: 1.06-2.86). Five (16.7%) died in the propranolol group, while 1 (4.2%) died in the placebo group (RR=1.6 (1.02-2.51)). Furthermore, decreased pulmonary function, ABI, and QL was noticed in the propranolol group. Consequently, the trial was stopped after two years. Ninety-five percent of the measurements of the AAA were measured within 2 mm variation. If expansion was defined as above 2 mm annually, the relative risk of expansion in the placebo group was 1.17 (0.74-1.85), and 2.44 (0.88-6.77) among the non-drop-outs., Conclusions: Only 22% of small screenings-diagnosed AAA were treatable with propranolol for two years. Consequently, only large scale studies are capable of showing potential minor inhibition of expansion by propranolol. However, whether such treatment ever becomes ethically acceptable is debatable.

Background: The short term experience of endovascular treatment of abdominal aortic aneurysms (AAA) seems promising but long term randomised data are lacking. Consequently, cases treated by endovascular procedures need to be closely followed for potential risks and benefits., Case Report: A 70 year-old mildly hypertensive male without previous or present arteriosclerotic, pulmonary, or urological manifestations was subjected to endovascular treatment after his mass-screening diagnosed abdominal aortic aneurysm had expanded to above 5 cm in diameter, the aneurysm having been found by CT-scanning and arteriography to be endovascularly treatable. A Vanguard bifurcated aortic stent graft was implanted under epidural/spinal anaesthesia and covered by cephalosporine and heparin (8000 IE) protection. Apart from treatment of a groin haematoma and stenosis of the left superficial femoral artery, the postoperative period presented no problems. A few days before the monthly follow-up visit, the patient developed uraemia, gangrene of one foot and dyspnoea. Blood glucose and LDH was elevated. Deterioration led to death a month and a half after stent implantation. Autopsy showed extraordinary large, extensive soft, brown vegetations in the lower part of the thoracic aorta above the properly infrarenally-placed stent. Microscopic examination revealed multiple microemboli in the liver, spleen, pancreas, intestines, testes, and especially the kidneys., Discussion: Early death from microemboli after aortic stent implantation has been reported. However, the present case developed fatal multiple microemboli so late that they could not have originated from the excluded mural thrombus. The sudden death of an otherwise healthy man of extensive microemboli is difficult to explain. The stent application may have altered the proximal flow and wall movements disposing to microemboli in the case of vegetations.

In spite of increasing number of elective resections of abdominal aortic aneurysms (AAA) the mortality or ruptured AAA is increasing. The advantages of elective operations are obvious; the lethality is 2-6% while the lethality of ruptured AAA is 75-95%. However, AAA seldom causes symptoms before rupture. Ultrasonographic screening for AAA takes 10 minutes per scan, and the sensitivity and specificity are high. Ultrasonographic screening for AAA is a reliable, safe and inexpensive method for screening, and screening for AAA is discussed worldwide. One point four percent of deaths among men from 65 to 80 year of age are caused by ruptured AAA. Screening men over 65 for AAA can theoretically prevent a substantial number of deaths. Our calculations predict one prevented AAA-death per 200-300 scans for a cost of about 4000 DKK per saved year of life. However, cost-benefit analyses are based on uncertain assumptions concerning prevalence, incidence and risk of rupture. Therefore a randomized trial screening of 65-73 year old males is taking place in the County of Viborg in Denmark.

The incidence of abdominal aortic aneurysms (AAA) and ruptured AAA is increasing. One to three percent of deaths among 65-80 year-old males are caused by AAA. Sixty-six to ninety-five percent of ruptured AAA are lethal, while elective resection has a 3-6% operative mortality. Most AAA's are asymptomatic before rupture. Ultrasonographic scanning of the aorta takes below ten minutes with close to 100% sensitivity and specificity. The County of Viborg has started a randomized screening trial including 13,500 65-73 year-old males. Half of these are invited to the nearest hospital over a period of three years. In 1994-1995 4938 were invited and 3748 were scanned, resulting in an acceptance rate of 76%. The aorta was visible in 99.7%, and the total time consumption was 9.7 minutes per scan. The costs were 83.75 DKK per scan. One hundred and fifty-three (4.1%) had an AAA defined as an aortic diameter above 29 mm. Twenty were above 49 mm and were offered operation, i.e. 5.3 per thousand scans or 13% of the diagnosed AAA.

OBJECTIVE - To analyse the benefits of screening older men for abdominal aortic aneurysms. METHODS - A hospital based screening trial concerning 13 500 65-73 year old men using B-mode ultrasonographic scanning. To improve the response rate the invited men could change their appointment, and nonresponders were reinvited. RESULTS - Results from the first year of the trial are presented. Among 4404 invited, 3344 (76%) were scanned. The primary response rate was 64.8%, but a further 11.2% were scanned after revised appointments or reinvitation. The whole infrarenal aorta could be visualised in 97-6%, and the distal part in 99.7% of the scans. The time taken for each scan was 9-7 minutes and the costs per scan were $9.50. One hundred and fifty three subjects (4.6%) had aortic diameters of 25-29 min, and 141 (4.2%) had an abdominal aortic aneurysm, 19 (0.6%) above 49 mm in diameter. CONCLUSION - In Denmark the short term costs and benefits of screening older men for abdominal aortic aneurysms seem realistic. Long term costs and benefits need to be investigated.

In order to analyze the possible benefits on the mortality of abdominal aortic aneurysms (AAA) in Viborg county from the establishment of a specialized vascular unit in the county, the periods just before (1986-1988) and just after (1989-1991) the start of the unit were reviewed. Three times as many operations for AAA (104/mill/yr) were carried out after the unit opened. Acute operations increased sevenfold. In 1986-1988 42 persons experienced rupture of AAA. Twenty-six (63%) died outside hospital. Thirteen (32%) died at primary receiving hospitals. Only three patients (7%) were operated. One survived, making the overall mortality 97.5%. The mortality in this period was 187/million persons over 50 years. In 1989-1991 39 persons experienced rupture. Eleven (28%) died outside hospital. Eight (20.5%) died at primary receiving hospitals. One died preoperatively on the vascular unit. Nineteen (49%) reached operation, 13 survived (33%) and six (15.4%) died postoperatively. The overall mortality was 67%, the mortality of AAA was 127/million persons over 50 years. Comparing the two periods, deaths, mortality and overall mortality due to ruptured AAA decreased by 32% after the introduction of the vascular unit.

The diagnosis of pulmonary embolism (PE) remains one of the most difficult in clinical medicine, and the diagnostic value of lung scintigraphy has been questioned. To evaluate the observer variation in the interpretation of ventilation-perfusion lung scanning in the diagnosis of PE, 87 lung scintigrams from consecutive patients with phlebography-proven deep venous thrombosis and without clinical signs of PE were randomly mixed with 50 reference lung scintigrams from patients with PE symptoms. The scintigrams were reevaluated blind by two experienced clinical physiologists. Each observer evaluated each lung scintigram twice and recorded whether the lung scan was normal or abnormal. If it was abnormal, the location and number of segment defects were registered. The intraobserver agreement, including number and location of segments, ranged from 0.77 to 0.85 and for the diagnosis of PE from 0.88 to 0.92 with a kappa of 0.80-0.84. The values for the interobserver agreement for the diagnosis of PE were 0.73-0.80 with a kappa of 0.56-0.67. It is concluded that in the interpretation of ventilation-perfusion lung scintigraphy the use of a simple scheme-deciding whether there is segmental ventilation-perfusion mismatch or not-has a good reproducibility with a high kappa for inter- and intraobserver variation and can serve as a simple routine method for diagnosing PE.

In June 1988 a Department of Vascular Surgery was established in the county of Viborg, Denmark. In this retrospective study of the periods 1986-87 and 1989-90, we have observed a significant rise in the number of patients evaluated by a vascular surgeon before amputation, from 19 to 49%. At the same time the number of major lower limb amputations significantly decreased. This reduction was most marked in 1990 probably due to a rise of 43% in the number of distal reconstructions. The distribution between below knee, through knee and mid-thigh amputation was unaffected by the increased vascular surgical activity. The frequency of major amputations in the county in 1986-87 of 40.9 per 100,000 per year declined by 25% to 30.9 per 100,000 per year in 1989-90. We conclude that vascular surgery reduces the number of major lower limb amputations and consequently all patients threatened with amputation must be evaluated if vascular reconstruction is possible.

In June 1988 a Department of Vascular Surgery was established in the County of Viborg, Denmark. In a retrospective study, 314 patients had 337 major amputations within two time periods: 1986-1987, and 1989-1990. The number of patients seen by a vascular surgeon rose significantly from 19% in the first period to 49% in the last period, and the number of amputations was concurrently significantly reduced by 25%. The largest reduction was observed in 1990, probably due to an increase of vascular reconstructions of 43%. Assuming there is a latency between diagnosing "critical leg ischaemia" and amputation, this will further delay the already convincing results showing that vascular surgery does reduce the frequency of amputations. All patients with suspected critical leg ischaemia or threatened by amputation must be seen, or at least conferred with a vascular surgeon.