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UNLABELLED: Vascular complications following total knee arthroplasty (TKA) are rare in the general population; however, the consequence could be devastating and limb threatening. Many of the patients who develop these complications, if not all, have pre-existing peripheral vascular disease (PVD). Following guidelines in the pre-operative assessment, intra-operative procedure and post-operative management in this group of patients can help orthopaedic surgeons to assess candidates for TKA and trim down the arterial complications afterwards. OBJECTIVE: To propose a strategy to assess TKA candidates with underlying PVD, in order to address the increasing concerns of the orthopaedic surgeons with regard to the likelihood of vascular complications in these patients. METHODS: Review of the literature looking for relevant studies and case reports using different medical search engines (PubMed, EMbase and Cochrane Library). RESULTS: Our search produced very few studies relevant to our topic. Most of these are case reports dealing with various vascular complications following TKA and are therefore not helpful in making conclusive recommendations. However, there are a handful of studies that have specifically addressed this issue and have been included in our review. CONCLUSION: Vascular complications following TKA are rare (<0.5%). There are conflicting views in the literature with regard to the optimum management of these patients. However, patients with risk factors of PVD should be referred to the local vascular surgeons for assessment prior to TKA. The use of tourniquet in these patients is generally not recommended and should be based on the advice obtained from vascular surgeons. Individual orthopaedic surgeons or units, together with their vascular colleagues, should have agreed protocols for pre- and post-operative vascular assessments of patients undergoing TKA.

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OBJECTIVES: To determine the prevalence of asymptomatic carotid artery stenosis (ACAS) in patients with peripheral vascular disease (PVD). METHODS: Literature search was carried out through Pubmed, Medline and Cochrane library. Prospective studies published on prevalence of significant carotid stenosis in patients with PVD and used a duplex scan for screenings were included. RESULTS: Nineteen studies with a total of 4573 patients were included. A prevalence of 28% (fixed effect model) and 25% (random effect model) was seen for >50% stenosis, and 14% (in both fixed and random effect models) for 70% stenosis. Significant statistical heterogeneity existed between studies (I(2)=82.7%, >50% group) (I(2)=77.5%, >70% group). Larger studies revealed a higher prevalence of carotid stenosis. CONCLUSION: High prevalence of ACAS exists in patients with PVD. A large multi centre prospective study may help to combat heterogeneity and identify subgroups of PVD patients with higher prevalence. Clinicians who believe in the benefits of carotid endarterectomy for asymptomatic carotid stenosis would gain a greater yield by targeting this group for routine screening rather than a healthy population.

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OBJECTIVE: To quantify the risk of DVT in arterial surgery, and to assess the need for prophylaxis. METHODS: A search was carried out through Medline, Embase and Cochrane databases to identify published studies on DVT in arterial surgery. To quantify the risk of DVT both randomised and prospective non-randomised studies were included for analysis. However, to assess the need for prophylaxis only randomised controlled trials were considered. RESULTS: Twenty three prospective studies that evaluated DVT in arterial surgery were identified. Ten reported data about DVT in aortic surgery, seven studies evaluated DVT in general vascular surgery, three studied DVT in infra-inguinal vascular surgery and three studied DVT incidence in patients after limb amputations. CONCLUSION: There is a wide variation in the reported incidence of DVT in arterial surgery (2%-24%). This is mostly due to the diversity of screening methods used and the inclusion or exclusion of below knee DVT. There is insufficient evidence to make a valid conclusion regarding the routine use of anticoagulants prophylaxis in arterial surgery. However, until such evidence becomes available, DVT prophylaxis in patients undergoing arterial surgery will continue to be guided by evidence gained from studies of general surgical patients.

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OBJECTIVES: To establish the incidence, costs and causes of medical negligence claims in relation to vascular surgery in the UK's NHS. METHODS: All claims related to vascular surgery reported to the NHS Litigation Authority from April 1995 to April 2007 were included in the study. Data was subsequently reviewed, coded and analysed. RESULTS: 395 claims were identified (mean: 49/year over last 5 years) of which 303 had been settled. Damage compensation was given in 160 cases, with overall litigation costs of approximately 17 million pounds (21 million euros). The main complaint reasons in successful claims were intra-operative problems (50%), failure/delay of treatment (14%) and failure/delay of diagnosis (11%). Varicose vein (VV) surgery was involved in 48% of successful claims, with intra-operative nerve and vessel damage being the major causes. Peripheral vascular disease (PVD) and abdominal aortic aneurysm (AAA) disease were the next two types of disease/procedures involved in successful claims with 21% and 6% respectively. CONCLUSIONS: The number of claims related to vascular surgery has remained stable over the past 5 years. Improved consenting and higher surgical skill levels especially in relation to VV surgery and increased diagnostic vigilance in PVD, AAA disease and infections are potential areas for future improvement.

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BACKGROUND: Deep vein thrombosis (DVT) is one of the most common, preventable complications of surgery. Although the relationship between surgery and DVT is well established in general surgical operations and most other subspecialties, the same cannot be said about arterial surgery. Deep vein thrombosis is believed to be less common in aortic surgery where its management is rather controversial with a reported incidence of DVT from 2% to 18%.Intra-operative heparin is believed to provide protection during the period when DVT is most likely to develop. However, the practice of using intra-operative heparin could increase the risk of haemorrhagic complications if further heparin is used during the recovery period. This can significantly limit the use of such prophylactic measures especially with the low perceived risk of venous thromboembolism (DVT or pulmonary embolism (PE)) following abdominal aortic surgery. However, vascular patients are usually older, with more co-morbidity and are subject to prolonged immobility, all of which increase the likelihood of developing venous thromboembolism. OBJECTIVES: To determine the efficacy of anticoagulant prophylaxis (with or without mechanical devices) in patients undergoing surgery for abdominal aortic aneurysm. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched 8 August 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, (last searched Issue 3, 2007). The authors searched for additional trials through reference lists of retrieved studies and conference proceedings. SELECTION CRITERIA: Randomised controlled trials comparing the use of anticoagulants (with or without mechanical devices) with control or no intervention in preventing DVT or PE after abdominal aortic operations. DATA COLLECTION AND ANALYSIS: Three authors independently selected potential trials and assessed trial quality. MAIN RESULTS: Two studies (n=147) were included. Both studies had methodological limitations. There were no data to indicate that post operative anticoagulation, with or without the use of mechanical devices, can safely reduce the incidence of DVT after aortic surgery. Neither study reported a significant effect of anticoagulants on the incidence of PE or related mortality. One study was terminated before recruiting sufficient participants due to a higher incidence of bleeding with the use of anticoagulants. The incidence of minor bleeding events was also slightly higher with anticoagulants. AUTHORS' CONCLUSIONS: There is not enough evidence to make a definitive conclusion about the use of anticoagulant drugs (with or without mechanical devices) for DVT prophylaxis in patients undergoing abdominal aortic surgery.

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PURPOSE: To compare results of carotid Doppler ultrasound (CDUS) and spiral computerised tomographic angiography (CTA) in patients with suspected carotid artery stenosis and to evaluate their combined effect on decision making for carotid endarterectomy (CEA). METHODS: A total of 107 patients were studied. All of the patients had CDUS followed by CTA as a standard method of investigation. Data included the indications for investigation, stenosis degree measured in both modalities, in addition to difficulties and limitations faced while doing them. RESULTS: Out of the 214 carotid scans performed, 187 scans were included in the comparison, while 27 scans were excluded due to inadequate data or imaging difficulties. The overall concordance between both CDUS and CTA was 79.1% (148/187) (95% CI 0.72-0.83). CDUS under-estimated and over-estimated the degree of stenosis in 26/187 (14%, 95% CI 0.09-0.19) and 13/187 (7%, 95% CI 0.04-0.12), respectively. When CTA was considered in conjunction with CDUS, the decision regarding operative treatment was changed in 29/187 cases (16%) (95% CI 0.11-0.21). CONCLUSIONS: CDUS remains the first line non-invasive imaging for carotid artery stenosis. However, in cases where it is inconclusive, CTA is an excellent, reliable, minimally invasive, and outpatient alternative for patient selection for CEA.

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OBJECTIVE: To review the role of CRP as a marker for the prediction of development of Peripheral Vascular Disease (PVD) and as a prognostic indicator. METHODS: Search of the Cochrane Vascular Group Control Trials Register, Medline and Embase for all published studies on the role of CRP as a marker in peripheral vascular disease was undertaken.13 prospective studies were found. RESULTS: 12 of the 13 prospective studies showed a strong association between CRP and PVD. Three population studies involving 16,561 people, over a period of 6.5 to 12 years, revealed that high CRP levels approximately tripled the risk of developing PVD, independently of all other risk factors. Three case-control studies found that hsCRP was much higher in patients with PVD. Four other studies, which covered 2337 people, demonstrated that CRP levels were associated inversely with lower ankle brachial pressure index. One study conducted on 384 people failed to show a link between hsCRP and progression of ABPI. Two further small studies showed that raised pre and post intervention hsCRP were associated with restenosis after angioplasty. CONCLUSIONS: CRP appears to be a strong predictor and marker of severity of PVD and also may predict the risk of restenosis after angioplasty.

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Hypothenar hammer Syndrome (HHS) is a condition characterised by digital ischaemia as a result of repetitive trauma to the hypothenar eminence of the hand. It occurs in people who repeatedly use the palm of the hand as a hammer to push, grind or twist objects. It is a curable and a preventable cause of upper digital ischemia. In this report we present a case of HHS and discuss the causes and pathogenesis of this syndrome. We review the incidence, clinical characteristics, differential diagnosis, investigation and treatment.

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AIMS: To review the available literature regarding patency rates and complications of the brachial-basilic arterio-venous fistula (BBAVF) and to discuss this with relation to the current dialysis outcomes quality initiative guidelines. METHODS: An internet based literature search was performed using Pubmed, Medline and Medscape databases to identify all published reports of the BBAVF in the English language from which the full articles were retrieved and cross-referenced. RESULTS: Of 136 papers identified, 28 were directly relevant to this review including four prospective studies (one randomised trial, three non-randomised trials) and 24 retrospective studies. First described by Dagher in 1976, the BBAVF has since been modified to a two-stage procedure with initial fistula formation followed by superficialisation of the basilic vein 6 weeks later. It can be formed successfully in 95% of cases. Mean 1-year primary and secondary patency rates were 72 and 74.6%, respectively. Complications included haematoma (3.8%), stenosis (2.3%), thrombosis (9.7%), transient arm oedema (3.7%), steal syndrome (2.9%) and aneurysm/pseudoaneurysm formation (1.9%). The BBAVF had a lower rate of infection than prosthetic fistulas (3.6 vs. 16%). CONCLUSIONS: The BBAVF has good primary and secondary patency rates with lower rates of infection than prosthetic fistulas making it a preferred secondary access procedure.

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OBJECTIVES: To quantify the risk of venous thromboembolism (VTE) following air travel and assess methods of prevention. DESIGN: Review of literature. METHODS: We reviewed Pubmed, Medline, Embase and Cochrane Databases for studies that have assessed the risk of VTE associated with air travel. RESULTS: There is an association of VTE with air travel with pooled odds ratio of 1.59 (confidence interval 1.04-2.43) from three case control studies and relative risk of 2.93 (confidence interval 1.5-5.58) from two controlled cohort studies. The incidence of symptomatic pulmonary embolism (PE) is extremely low but there is substantial increase when the distance travelled is more than 5,000 miles (1.5 PE per million passengers) or time of flight is more than 8h duration (2.57 PE per million passengers). The quantitative risk of lower limb venous thrombosis in high-risk subjects is 5% per flight and 1.6% per flight for low risk subjects following long haul flights. All six randomised trials to test the below knee compression stockings with ankle pressures of 14-30 mmHg have shown reduction in lower limb venous thrombosis. CONCLUSION: VTE is more common in those with additional risk factors when the risk is about 5% per air travel for long haul flights. Class I or II below knee compression stockings are effective in the prevention of lower limb venous thrombosis.

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BACKGROUND: The isolated internal iliac artery aneurysm (IIIAA) is rare but rupture has a high mortality rate. This paper reviews the available literature regarding the epidemiology, aetiology, natural history, diagnosis and management with a focus on aneurysms of atherosclerotic origin. METHODS: A literature search was performed using internet databases PubMed, Medline and Medscape followed by manual cross referencing of relevant articles. Data were retrieved from the papers, tabulated and analysed to form a review of atherosclerotic IIIAA. RESULTS: Three hundred and seventy-two papers were found relating to internal iliac artery aneurysms in general and 82 were directly relevant to this paper, reporting 94 cases of atherosclerotic IIIAA. For atherosclerotic aneurysms, the median (range) age was 71.9 (47-89) years and 95% were male. The natural history is unclear but is probably one of increasing size, with corresponding increased risk of rupture. Presentation was with rupture in 40%, leading to rapid death if untreated. The death rate in the group as a whole was 31%. The median (range) size of aneurysms at diagnosis was 7.7 (2-13) cm and death was significantly associated with rupture (Spearman correlation coefficient r=0.327, p=0.007). Symptoms included abdominal pain (31.7%), urological symptoms (28.3%), neurological symptoms (18.3%), groin pain (11.7%), hip or buttock pain (8.3%) and gastrointestinal symptoms (8.3%). Diagnosis may also be coincidental as a result of investigation for other conditions. Of particular use in diagnosis and assessment are ultrasound, computerised tomography and magnetic resonance angiography. Surgical treatment is difficult but can be achieved by ligation, excision or endoanneurysmorrhaphy. More recently, radiological treatments include coil embolisation and endoluminal stenting (often in combination) with the established advantages of endovascular repair have yielded promising short term results, although long term follow-up is required to assess complications and the durability of the devices. CONCLUSIONS: Atherosclerotic IIIAA is a rare condition and if undiagnosed is often fatal. Early diagnosis and treatment may reduce morbidity and mortality particularly with the advent of endovascular techniques.

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OBJECTIVES: To describe a modification in brachio-cephalic fistula formation for prevention of dialysis access-associated steal syndrome (DASS). DESIGN: Short report. MATERIALS: From September 2001 to December 2003, 32 upper arm autogenous fistulae were formed using the 'extension technique' in patients at high-risk for developing DASS i.e. diabetics. METHODS: In this technique, the fistula is formed by anastomosing the median vein to the radial or ulnar artery just below the brachial bifurcation, thus preserving part of the blood supply to the hand, to prevent steal syndrome. All patients were evaluated for patency, adequacy of needling and the absence of steal symptoms. RESULTS: Only 1 patient (3.1%) developed DASS. On investigation, he was found to have the fistula formed distal to the origin of a posterior branch with the bifurcation further distally. Symptoms improved with revision of the fistula. Thrombosis of the cephalic vein (6.2%), difficulty in needling (3.1%) and deep cephalic vein in upper arm that required superficialization (15.6%) were the other complications noted. CONCLUSIONS: The 'extension technique' has been found to be a safe and effective procedure for prevention of DASS, with a good patency rate. Additional advantage of this technique is maturation of both cephalic and basilic veins.

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OBJECTIVES: To review the importance, clinical features, investigations, management and prognosis of non-traumatic vascular injuries, affecting the lower limbs of endurance athletes. DESIGN: Review of literature. MATERIALS AND METHODS: A literature search was conducted from Medline, Pubmed, the National Electronic Library for Health, Google and Yahoo search engines for related articles and case reports regarding non-traumatic vascular complications involving the lower limb of endurance athletes. CONCLUSIONS: Non-traumatic vascular complications affecting the lower limbs include endofibrosis, stenosis/kinking of iliac arteries, dissection of external iliac artery, adductor canal syndrome, popliteal entrapment syndrome, chronic exertional compartment syndrome and effort-induced venous thrombosis. These are important as they affect athletes at the peak of their career and can be confusing to diagnose. The management is relatively well documented and produces good results in short term but the long term results are not known.

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Approximately 1-2% of the UK population suffers from venous ulcers. Incompetent perforator leg veins are thought to be a major contributory factor. Subfascial endoscopic perforator surgery treats incompetent perforators in a minimally invasive fashion with significant improvement in wound healing and reduction in ulcer recurrence rates.

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Thrombophilia may be defined as the tendency to arterial or venous thrombosis. Thrombophilia can be acquired or hereditary. Acquired conditions leading to arterial thrombosis are commonly encountered in vascular surgical practice, but less well known is the potential influence of genetic factors. In recent years, evidence has accumulated for a crucial role of genetic factors in the pathogenesis of venous thrombosis, many previously unknown genetic defects having been recently identified. The role of genetic predisposition for the pathogenesis of arterial occlusive disease on the other hand is unknown, although recent publications suggest a definite link. This may have implications for the vascular surgeon in the management of patients with arterial disease. A medline search was performed in order to identify papers published between 1990-2002 on thrombophilia, arterial disease and peripheral arterial occlusive disease (PAOD). With regard to venous thrombosis we obtained a much wider knowledge about genetic defects leading to thrombophilia. This has altered the diagnostic and therapeutic approach to patients with venous thrombosis, and has had an important influence on counselling and screening of family members, especially females of childbearing age. With regard to arterial thrombosis, certain thrombophilic disorders have a definite pathophysiological role. Hyperhomocysteinaemia, inherited or acquired, has been demonstrated to be an independent risk factor for athero-thrombosis. The antiphospholipid antibody syndrome (APS), an acquired condition, also predisposes to arterial thrombosis. Other thrombophilic conditions, such as prothrombin gene G20210A variant or factor V Leiden, have been investigated, but current evidence does not unequivocally support the hypothesis of a pathophysiological role in athero-thrombosis. Routine screening for thrombophilia in patients with athero-thrombosis is therefore not generally recommended on the basis of current evidence, but there is a role for selective screening.

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AIM: To determine the results of transluminal angioplasty in patients with Brescia-Cimino arteriovenous fistulae. PATIENTS AND METHODS: Thirty-one patients underwent transluminal angioplasty of 36 stenotic lesions related to Brescia-Cimino arteriovenous fistulae over a 5-year period. The lesions treated were characterized by review of pre-angioplasty fistulograms. Medical and radiological records were reviewed to assess medium-term patency of each patient's fistula. RESULTS: Angioplasty was performed successfully in 28 out of 31 patients initially (90% technical success rate). Duration of follow-up for the 31 patients ranged from 4 to 65 months (median = 34 months). At 6 months, seven patients required further surgical or endovascular intervention (18 patients remained event-free) and at 1 year, 10 patients required further endovascular or surgical intervention (14 patients remained event-free). Life-table analysis revealed primary patency rates of 77%, 64% and 39% at 6 months, 1 year and 2 years, respectively. At 6 months and 1 year, four and five patients, respectively, required surgical revision or closure of fistula. Secondary patency rates were 85%, 81% and 65% at 6 months, 1 year and 2 years, respectively. All patients with a primary patency at 2 years remained event-free during the follow-up period. CONCLUSIONS: Transluminal angioplasty is an effective treatment for stenoses developed in relation to Brescia-Cimino haemodialysis fistulae. Further endovascular procedures may be required, especially in the first 24 months, to preserve patency. These techniques extend the lifetime of fistulae, thereby preserving proximal venous access sites for future use. Our result is in broad agreement with results from other series.

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In June 1989, we set out to implant 200 albumin-coated aortic bifurcation grafts and to track the patients for a period of 5 years to determine whether coating the prosthesis with albumin affected the patency or the incidence of complication. Two hundred and one prostheses were implanted between June 1989 and July 1991. The primary and secondary patency at 5 years was 95% and 98%, respectively. No relation between gender and patency or between the state of the runoff and patency was found, but there was a statistically significant relation between age and patency (p = 0.00). Graft infection was recorded in three patients (1.5%). There were no instances of bleeding through the graft at the time of implantation. The mean intra- and postoperative blood requirement was 2 units. There have been no incidences of false aneurysm in the groin. We conclude that there are no disadvantages of coating the prosthesis with albumin, and a trial of coated versus uncoated prostheses would be impractical.

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Transcranial Doppler ultrasound measurement of the velocity of blood flow in the middle cerebral artery (MCA) was performed in 24 consecutive patients undergoing carotid endarterectomy. Measurements were performed preoperatively at rest, following common carotid artery compression, and continuously during surgery. In addition, internal carotid artery stump pressures were measured and a subjective assessment of back flow was made. No relationship between MCA flow velocity and stump pressure following carotid clamping was demonstrated. Peak and mean MCA flow velocity was significantly lower in patients with stump pressures < 30 mm Hg (p < 0.03) and those with poor back flow (p < 0.02).

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A randomized placebo-controlled study was undertaken in 188 patients with severe intermittent claudication attending two vascular clinics in Manchester and Liverpool. After a 4-week run-in period, patients received active or placebo treatment for 24 weeks. Patients were assessed on a treadmill prior to the 4-week run-in period, at randomization, and at 8, 16, and 24 weeks. Outcome was measured in terms of change in pain-free walking distance, maximum walking distance, and pressure indices. In this severe claudication population, in which the patients presented with a mean pain-free walking distance of 60 m, an intention-to-treat analysis demonstrated that the outcome in the naftidrofuryl-treated group was significantly better than in the group receiving placebo (p = 0.045). Additionally, 7% of patients in the naftidrofuryl group deteriorated compared with 22% in the placebo group (p = 0.005). Of the various risk factors that were recorded during the study--smoking habits, the presence of hypertension, diabetes, obesity, and duration of illness--only duration of illness had a significant influence on outcome. Maximum walking distances alone were not significantly influenced by treatment, but the use of a combined index of pain-free walking distance, maximum walking distance, and pressure indices to record success or failure confirmed a significant treatment effect (p = 0.047). A higher incidence of minor gastrointestinal symptoms was recorded in the naftidrofuryl-treated group. Treatment with naftidrofuryl was shown to prevent or slow the deterioration observed in a group of patients with severe claudication over a 24-week period.

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