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OBJECTIVES: Antiplatelet therapy following peripheral arterial endovascular intervention lacks high quality evidence to guide practice. The aim of this study was to assess the effect of three months of dual antiplatelet therapy on amputation-free survival following peripheral arterial endovascular intervention in patients with chronic limb threatening ischemia. METHODS: A retrospective review of symptomatic patients undergoing primary peripheral arterial endovascular intervention over a seven-year period was performed. The primary outcome measure was amputation-free survival. A sample size calculation based on previous cohort studies suggested that 629 limbs would be required to show a difference between single and dual therapy. Kaplan-Meier estimates and multivariate logistic regression analysis of recorded baseline characteristics was performed to determine predictors of amputation-free survival. Dual antiplatelet therapy was routinely given for 3 months. RESULTS: 754 limbs were treated with primary angioplasty and/or stenting over a 7-year period, 508 of these for chronic limb threatening ischemia. There was no difference in unadjusted amputation-free survival between patients with chronic limb threatening ischaemia taking single vs. dual antiplatelet therapy (69% vs. 74% respectively Log rank Chi2 = 0.1, p = .72). After adjusting for confounders, at 1 year there was also no significant difference in amputation-free survival between patients taking single vs. dual antiplatelet therapy [OR 0.8, 95% CI 0.5-1.2, p = .3]. There was no difference in rates of major bleeding between single and dual antiplatelet therapy. CONCLUSIONS: There was no clear evidence of reduced amputation-free survival in patients with chronic limb threatening ischemia undergoing peripheral arterial endovascular intervention being treated with dual antiplatelet therapy for 3 months. This is at odds with other retrospective case series and highlights the limitations in basing clinical practice on such data. There is a need for an adequately powered, independent randomised trial to definitively answer the question.

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PURPOSE: To describe the use of a re-entry catheter in the endovascular treatment of left subclavian stenosis. MATERIALS AND METHODS: We present three patients where initial attempts at re-vascularisation using standard techniques were unsuccessful. An OUTBACK catheter was employed to facilitate re-entry in these patients. RESULTS: True lumen re-entry was achieved in all patients, leading to successful treatment of all stenoses. There was a lack of filling of the left vertebral artery post-angioplasty in one patient; this was not clinically significant. CONCLUSION: The case series presented is encouraging for the use of a re-entry catheter in the treatment of subclavian occlusion. In our limited experience this has proved to be a safe technique for use in patients who fail re-vascularisation by standard methods; a larger study is required to confirm this.

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We present a case of a pseudotumor causing a deep femoral vein thrombosis 16 months after undergoing a metal-on-metal total hip arthroplasty. There is increasing concern over the effect of metal ions that are produced by wear in metal-on-metal hip arthroplasty systems. Recently, a number of articles have reported the development of an inflammatory pseudotumor causing a number of different problems early on in the lifespan of the implant necessitating revision surgery. This case reports the first presentation of a pseudotumor causing a serious venous thrombosis due to pressure effect and indicates further possible evidence for caution when considering metal-on-metal bearing hip arthroplasty.

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STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To present our institution's experience of selective embolization of renal angiomyolipomas with alcohol and the long-term follow up data. PATIENTS AND METHODS: This retrospective study included 34 patients treated between October 1997 and October 2007 (29 women and five men, mean age 44 years). Of these patients, nine had tuberous sclerosis, 14 were bilateral and 16 were multifocal. Indications for treatment were previous haemorrhage (14), size >4 cm (19) and increasing size over a short period (one). The largest treated lesion was 24.4 cm, and the mean (range) size was 11.9 (2.9-24.4) cm. All patients were treated by selective embolization using a mixture of alcohol and lipiodol. Three patients also had coiling of aneurysms and two patients had additional embolization with polyvinyl alcohol particles. The follow-up was both radiological and clinical, with recurrence defined as growth by >2 cm or symptoms requiring further treatment. RESULTS: The technical success rate was 100%, with only one significant complication of non-target renal embolization, with self-limiting effects. Minor complications included 11 patients with post-embolization syndrome, all of which settled with conservative measures. The mean (range) combined radiological and clinical follow-up was 44.2 (12-116) months, with all patients having a follow-up of >1 year. Radiological success was achieved in 97%, with only one lesion growing by >2 cm. The combined clinical and radiological success rate was 85%, with two patients undergoing surgery, two having repeat embolization and one currently offered surgery due to a recent increase in size. CONCLUSION: Our study provides long-term evidence that selective arterial embolization with alcohol is a safe and effective method for improving clinical symptoms (85%) and preventing tumour progression (97%) in patients with renal angiomyolipoma.

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