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Background Venous thromboembolism is rare following varicose vein ablation procedures, but uncertainty about its incidence combined with a lack of evidence-based clinical guidelines regarding thromboprophylaxis has led to debate about best practice. We conducted a national survey to investigate current practice among Irish vascular surgeons. Methods An anonymous online questionnaire was emailed to all members of the Irish Association of Vascular Surgeons and the Northern Ireland Vascular Society. Results Response rate was 60%. With regard to procedure type, 36.7% of respondents use only endovenous techniques and 53% use a combination of open and endovenous. Formal duplex imaging on all patients is obtained by 53.3%. With regard to VTE prevention, 73.3% always give thromboprophylaxis. For those who give it selectively, a variety of factors were considered as risks. Pharmacological agents used are enoxaparin in 73.3% of cases or tinzaparin, and 71.4% use a single dose (either 20/40 mg or 3500/4500 IU respectively). If patients are already taking anticoagulation, this is continued by 46.7% of respondents. Routine post procedure duplex imaging is carried out by 23.1% of recipients, either by the surgeon or formally and 80% review patients clinically. Moreover, 43.3% of respondents claim to know their post-operative VTE rate and this varies from 0 to 1% with one mortality reported. Conclusions The majority of respondents use single-dose thromboprophylaxis periprocedurally for varicose vein ablation procedures. VTE rates are low but the true incidence may be unknown.

Vascular endothelial growth factor (VEGF) is an angiogenic cytokine that regulates tumour angiogenesis. The prognostic significance of VEGF expression remains incompletely investigated for patients with oesophagogastric cancer. This study assesses the significance of tumour VEGF (T-VEGF) and circulating VEGF (C-VEGF) expression in a 10-year follow-up of patients with oesophagogastric cancer. Patients undergoing surgical resection were prospectively recruited between February 1999 and August 2000. Circulating VEGF, derived both from plasma (P-VEGF) and serum (S-VEGF), and T-VEGF were assessed using a commercial enzyme-linked immunosorbent assay (ELISA). As platelet count may contribute to C-VEGF, pre-operative platelet levels were also recorded to exclude a confounding effect. Patients were followed up over a 10-year period using the Northern Ireland Cancer Registry. Sixty-one patients were recruited (men=45) with a mean age of 65.7 years. The 10-year survival was 19.7% (n=12) with a median follow-up of 808 days (inter-quartile range [IQR]: 349.5-2358.5). Union for International Cancer Control (UICC) tumour staging was Stage I=9 (14.8%), Stage II=15 (24.6%), Stage III=33 (54.1%) and Stage IV=4 (6.6%). The only significant relationship between clinicopathological features and the study variables was for S-VEGF, which was elevated in patients with advanced T-stage (P = 0.05). Circulating VEGF did not correlate with platelet count. Although a trend towards decreased survival was observed for patients who had positive lymph nodes (P = 0.08) and advanced UICC stage (P = 0.09) on univariate analysis, only lymphovascular invasion significantly predicted poor prognosis in this cohort (P = 0.05). Therefore, ELISA quantification of circulatory or tumour VEGF does not appear to be a significant predictor of mortality in patients with oesophagogastric cancer.

Background Surgical revascularization for lower limb ischemia remains an important component for optimization of quality of life and symptoms in patients with peripheral arterial disease. In the absence of a vein graft, prosthetic alternatives are considered. The objective of this meta-analysis was to establish which prosthetic graft, Dacron or polytetrafluroethylene (PTFE), has the better long-term patency in patients undergoing an above-knee femoropopliteal arterial bypass. Methods This meta-analysis was performed by use of Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search of all relevant databases was performed from 1990 to 2013 with the Medical Subject Headings "Dacron," "polytetrafluroethylene," "PTFE," "above knee," "femoropopliteal," and "bypass" combined with the Boolean operator "AND." The inclusion criteria were randomized controlled trials, use of Dacron vs PTFE prosthetic conduits, and completion of an above-knee femoropopliteal arterial bypass involving adult patients older than 18 years presenting with disabling claudication, rest pain or tissue loss, occlusion of the superficial femoral artery, and reconstitution of the above-knee popliteal artery. Whenever studies included above- and below-knee data, only the above-knee arterial bypass data were extracted and analyzed. Graft patency rates were calculated with RevMan 5.1 software provided by the Cochrane Collaboration. Results Ninety-one publications were reviewed. After exclusion of duplicate, nonrandomized, and alternative bypass surgery studies, eight randomized controlled trials were identified and included in the meta-analysis. Two of the included trials represented follow-up evaluation of two previous studies, and for the purpose of this analysis, the initial and follow-up studies were subsequently evaluated as one trial. In this meta-analysis, 1192 patients were assessed, including 601 Dacron and 591 PTFE above-knee lower limb arterial bypasses. Primary patency was calculated from all included studies. However, only four studies provided data to evaluate secondary patency. Mean age reported was 66 years. Although all studies described cardiovascular comorbidities and risk factors including myocardial ischemia, diabetes, hypertension, and smoking, exact patient numbers were not consistently provided. Included studies evaluated grafts from 5 to 8 mm. Although primary and secondary patency rates at 12 months were not significantly different (relative risk [RR], 0.78; P = .08, and RR, 0.84; P = .52), 24-, 36-, and 60-month primary patency rates were significantly better with Dacron compared with PTFE grafts (RR, 0.79; P = .003; RR, 0.80; P = .03; RR, 0.85; P = .02). Statistical analysis also supported higher secondary patency rates for Dacron at 24 months (RR, 0.75; P = .02) and 60 months (RR, 0.76-0.77; P = .03-.27). Although primary patency was similar between grafts (28% vs 28%; P = .12), secondary patencies were better with Dacron at 10 years (49% vs 35%; P = .01). Antiplatelet and anticoagulation protocols varied between the trials. There was no difference in amputation, overall morbidity, or mortality rates between the two surgical graft populations. Conclusions Current evidence suggests that Dacron prosthetic grafts are superior to PTFE grafts in above-knee femoropopliteal arterial bypass procedures. Further randomized trials targeting standardization of confounding variables, particularly graft size and best medical therapy, are warranted.

Streptococcus bovis can lead to bacteraemia, septicaemia, and ultimately endocarditis. The objective of this study was to evaluate the long-term implications of S. bovis endocarditis on cardiac morbidity and mortality.A retrospective cohort study was performed between January 2000 and March 2009 to assess all patients diagnosed with S. bovis bacteraemia from the Belfast Health and Social Care Trust. The primary end-point for cardiac investigations was the presence of endocarditis. Secondary end-points included referral for cardiac surgery and overall mortality.Sixty-one positive S. bovis blood cultures from 43 patients were included. Following echocardiography, seven patients were diagnosed with infective endocarditis (16.3 % of total patients); four patients (9.3 %) had native valve involvement while three (7.0 %) had prosthetic valve infection. Five of these seven patients had more than one positive S. bovis culture (71.4 %). Three had significant valve dysfunction that warranted surgical repair/replacement, one of whom was unfit for surgery. There was a 100 % recurrence rate amongst the valve replacement patients (n = 2) and six patients with endocarditis had colorectal pathology. Patients with endocarditis had similar long-term survival as those with non-endocarditic bacteraemia (57.1 % alive vs. 50 % of non-endocarditis patients, p = 0.73).Streptococcus bovis endocarditis patients tended to have pre-existing valvular heart disease and those with prosthetic heart valves had higher surgical intervention and relapse rates. These patients experienced a higher rate of co-existing colorectal pathology but currently have reasonable long-term outcomes. This may suggest that they represent a patient population that merits consideration for an early surgical strategy to maximise long-term results, however, further evaluation is warranted.

Background This study evaluated the effect of statins in Primary biliary cirrhosis (PBC) on endothelial function, anti-oxidant status and vascular compliance. Methods Primary biliary cirrhosis patients with hypercholesterolaemia were randomized to receive 20 mg simvastatin or placebo in a single blind, randomized controlled trial. Body mass index, blood pressure, glucose, liver function, lipid profile, immunoglobulin levels, serological markers of endothelial function and anti-oxidant status were measured as well as vascular compliance, calculated from pulse wave analysis and velocity, at recruitment and again at 3, 6, 9 and 12 months. Results Twenty-one PBC patients (F = 20, mean age = 55) were randomized to simvastatin 20 mg (n = 11) or matched placebo (n = 10). At completion of the trial, serum cholesterol levels in the simvastatin group were significantly lower compared with the placebo group (4.91 mmol/L vs. 6.15 mmol/L, P = 0.01). Low-density lipoprotein (LDL) levels after 12 months were also significantly lower in the simvastatin group (2.33 mmol/L vs. 3.53 mmol/L, P = 0.01). After 12 months of treatment, lipid hydroperoxides were lower (0.49 μmol/L vs. 0.59 μmol/L, P = 0.10) while vitamin C levels were higher (80.54 μmol/L vs. 77.40 μmol/L, P = 0.95) in the simvastatin group. Pulse wave velocity remained similar between treatment groups at 12 months (8.45 m/s vs. 8.80 m/s, P = 0.66). Only one patient discontinued medication owing to side effects. No deterioration in liver transaminases was noted in the simvastatin group. Conclusions Statin therapy in patients with PBC appears safe and effective towards overall reductions in total cholesterol and LDL levels. Our initial study suggests that simvastatin may also confer advantageous effects on endothelial function and antioxidant status.

Detection of bone marrow micrometastases (BMMs) in patients with esophageal carcinoma may indicate a metastatic phenotype. We assessed if the presence of BMMs had adverse prognostic significance in a 10-year follow-up study. Patients undergoing surgery for esophageal cancer were prospectively recruited between February 1999 and August 2000. Bone marrow aspirates were obtained from the iliac crest of patients under general anesthesia at the time of surgery. Immunocytochemical analysis using anticytokeratin antibodies CAM 5.2 and AE1/AE3 was undertaken to determine the presence of BMMs. Union International Contre le Cancer staging was recorded for all patients. Patient follow-up was completed over a 10-year period through analysis of the Northern Ireland Cancer Registry. Forty-two patients (male = 35) were included, with a mean age of 67.2 years (range 39-83). BMMs were detected in 19 patients (45.2%). International Contre le Cancer tumor staging was stage I = 6, stage II = 10, stage III = 24, and stage IV = 2. BMMs were associated with lymphovascular invasion (P= 0.02) and advanced T stage (P= 0.02). Overall, 10-year survival was 21.4% (n= 9), with a median follow-up of 877.5 days (interquartile range 391.5-2546.3). There was no statistically significant difference between the survival of patients with or without BMMs (1451.4 vs. 1431.6 days, P= 0.99). Univariate analysis demonstrated a trend toward decreased survival for patients with positive lymph nodes (P= 0.07), an increased T stage (P= 0.06), and lymphovascular invasion (P= 0.07). Multivariate analysis demonstrated that none of the variables were significant predictors of mortality. Although the presence of BMMs correlates with recognized adverse tumor characteristics in patients with esophageal cancer, micrometastases detected in the bone marrow at time of surgery does not influence long-term survival.

Background Patients with chronic kidney disease (CKD) have better outcomes when they have access to specialist nephrology services early in the course of their disease. However, up to 30% of patients with advanced kidney disease face late referral. Virtual clinics represent a potentially innovative mechanism for early assessment of high patient volumes efficiently and cost effectively while maintaining high standards of care. Methods A retrospective observational cohort study was completed over a 4-year period from April 2004 to March 2008 at a regional nephrology centre within Northern Ireland. All new patient attendances at the nephrology clinic were identified and those managed via the virtual renal clinic approach were included in this study. A cost comparison of this innovative modality was made with the traditional outpatient service model. Results There were 427 patients (51.3% female, 48.7% male) managed through the virtual renal clinic. Comorbidities included 180 patients (42.1%) with known CKD and 31 patients (7.3%) with newly identified kidney disease. A total of 118 patients (27.6%) had hypertension while 6 (1.4%) and 57 (13.3%) had type I and II diabetes mellitus (DM) respectively. Referral indications included 211 patients (49.4%) with abnormal renal biochemistry, 35 (8.2%) with proteinuria, 12 (2.8%) with haematuria and 87 patients (20.4%) with a combination of issues. A conservative treatment plan consisting of biochemical surveillance was appropriate for 246 patients (57.6%) while medication review was completed for 113 patients (26.5%) and surgical referral was indicated in 20 patients (4.7%). The virtual renal clinic provided a minimum cost saving of £111.56 per patient attendance compared with traditional outpatient care resulting in 23.3% of patient referrals being managed by the virtual clinic approach in 2009. Conclusion Delayed referral to a renal specialist adversely affects patient outcomes. This study suggests that the implementation of a virtual renal clinic for non-complex renal pathologies can offer a cost-effective, rapid referral mechanism for patient assessment combined with readily available specialist advice.

Successful palliation of dysphagia in patients with inoperable esophageal carcinoma has a major effect on quality of life. Self-expanding metal stents (SEMS) are currently recommended for rapid symptomatic relief when life expectancy is less than 3 months. We assessed complication and reintervention rates along with survival outcomes in patients with inoperable esophageal carcinoma undergoing stent insertion. A retrospective audit was performed from April 2007 to June 2009 for all inoperable primary esophageal carcinoma patients who had an esophageal stent inserted for dysphagia. Case notes were reviewed for clinical, pathological, stent and complication details, while ICD-10 causes of death were obtained from the Department of Health and Social Services, Northern Ireland. Fifty-six stents were inserted into 53 patients (66.0% male, mean age of 70 years). Inoperability was defined by metastatic spread (n= 34, 64.2%), locally advanced disease (n= 7, 13.2%), and severe medical comorbidities (n= 12, 22.6%). The median time from diagnosis to stent insertion was 109 (interquartile range [IQR] 43-187) days. Fifty stents (94.3%) were successfully deployed, while three patients (5.7%) required an additional stent as the primary stent had not bridged the tumor (proximal deployment = 2, suboptimal stent length = 1). Post-SEMS dysphagia scores were significantly better than pre-SEMS scores (2.90 vs. 1.54, P < 0.001). There were 27 complications identified in 23 (43.4%) patients (major complications = 9, minor complications = 14). Twelve patients (22.6%) required additional endoscopic procedures. The 30-day mortality rate was 11.3% (n= 6). Only one patient (1.9%) remains alive with a cumulative median survival rate of 84 (IQR 38-156) days. Esophageal stent insertion in this group of patients still presents a clinical challenge, with complication and endoscopic reintervention rates of 43.4 and 22.6%, respectively. Our results are comparable with previously published series, and as a palliative modality stent insertion remains appropriate when expected survival is less than 3 months. A range of SEMS is currently available with broadly similar efficacy and safety profiles. Data regarding the newly available fully covered SEMS suggest that they should be avoided.

Summary Background: Previous studies have reported a conflicting relationship between the effect of live and televised sporting events on attendance rates to emergency departments (ED). The objectives of this study were to investigate the relationship of major sporting events on emergency department attendance rates and to determine the potential effects of such events on service provision. Methods: A retrospective analysis of ED attendances to a district general hospital (DGH) and subsequent admissions over a 24-h period following live and televised sporting activities was performed over a 5-year period. Data were compiled from the hospital’s emergency record books including the number of attendances, patient demographics, clinical complaint and outcome. Review patients were excluded. Analysis of sporting events was compiled for live local, regional and national events as well as world-wide televised sporting broadcasts. Results: A total of 137,668 (80,445 men) patients attended from April 2002 to July 2007. Mean attendance rate per day was 80 patients (men = 47). Mean admission rate was 13.6 patients per day. Major sporting events during the study period included; Soccer: 4 FA Cup and 1 World Cup (WC) finals; Rugby: 47 Six Nations, 25 Six nations games involving Ireland, 1 WC final, 2 WC semi-finals, 2 WC quarter-finals and 4 WC games involving Ireland; and Gaelic Football [Gaelic Athletic Association (GAA)]: 5 All-Ireland finals, 11 semi-finals, 11 quarter-finals and 5 provincial finals. There was a significantly higher patient admission rate during the soccer FA Cup final, Rugby Six Nations and games involving Ireland and for GAA semi- and quarter-final games (p = 0.001–0.01). There was no difference identified in total attendance or non-admission rates for sporting events throughout the study period. Although there was no correlation identified between any of these sporting events and total emergency department attendances (r 0.07), multinomial logistic regression demonstrated that FA Cup final (p = 0.001), Rugby Six Nations (p = 0.019), Rugby WC games involving Ireland (p = 0.003), GAA All-Ireland semi- and quarter-finals (p = 0.016; p = 0.016) were predictors of patient admission rates. Conclusion: This study suggests that live or televised sporting events do not significantly affect ED attendances to a DGH. However, some events appeared to be predictors of patient admission rates. Although it may be beneficial to consider the effect of sporting events on service stratification during these periods, the overall effect is probably minimal and should not create a major concern for future service provision despite the implementation of the European Working Time Directive.

Conventional open repair of inflammatory abdominal aortic aneurysms (IAAA) remains challenging through the presence of extensive peri-aortic inflammation and fibrosis which makes dissection and vascular control difficult with a risk of inadvertent injury to adjacent visceral structures such as the ureters, duodenum, inferior vena cava, left renal vein and sigmoid colon. We describe a case of a 69-year-old gentleman who presented with acute renal failure due to bilateral ureteric obstruction in association with an IAAA and discuss the various management options available. IAAAs and the associated peri-aortic inflammation and fibrosis can be successfully treated using endovascular abdominal aortic aneurysm repair with concurrent ureteric stenting.

We present a rare case of a patient who presented with acute abdominal pain with a previous history of alpha-1-antitrypsin deficiency (alpha1-antitrypsin deficiency). Further clinical deterioration necessitated computed tomography (CT) imaging, which demonstrated a hemoperitoneum. Angiography confirmed the rupture of multiple aneurysms originating from the mesenteric arterial arcade, which were treated successfully with endovascular embolization. The association between mesenteric arterial aneurysm rupture and alpha-1-antitrypsin deficiency is explored.

Radiological investigations have become a key adjunct in patient management and consequently radiation exposure to patients is increasing. The study objectives were to examine the use of radiological investigations in the management of acute surgical patients and to assess whether a guideline-based radiation exposure risk/benefit analysis can aid in the choice of radiological investigation used. A prospective observational study was completed over a 12-week period from April to July 2008 for all acute surgical admissions. Data recorded included demographics, clinical presentation, differential diagnosis, investigations, surgical interventions, and final clinical outcome. The use of radiological investigative modalities as an adjunct to clinical assessment was then evaluated against The Royal College of Radiologists (RCR) guidelines. A total of 380 acute surgical admissions (M = 174, F = 185, children = 21) were assessed during the study period. Seven hundred thirty-four radiological investigations were performed with a mean of 1.93 investigations per patient. Based on the RCR guidelines, 680 (92.6%) radiological investigations were warranted and included 142 CT scans (19.3%), 129 chest X-rays (17.6%), and 85 abdominal X-rays (11.6%). Clinically, radiological imaging complemented surgical management in 326 patients (85.8%) and the management plan remained unchanged for the remaining 54 patients (14.2%). This accounted for an average radiation dose of 4.18 millisievert (mSv) per patient or 626 days of background radiation exposure. CT imaging was responsible for the majority of the radiation exposure, with a total of 1310 mSv (82.6%) of the total radiation exposure being attributed to CT imaging in 20.8% of acute admissions. Subgroup analysis demonstrated that 92.8% of the CT scans performed were appropriate. Radiation exposure was generally low for the majority of acute surgical admissions. However, it is recommended that CT imaging requests be evaluated carefully, particularly for patients with clinically confirmed pathologies and in younger women.

Background Hyperglycaemia impairs many of the physiological processes involved in recovery from surgery but there is limited research on the effect of optimal peri-operative glucose control in diabetic general surgery patients. The objectives of this study were to assess blood glucose management in diabetic general surgical patients and to determine if protocol deviations were associated with adverse outcomes. Methods All diabetic patients undergoing elective and emergency general surgical procedures between August 2007 and July 2008 were included in the study. The hospital protocol for peri-operative blood glucose control was based on the Alberti Regimen. Data was collected regarding blood glucose measurements, adherence to protocol and complications following surgery. Results A total of 69 adult patients ( M = 44, F = 25; median age 61, range 15–93 years; T1DM = 35, T2DM = 34) were included. 38 patients underwent elective surgery (cholecystectomy, hernia repair, varicose vein surgery) and 31 underwent emergency surgical procedures (laparotomy, incision and drainage of abscess). 10.3% of capillary blood glucose readings were less than 6.1 mmol/l, 32.8% were between 6.1 and 10.0 mmol/l, 44.6% were greater than 10.0 mmol/l 12.3% of scheduled blood glucose measurements were not completed. An insulin–dextrose infusion was indicated in 30 patients, of which 14 (46.7%) were treated according to protocol. In the 16 protocol-deviation cases, insulin was generally either administered according to a sliding scale (6 patients) or not at all during their time on the ward. While an insulin–dextrose infusion was not indicated in 39 patients, 14 (35.9%) of these patients were inappropriately given insulin either as an infusion (8 patients) or according to a sliding scale (6 patients). Overall, only 39 (56.5%) patients were treated according to protocol. The overall complication rate was 29%, which included 7 out of 39 (17.9%) and 13 out of 30 (43.3%) protocol-based and protocol-deviation patients respectively ( p = 0.45). Conclusion Although not statistically significant, optimal glucose homeostasis according to hospital protocol was associated with a 25.4% reduction in peri-operative complications. We recommend careful blood glucose management according to pre-defined guidelines in all diabetic patients undergoing general surgical procedures.

Summary Background: Ultrasound is the first-line breast imaging modality in younger patients and an adjunct to mammography in older patients. The objectives of this study were to evaluate the complementary value of ultrasound to mammography in breast cancer and to investigate the use of ultrasound in patients above and below the age of 50 years. Methods: Clinical presentation and investigations for consecutive patients undergoing triple assessment at a symptomatic breast clinic were prospectively recorded between January 2000 and August 2003. Clinical data were compared with pathological findings. Patients were divided into two groups, above and below 50 years of age for subgroup analyses. Results: A total of 999 of 2185 patients had both mammography and ultrasound investigations performed and constituted the study population. Subgroup analysis of the 2185 patients demonstrated that 99 of the 127 patients who were diagnosed with breast cancer had both investigations performed (median age 57.0, range: 34–89 years). Mammography was normal/benign in 14.1%, indeterminate in 29.3% and suspicious of cancer in 56.6% of patients. Adjunctive ultrasound was normal/benign in 13.1%, indeterminate in 6.1% and suspicious of cancer in 80.8% of patients. In these 99 patients, adjunctive ultrasound was more sensitive than mammogram alone (80.8% vs. 56.6%, p

Background: Fine needle aspiration (FNA) is an important adjuvant to the diagnosis of a palpable lesion which often permits the complete assessment of patients. The main objective of this study was to determine the clinical benefit of a dedicated FNA service at a tertiary referral Head and Neck Clinic and to assess if such a service is cost effective. Methods: All patients attending the Head and Neck Clinic during 2004 were prospectively assessed in this study. Patient records were analysed regarding investigative modalities including FNA, the subsequent cytology result and the requirement for further histopathological investigations. A cost analysis for all investigative procedures was performed. Results: A total of 135 patients (36 males) had FNAs performed during the study period. The median age was 51.5 years (range 17–92). Patients presented with lesions of lymph nodes (n = 46), thyroid (n = 41), salivary, parotid or submandibular glands (n = 22) and other cutaneous or cystic lesions (n = 26). Cytological grading results were; C1 = 26, C2 = 93, C3 = 8, C4 = 2 and C5 = 6. Patients with lesions C3 or above normally proceeded to further investigations. The overall cost of the FNA per episode in the out-patient clinic was £114 per episode compared to day case open biopsy per patient of £333 and an in-patient stay per patient was £2371. FNA provided sufficient pathological diagnosis to avoid day case surgery in 57 patients (42.2%), and inpatient surgery in 65 patients (48.1%) resulting in a total saving of £158 372 in 2004. Conclusion: This study demonstrates the clinical benefit and cost-effectiveness of FNA services in a dedicated Head and Neck clinic.

sObjectivesCilostazol improves walking distance in peripheral arterial disease (PAD) patients. The study objectives were to assess the effects of cilostazol on walking distance, followed by the additional assessment of cilostazol on exercise-induced ischaemia–reperfusion injury in such patients.MethodsPAD patients were prospectively recruited to a double-blinded, placebo-controlled trial. Patients were randomised to receive either cilostazol 100mg or placebo twice a day. The primary end-point was an improvement in walking distance. Secondary end-points included the assessment of oxygen-derived free-radical generation, antioxidant consumption and other markers of the inflammatory cascade. Initial and absolute claudication distances (ICDs and ACDs, respectively) were measured on a treadmill. Inflammatory response was assessed before and 30min post-exercise by measuring lipid hydroperoxide, ascorbate, α-tocopherol, β-carotene, P-selectin, intracellular and vascular cell-adhesion molecules (I-CAM and V-CAM), thromboxane B2 (TXB2), interleukin-6, interleukin-10, high-sensitive C-reactive protein (hsCRP), albumin–creatinine ratio (ACR) and urinary levels of p75TNF receptor. All tests were performed at baseline and 6 and 24 weeks.ResultsOne hundred and six PAD patients (of whom 73 were males) were recruited and successfully randomised from December 2004 to January 2006. Patients who received cilostazol demonstrated a more significant improvement in the mean percentage change from baseline in ACD (77.2% vs. 26.6% at 6 weeks, p=0.026 and 161.7% vs. 79.0% at 24 weeks, p=0.048) as compared to the placebo. Cilostazol reduced lipid hydroperoxide levels compared to a placebo-related increase before and after exercise (6 weeks: pre-exercise: −11.8% vs. +5.8%, p=0.003 and post-exercise: −12.3% vs. +13.9%, p=0.007 and 24 weeks: pre-exercise −15.5% vs. +12.0%, p=0.025 and post-exercise: −9.2% vs. +1.9%, p=0.028). β-Carotene levels were significantly increased in the cilostazol group, compared to placebo, before exercise at 6 and 24 weeks (6 weeks: 34.5% vs. −7.4%, p=0.028; 24 weeks: 34.3% vs. 17.7%, p=0.048). Cilostazol also significantly reduced P-selectin, I-CAM and V-CAM levels at 24 weeks as compared to baseline (p

Objectives: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. Methods: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. Results: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. Conclusions: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Le but de cette etude experimentale ex vivo etait d'evaluer l'effet du tabagisme, du diabete, et de l'hypertension sur la fonction endotheliale de la veine saphene humaine, conduit utilise pour la chirurgie arterielle coronaire et peripherique. Un segment de veine grande saphene preleve pendant une chirurgie de pontage sous-inguinal etait monte dans un bain d'organe pour des etudes isometriques de tension. Des anneaux de veine etaient pre-contractes a une contraction sous-maximale avec de la phenylephrine, suivie d'une relaxation endothelium dependante avec de l'acetylcholine. Des segments de veine grande saphene ont ete rassembles de 26 patients, y compris cinq femmes, d'un âge moyen de 66,4 ans (extremes 48-92). Les fumeurs actifs avaient une relaxation dependant de l'endothelium alteree comparee aux ex- et aux non-fumeurs (10,2%, n = 13, contre 32,9%, n = 13; p

El objetivo del presente estudio experimental ex vivo fue evaluar el efecto del tabaquismo, la diabetes mellitus y la hipertension arterial sobre la funcion endotelial en la vena safena humana, un conducto usado habitualmente para cirugia mediante bypass coronario y de arterias perifericas. Durante intervenciones de bypass infrainguinal, se obtuvieron segmentos de vena safena interna que se prepararon en un bano de organos para los estudios de tension isometrica. Los anillos venosos se sometieron a una precontraccion con concentraciones crecientes de fenilefrina hasta una contraccion submaxima, seguido de relajacion dependiente de endotelio con acetilcolina. Los segmentos de vena safena interna se obtuvieron de 26 pacientes, incluidas cinco mujeres, con una edad media de 66,4 anos (limites 48-92). En fumadores actuales se identifico un deterioro de la relajacion dependiente de endotelio, comparado con ex fumadores y no fumadores (10,2%, n = 13, comparado con 32,9%, n = 13; p < 0,010). No obstante, en ex fumadores y no fumadores no se observo una diferencia significativa en las respuestas de relajacion a acetilcolina (29,1%, n = 8, comparado con 24,6%, n = 5; p = no significativo [NS]). De forma parecida, en pacientes diabeticos y no diabeticos, no se demostro una diferencia significativa en la relajacion dependiente de endotelio (23,1%, n = 10, comparado con 15,6%, n = 16; p = NS). Las respuestas de relajacion en pacientes hipertensos y normotensos no fueron diferentes (20,4%, n = 12, comparado con 22,5%, n = 14; p = NS). El tabaquismo produce un efecto lesivo sobre la funcion endotelial de la vena safena, y el abandono del habito puede mejorar la permeabilidad a largo plazo de esta vena usada como injerto de bypass en pacientes sometidos a reconstruccion arterial.

The aim of this ex vivo experimental study was to assess the effect of smoking, diabetes mellitus, and hypertension on endothelial function in human saphenous vein, a commonly used conduit for coronary and peripheral arterial bypass surgery. A segment of long saphenous vein harvested during infrainguinal bypass surgery was mounted in an organ bath for isometric tension studies. Vein rings were precontracted to submaximal contraction with phenylephrine, followed by endothelium-dependent relaxation with acetylcholine. Long saphenous vein segments were collected from 26 patients, including five females, with a mean age of 66.4 years (range 48-92). Current smokers had impaired endothelium-dependent relaxation compared to ex- and nonsmokers (10.2%, n=13, vs. 32.9%, n=13; p0.010). However, ex-smokers and nonsmokers did not have a significant difference in relaxant responses to acetylcholine (29.1%, n=8, vs. 24.6%, n=5; p=nonsignificant [ns]). Similarly, diabetic and nondiabetic patients did not show a significant difference in endothelium-dependent relaxation (23.1%, n=10, vs. 15.6%, n=16; p=ns). The relaxant responses in hypertensive and normotensive patients were not different (20.4%, n=12, vs. 22.5%, n=14; p=ns). Smoking has a deleterious effect on the endothelial function of saphenous vein, and smoking cessation may improve the long-term durability of saphenous vein used as a bypass graft in patients undergoing arterial reconstruction.

SHOT data can be used to inform policy, improve standards and educate users on transfusion hazards.

This ex vivo study is aimed at determining the beneficial effects of antioxidant agents on human saphenous vein endothelial function. Vein rings harvested during infrainguinal bypass surgery were assessed in an organ bath for endothelium-dependent relaxation, initially without and then with the addition of 10 μM manganese tetrakis benzoic acid porphyrin (MnTBAP), 0.01% N-acetylcysteine (NAC), 0.02% NAC, 10 μM vitamin C, and 100 μM vitamin C. Fifty-five vein rings from 22 patients were analyzed. MnTBAP improved the endothelium-dependent relaxation when compared with control (57.0% vs 37.8%, P < .01). Addition of 0.01% or 0.02% NAC did not improve the endothelium-dependent vasorelaxation (28.2% vs 18.6%, P = ns and 37.8% vs 29.8%, P = ns, respectively). Although 10-μM vitamin C failed to improve endothelial function (50.6% vs 37.2%, P = ns), 100-μM vitamin C significantly enhanced endothelium-dependent relaxation (66.5% vs 38.3%, P < .001). These results suggest that the addition of MnTBAP and high-dose vitamin C can improve the endothelial function of harvested saphenous vein segments in an ex vivo model.

Screening for abdominal aortic aneurysm (AAA) has been suggested for older men. Our aim was to determine the effect of participant selection on prevalence and treatment suitability. Men aged 65 to 75 years attending cardiology clinics composed the high-risk group; the control group was from the community. AAA screening was performed, with follow-up or surgery arranged. Four hundred eight of 651 (62.7%) high-risk men and 109 of 908 (45.0%; p < .0001) men attended from the community. In the high-risk patients, 40 AAAs were diagnosed, with a mean diameter of 41.4 mm (± 10.4 mm). In the control group, 22 new AAAs were found, with an average size of 40.9 mm (± 10.4 mm). Higher polypharmacy existed in the high-risk group (4.6 ± 2.2 vs 2.3 ± 2.0; p < .0001). More aneurysm patients were on dual-antiplatelet therapy (32.5% vs 15.4%; p = .048) compared with the overall high-risk group. In this group, three underwent surgery; one was anatomically unsuitable for endovascular repair and medically unfit for open repair. Two in the control group had surgery. A higher prevalence of AAA is encountered in high-risk men. Most aneurysms are small; however, a significant proportion of the aneurysms detected were of a size that would warrant repair. The decision to perform surgical repair is likely to be influenced by the comorbid medical conditions, which placed the patients in the high-risk category.

Although the urinary bladder is involved in 1-4% of all inguinal hernias, extensive inguinoscrotal herniation of the bladder, termed scrotal cystocele, is very rare. Most small asymptomatic bladder hernias are commonly encountered and reduced successfully via the same incision during elective inguinal hernia repair. However, larger bladder herniations can be associated with bladder infarction or obstruction, which require urgent intervention to preserve renal function and reduce morbidity and mortality. We present two cases of elderly men presenting with significant scrotal cystocele complications which necessitated urgent surgical intervention. We compare and contrast the two cases and discuss the presentation, investigation, diagnosis and treatment of these pathophysiological conditions.

Introduction: the objective of this abdominal aortic aneurysm (AAA) screening study was to determine attendance and disease prevalence patterns in Northern Ireland and the role of deprivation and other risk factors. Patients and methods: patients from primary care practices from Belfast, Lisburn, and Saintfield were screened. Past medical history and deprivation details were determined. Results: 2264 men from Belfast, 1104 men in Lisburn, and 284 in Saintfield were invited to attend. Overall, 1659 (45.3%) men attended, with 40.6% from Belfast, 55.0% from Lisburn, and 45.8% from Saintfield ( P < .0001). Ninety-two (5.5%) new AAAs were diagnosed, with 6.5%, 3.8%, and 6.2% in the 3 areas ( P = .055). As deprivation decreased, attendance increased and prevalence decreased. Smoking, peripheral arterial disease, number of medications prescribed, and geographical origin were independent risk factors for AAAs. Conclusion: aneurysm prevalence is influenced by geographical origin and deprivation, which should, therefore, be important factors in health care planning and screening provision.

Since its first description in 1879, popliteal artery entrapment syndrome remains a debilitating condition, which frequently affects young active people. Increased awareness of popliteal artery entrapment syndrome combined with improvements in investigative modalities has resulted in a more frequent diagnosis of this eminently treatable condition. In this article, a rare case of bilateral popliteal artery entrapment syndrome in a physically active 33-year-old man precipitated by competitive Bicycle Moto-Cross riding is presented. A higher index of suspicion for popliteal artery entrapment syndrome is recommended as the underlying pathology in a young active person with symptoms of lower limb claudication. Popliteal artery entrapment syndrome should be investigated with thorough radiological assessment prior to any therapeutic intervention, which is often fraught with difficulty due to chronically diseased vasculature and inherent anatomical anomalies.

An 83-year-old lady was admitted with a 3-day history of non-specific abdominal pain that had rapidly increased in severity on the day of admission necessitating an emergency laparotomy. Intra-operative findings demonstrated a mechanical small bowel obstruction secondary to a chronically inflamed appendix acting as a tourniquet around a loop of terminal ileum. This case highlights an extremely rare and life-threatening complication of appendicitis. True mechanical small bowel obstruction secondary to an acutely or chronically inflamed appendix encircling the distal small bowel remains extremely rare with only ten cases reported in the literature. Clinical assessment remains paramount in the treatment of these patients to facilitate prompt diagnosis and treatment which is vital to provide an optimal platform for post-operative recovery and survival. Although CT imaging is a highly effective investigative modality in these cases, operative treatment should not be delayed for a radiological investigation in the presence of abdominal peritonism.

We present a case of mesenteric ischemia in a 32-year-old woman. The rarity of this potentially fatal condition in this age group, the diagnostic and therapeutic challenges associated with such a condition, and secondary causes that must always be investigated are highlighted. In this case, activated protein C resistance resulted in thrombosis of the superior mesenteric artery and subsequent bowel ischemia.

Purpose: To investigate the morphological effects of suprarenal fixation of aortic stent-grafts on the renal artery ostia (RaO) by analysis of suprarenal stent wire distribution and vascular calcification across the RaO using virtual intravascular endoscopy (VIE). Methods: Fourteen consecutive patients (11 men; mean age 75 years) from a single institution were studied following endovascular aortic aneurysm repair (EVAR) using the Zenith endograft system from September 1999 to March 2002. Imaging assessment included computed tomographic (CT) measurement of renal artery intraluminal ostial diameter and quantification and analysis of uncovered stent struts across the RaO and radiological determination of RaO calcification. Morphological changes following EVAR at 3 time points (before and within 1 week after stent-grafting, and at the most recent follow-up) were compared for each patient to determine whether suprarenal stent struts or RaO calcification affected intraluminal ostial diameter. Renal function was assessed by temporal measurements of serum creatinine concentration and creatinine clearance. Results: The renal ostium was distorted to variable degrees in all cases at a mean follow-up of 41±6.6 months. An increase in ostial diameter was identified in most patients if the right RaO was calcified when comparing the 1-week postoperative and most recent follow-up CT images (p0.05). Renal function was not significantly affected. Conclusion: Patients undergoing suprarenal fixation of aortic stent-grafts experienced morphological changes of the RaO to a variable extent at midterm follow-up. Although the presence of stent struts did not significantly affect dimensional changes, we observed that calcification at the renal artery ostium may influence the development of atherosclerotic effects as a direct relationship between the calcification and ostial diameter. Future studies utilizing VIE to determine the long-term safety of this technique in these particular patients requires investigation.

Background Increasing evidence suggests an autoimmune component to abdominal aortic aneurysm (AAA) formation. This study was conducted to determine if a difference exists in human leukocyte antigen (HLA) allele distribution between patients with AAA and population controls, and between patients with small and large AAA. Methods Patients with known AAA attending the vascular unit were consented for recruitment. HLA-A, HLA-B and HLA-DR was determined by polymerase chain reaction and sequence-specific oligonucleotide probes. The distribution of these alleles in the Northern Ireland general population was obtained from the histocompatability and immunogenetics database. The χ 2 test was used for statistical analysis with Bonferroni correction. Results A total of 241 AAA patients were recruited, with a wide range of aneurysm size. In class I, the most frequent allele families were HLA-A*02 and *01 and HLA-B*07, *08, and *44. In class II, HLA-DRB1*03, *04, *07, and *15 were the most frequent. HLA-A*11 was lower in AAA cases (10.4% vs 15.0%; P = .08), whereas HLA-B*08 was lower in the controls (29.8% vs 36.5%; P = .05) and HLA-DRB1*11 was lower in cases (4.2% vs 8.1%; P = .05). After Bonferroni correction, however, the proportion of allele families was not significantly different in AAA patients compared with the proportion seen in controls. HLA-DRB1*11 and *14 had a lower prevalence in large AAAs (0.9% vs 6.7% [ P = .05]; 0.0% vs 5.9% [ P = .03]). HLA-A*68 was also lower in large AAA (1.9% vs 11.9%; P = .0075). After Bonferroni correction, however, no difference was demonstrated between small and large aneurysms. Conclusion This study provides more definitive results on this important subject and has failed to demonstrate the risk association between AAA and these alleles as reported by others. Therefore, the role of these particular genes and the autoimmune component in AAA etiology does not appear to be as crucial as previously proposed.

This study assessed the validity of the Hardman index in predicting outcome following open repair of ruptured abdominal aortic aneurysm and whether this scoring system can be used reliably to select patients for surgical repair. Patients undergoing open repair of ruptured abdominal aortic aneurysm in two university teaching hospitals over a 5-year period were identified from a computerized hospital database. Thirty-day mortality was the main outcome measure. Five Hardman index factors were calculated and related to outcome retrospectively. There were 178 patients with a mean age of 73.9 years (range 51–94) and a male to female ratio of 5.4:1. The overall in-hospital mortality was 57.3% (102/178). Univariate analysis of risk factors showed that age >76 years ( P = 0.007, odds ratio [OR] 2.34, 95% confidence interval [CI] 1.26-4.37) and electrocardiograghic evidence of ischemia on admission ( P = 0.002, OR 3.75, 95% CI 1.57-8.93) were associated with high mortality. However, loss of consciousness ( P = 0.155, OR 1.56, 95% CI 0.85-2.86), hemoglobin P = 0.118, OR 1.89, 95% CI 0.85-4.22), and serum creatinine >0.19 mmol/L ( P = 0.691, OR 1.25, 95% CI 0.42-3.70) were not significant predictors of mortality. Using a multivariate analysis, age >76 years ( P = 0.043, OR 2.29, 95% CI 1.03-5.11) and myocardial ischemia ( P = 0.029, OR 2.93, 95% CI 1.12-7.67) were again found to be the significant predictors of mortality. The operative mortality was 44%, 46%, 68%, 79%, and 100% for Hardman scores of 0, 1, 2, 3, and 4, respectively. No patient had a score of 5. The Hardman index is not a reliable predictor of outcome following repair of ruptured abdominal aortic aneurysm. High-risk patients may still survive and should not be denied surgical repair based on the scoring system alone. Further evaluation of the risk factors is required to reliably and justifiably exclude those patients in whom the intervention is inappropriate.

Since their first description in 1882, malignant neoplasms of the appendix still remain rare. Malignant carcinoid tumours are the most common accounting for 85% of all appendiceal neoplasms. Preoperative diagnosis is invariably difficult, and precise treatment protocols for these neoplasms remain unclear. We reviewed our experience and searched published evidence to produce management guidelines. A retrospective review of all malignant carcinoid tumours diagnosed in our hospital between April 1994 and December 2003 was performed. Patient demographics, operative details, histological types and clinical outcomes were retrieved from case notes supplemented by a questionnaire to the patient's General Practitioner. A literature search was then performed. Nine patients were identified with classical carcinoid tumours (CCT); (M = 3 and F = 6, mean age: 43, range 14-81) and two patients with goblet-cell morphology (F = 2, age 46 and 76). Mean follow-up was 63 months (range 1-125 months). Nine patients were alive at the end of follow-up. Appendicectomy was performed for acute appendicitis. Other appendiceal pathologies were identified following hemicolectomy and oophorectomy. CCT are the most common tumours and have the better prognosis. From our experience and subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for malignant carcinoid tumours. However, small CCTs less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension can be treated by appendicectomy. Following oncological assessment, further adjuvant therapy should be considered for patients with advanced disease.

Background Endovascular repair of abdominal aortic aneurysm (AAA) is increasingly used. We evaluated if a difference exists in the rate of change of the aortic neck diameter between non-ruptured and ruptured AAAs after endovascular aneurysm repair (EVAR). Methods Details of patients undergoing elective (group I) and emergency (group II) EVAR using Talent stents between October 1999 and September 2005 were reviewed. Top neck diameters were prospectively recorded on the hospital database from computed tomography scans preoperatively and at 1, 3, 12, and 24 months postoperatively. The aortic neck diameter rate of change was calculated for each group. Results Endovascular repair was performed on 110 elective and 41 emergency patients, of which 100 (80 male) elective and 29 (26 male) emergency patients were included in this analysis. Mean age was similar in each group. Stents were oversized by 20.9% ± 13.6% in group I and by 24.7% ± 16.3% in group II ( P = .37). The preoperative mean proximal aortic neck was larger in group II (25.0 ± 3.3 mm vs 23.5 ± 2.8 mm; P = .029). The growth rate of the top neck diameter was significantly greater at 12 months (1.48 ± 2.4 mm/year vs 3.89 ± 6.24 mm/year; P = .04) and 24 months (.99 ± 1.1 mm/year vs 2.61 ± 3.3 mm/year; P = .04) in group II than in group I. A decreasing sac size was found in 68.2% of patients whose neck dilated. The complication rate was similar in each group. Conclusion Aneurysm necks in patients with ruptured aneurysms are larger and dilate at a greater rate than those with nonruptured aneurysms. The accelerated rate of expansion in some patients must be borne in mind during follow-up and in secondary endovascular interventions and conversion to open surgery.

Among various methods to achieve rapid occlusion of the aorta during endovascular repair for ruptured abdominal aortic aneurysm, particular emphasis is placed on two techniques that have been incorporated into our endovascular repair practice. The sheath-over-balloon technique (the Loan SOB technique) facilitates hemodynamic stability by transfemoral endovascular placement of an aortic occlusion balloon catheter to the infrarenal abdominal aorta. The balloon-ahead-of-graft technique (the Hornsby BAG technique) allows suprarenal hemodynamic control using a stent-graft system with a built-in balloon. The two techniques are simple, quick, and effective in achieving hemodynamic stability.

Results A sixty-two year-old female presented in May 2009 with an eighteen-month history of dysphagia due to a chronic benign esophageal structure, presumed secondary to previous radiotherapy treatment for breast cancer. She complained of occasional heartburn, indigestion and cough and described a 60lbs weight loss due to tolerance of a liquid only diet. She had a fifteen-year smoking history. She had been undergoing monthly esophageal dilatations over the previous six-months. Multiple previous esophageal biopsies were benign. Clinical assessment was unremarkable. Endoscopic ultrasound demonstrated a tight fibrotic stricture at 26cm.Additional biopsies were again negative for malignancy. She was referred for MIE surgical resection. After creation of the pneumoperitoneum and insertion of four trocars, the short gastric vessels were divided followed by mobilisation of the gastric fundus with preservation of the gastroepiploic artery. High mediastinal dissection was performed to mobilize the esophagus followed by a chemical pyloromyotomy. A mini-right posterior-lateral thoracotomy identified a small caliber esophagus which was dissected free of right bronchial adhesions. The esophagus was subsequently divided proximally and distally followed by a stapled anastomosis. Histopathological analysis confirmed an invasive adenocarcinoma consistent with a breast primary. She remains well four-years post-surgery. Unfortunately, in advanced cases, therapeutic interventional strategies tend to target symptomatic palliation rather than curative resection. Conventional open esophagectomy involves a myriad of incisions depending on the tumour site. These incisions create significant patient morbidity.MIE surgery has evolved to minimise patient morbidity compared to conventional open techniques. Shorter operative times without the need to reposition the patient is cost-effective, whilst preservation of the latisimus dorsi muscle may reduce post-operative pain and improve overall quality of life (QOL) post operatively. The four laparoscopic port sites provide adequate abdominal exposure whilst the mini-thoracotomy facilitates esophageal mobilisation and division. Higher physical function index scores have been reported twenty-four weeks following MIE surgery compared to conventional open surgeries.

This raritymay present a diagnostic challenge related to theinfrequency and the lengthy disease-free survival oftenseen before metastatic presentation. We present a rarecase report of esophageal metastasis from breast cancerafter a 13-year disease-free interval.CLINICAL SUMMARYA 62-year-old woman was seen at our institutionfor consideration of esophagectomy as the result of arecalcitrant esophageal stricture noted to be benign onbiopsy. She had experienced significant dysphagia to allbut liquids since 2007 and during that interval had a60-pound weight loss despite monthly esophageal dilations.Thepatienthadaprevioushistoryofleft-sidedlobularbreastcancer treated with lumpectomy, axillary dissection, andadjuvant chemoradiation therapy in 1994. The stricture waspresumed to be secondary to radiotherapy administered fortreatment of her left-sided breast cancer in 1994. Previousesophagealbiopsiesonmultipleoccasionshaddemonstratedbenign squamous cells with additional atypical glandularcells. An 18 mm 3 15 cm Polyflex esophageal stent(Boston Scientific Corporation, Marlborough, Mass) hadbeen previously deployed for a 7-week period, with acorresponding improvement in swallowing. The stentwas removed after 7 weeks because her swallowing hadimproved but never seemed to be normal.Endoscopic ultrasonography demonstrated a 5-cm tightfibrotic stricture starting at 26 cm where all layers of theesophagus were indistinct from each other. The muscularispropria appeared extremely fibrotic (Figure 1). Additionalbiopsy specimens were taken and again showed nomalignancy. Because of her recalcitrant but apparentlybenign symptomatic stricture, she was offered and thenscheduled for a minimally invasive esophagectomy, aprocedure that is based on a minimally invasive Ivor Lewisprocedure and has been previously described by our ownunit.

Buttressing of the bronchial stump after pulmonary resection has been reported to decrease the prevalence of bronchopleural fistula. This adjuvant maneuver is most commonly performed in patients undergoing resection for infection or in those who have received preoperative radiation. The anatomic location of the upper lobe bronchus often makes it difficult to create a tension-free flap using muscle or pericardial fat. Parietal pleura is often mobilized for such cases. We present a case in which the parietal pleura was not available, and the right inferior pole of the thymus was used for bronchial coverage following upper lobectomy.

Portomesenteric venous thrombosis (PMVT) is an uncommon complication of abdominal surgery. The objective of this study was to assess PMVT risk factor profiles and patient outcomes after colorectal surgery. A single center retrospective review of patients undergoing colorectal surgery was performed (2007–2012). PMVT was defined as thrombus within the portal, splenic, or superior mesenteric vein on computed tomography (CT). Inferior mesenteric vein thrombosis was excluded. Independent samples t test was used to compare data variables between PMVT and non-PMVT patients. Univariate and multivariate logistic regression analyses were used to assess PMVT risk factors. There were 1,224 patients included (mean age 62 years, male = 566). Elective bowel resection was performed for colon carcinoma (n = 302), rectal carcinoma (n = 112), ulcerative colitis (n = 125), Crohn’s disease (n = 78), polyps (n = 117), and diverticulitis (n = 215). Patients undergoing gynecological resections and emergent laparotomies were included (n = 275). Thirty-six patients (3 %) were diagnosed with PMVT by CT: 17/36 on initial presentation and 19/36 by expert radiologist review. Patients with PMVT were younger (53 vs. 62 years, p = 0.001) with higher BMI (30.5 vs. 26.7, p

Summary Objective Current clinical evidence reports that antiplatelet, statin, angiotensin-converting enzyme inhibitor and beta blockade therapies have advantageous effects on vascular surgery patient morbidity and mortality. Unfortunately, such patients appear to be less likely to receive optimal medical management when compared with coronary artery disease patients. This study assessed medical therapy prescribing in patients attending a regional vascular surgery unit. Methods A retrospective review between February 2010 and February 2011 was performed for patients undergoing aortic aneurysm, carotid, peripheral arterial and amputation surgeries. Gender, age, smoking history, body mass index and cardiovascular risk factors were documented from inpatient charts. Current admission medications and subsequent modification by the vascular team were recorded. Results Two hundred and forty-four patients (male = 165, mean age = 71 years) were identified. Prevalence of hypertension, hypercholesterolaemia, myocardial infarction, angina, stroke and diabetes was higher than in the general population. A total of 201 (82.3%) patients were on antiplatelets or antithrombotics upon admission to the vascular ward, which was improved to 231 (94.6%) patients on discharge. A total of 180 (73.7%) patients were on lipid-lowering therapy upon admission, which was improved to 213 (87.2%) patients on discharge. A total of 115 (47.1%) patients were on ACE-inhibitor or angiotensin 2 receptor blocker medications on admission and this was improved to 118 (48.3%) upon discharge. A total of 87 (35.6%) patients were on a beta-blocker, which was improved to 93 (38.1%) patients upon discharge. Conclusion Despite increased implementation of best medical therapy in the community with compliance rates greater than 73% for aspirin and statin therapy, further improvement is warranted. Vascular surgeons should remain vigilant for further opportunities to optimise medical therapy in this high-risk patient group particularly with antithrombotic, lipid lowering and antihypertensive therapies.

Glomus tumors are rare benign myoepithelial neoplasms that can present with intractable pain. We report the case of a 59-year-old gentleman who presented with upper abdominal and chest pain caused by a posterior mediastinal glomus tumor arising from the spinal column, which required surgical resection. As glomus tumors usually develop in the limbs, this case highlights the complexity of diagnosis and treatment of glomus tumors when they present in rare locations.

We describe the successful percutaneous treatment of acute-on-chronic IVC thrombosis 30 years following previous placement of Adams-DeWeese clip.

Objective Extracranial carotid artery aneurysms (ECCAs) are extremely rare with limited information about management options. Our purpose was to review our institution's experience with ECCAs during 15 years and to discuss the presentation and treatment of these aneurysms. Methods A retrospective review of patients diagnosed with ECCAs from 1998 to 2012 was performed. Symptoms, risk factors, etiology, diagnostic methods, treatments, and outcomes were reviewed. Results During the study period, 141 aneurysms were diagnosed in 132 patients (mean age, 61 years; 69 men). There were 116 (82%) pseudoaneurysms and 25 (18%) true aneurysms; 69 (49%) aneurysms were asymptomatic, whereas 72 (52%) had symptoms (28 painless masses; 10 transient ischemic attacks; 10 vision symptoms; 9 ruptures; 8 strokes; 4 painful mass; 1 dysphagia; 1 tongue weakness; 1 bruit). Causes of true aneurysms included fibromuscular dysplasia in 15 patients, Ehlers-Danlos syndrome in three, Marfan syndrome in one, and uncharacterized connective tissue diseases in two. Of 25 true aneurysms, 11 (44%) were symptomatic; 15 (60%) true aneurysms underwent open surgical treatment, whereas 10 (40%) were managed nonoperatively. Postoperative complications included one stroke during a mean follow-up of 31 months (range, 0-166 months). No aneurysms managed nonoperatively required intervention during a mean follow-up of 77 months (range, 1-115 months). Of 116 pseudoaneurysms, 60 (52%) were symptomatic; 33 (29%) pseudoaneurysms underwent open surgery, 18 (15%) underwent endovascular intervention, and 65 (56%) were managed medically. Pseudoaneurysm after endarterectomy (28 patients; 24%) presented at a mean of 82 months from the surgical procedure. Mean follow-up for all aneurysms was 33.9 months. One (0.7%) aneurysm-related death occurred (rupture treated palliatively). No patient undergoing nonoperative management suffered death or major morbidity related to the aneurysm. Nonoperative management was more common in asymptomatic patients (71%) than in symptomatic patients (31%). Conclusions ECCAs are uncommon and may be manifested with varying symptoms. All segments of the carotid artery are susceptible, although the internal is most commonly affected. Open surgical intervention was more common in patients with symptoms and with true aneurysms. Patients with pseudoaneurysms were more likely to undergo endovascular intervention. Nonoperative treatment is safe in selected patients.

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.