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Endoleaks are defined as persistent perfusion of an abdominal aortic aneurysm (AAA) after endovascular stent-graft deployment. The authors describe their experience treating six endoleaks with the liquid embolic agent Onyx (ethylene-vinyl-alcohol copolymer). Complete endoleak occlusion was achieved in five of six cases. Follow-up imaging has demonstrated decreased aneurysm diameter in all patients 7-29 weeks (mean = 19.2 weeks) after treatment.

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OBJECTIVES: To assess patient waiting times for vascular surgery and to determine if complications of the disease develop while the patients are awaiting surgery. DESIGN: Prospective cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: All 554 patients who underwent scheduled vascular surgical procedures between April 1995 and October 1996. OUTCOME MEASURES: A literature review carried out to develop guidelines for acceptable waiting times for surgery associated with various vascular disorders based on their natural history (benchmark target); actual waiting times, defined as the interval from the date each patient was booked for surgery to the date of admission to hospital for the procedure; the proportion of patients admitted within the benchmark targets; and whether prolonged waiting time placed patients at risk for complications of their disease. RESULTS: Of the 554 patients, 382 (69%) were admitted within the benchmark waiting times. Of 84 patients having an abdominal aortic aneurysm, the aneurysm ruptured during the waiting period in 6, and 4 of them died, for a complication rate of 7% and a death rate of 5%. Two of the 6 aneurysms ruptured after the patient had waited longer than the target time. Three of 100 patients with symptomatic carotid artery stenosis awaiting admission for carotid endarterectomy suffered ischemic stroke, for a 3% complication rate; all had waited longer than the target period. One patient suffered occlusion of a femoropopliteal bypass graft while awaiting revision of a stenosed bypass graft. CONCLUSIONS: This study suggests that although most patients are admitted for operation within the benchmark time, one-third are admitted late and may suffer serious complications of their disease while awaiting admission for the procedure.

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The purpose of this study was to determine the efficacy of intraoperative intraarterial urokinase (UK) in patients who suffered an acute stroke immediately following carotid endarterectomy (CEA). From January 1995 to March 1998, 823 carotid endarterectomies were performed. The subsequent results showed that intraarterial UK in the setting of early post-CEA neurologic events appears to be safe and may be a useful adjunct to re-exploration in improving neurologic outcomes.

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In the United States, the Phase I Feasibility Study under IDE G970065 was approved by the Food and Drug Administration on 04/11/97. The approved protocol called for implantation of the bifurcated Talent spring stent-graft system on patients who are high-risk candidates for conventional surgery because of cardio-respiratory, medical, general, or local anatomical reasons which would likely complicate the technical execution of the operation or be accompanied by a high expected mortality rate. Patient enrollment was complete with 16 cases as of September 26, 1997. This was a multicenter experience involving five different sites. This is an ongoing study and patients, of course, will continue to be followed longitudinally. Phase II will likely be approved by the FDA for initiation in January or February of 1998. Standard-risk AAA patients will be entered into the study at this time; comparison with concurrent controls will be used for comparison with conventional surgery.

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A nine-year-old neutered male cat developed an osteosarcoma 15 months after the surgical repair of the proximal femur using an intramedullary pin at the fracture site. The repair had been effective with good healing of the fracture and restoration of normal activity.

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Sclerotherapy treatment of varicose and telangiectatic leg veins is becoming a popular treatment in North America. Since the tools for performing this treatment are inexpensive and readily available, many health care practitioners are performing this technique with variable states of expertise and outcome. Understanding the professional and ethical issues facing phlebology nurses in Canada can enhance the care of phlebology patients in the United States.

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The authors report their initial experience in 52 patients with three different techniques of peripheral artery atherectomy--the Tracwright (Kensey), used in 19 patients, the Simpson AtheroCath, used in 19 patients and the transluminal extraction catheter, used in 14 patients. The indications for atherectomy were claudication in 42 (80%) and limb-threatening ischemia in 10 (19%). There were no deaths. Complications included three arterial perforations, one thrombosis and one groin hematoma requiring operative evacuation. There were no distal embolizations. Atherectomy was initially unsuccessful in 15 (29%) patients. For the successfully completed procedures, the 1-year primary patency rates were as follows: Tracwright (Kensey) catheter 56%, Simpson catheter (63%) and transluminal extraction catheter (0%). Use of subsequent nonoperative procedures on recurrent stenoses produced secondary patency rates of 77% for the Tracwright (Kensey) technique, 80% for the Simpson catheter technique and 78% for the transluminal extraction catheter technique. The authors conclude that their early results justify further evaluation of these three techniques. Use of the transluminal extraction catheter is associated with higher rates of occlusion and restenosis.

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Percutaneous balloon angioplasty is a recognized treatment for peripheral atherosclerosis involving the iliac and femoropopliteal segments. From their experience in 38 patients the authors have examined the efficacy of intraoperative balloon angioplasty for tandem lesions requiring both balloon angioplasty and surgical intervention. Between January 1988 and July 1990, 43 intraoperative balloon angioplasties were performed in 19 women and 19 men who required inflow or outflow angioplasty in addition to surgical bypass. The indication for surgery was incapacitating claudication in 32 (74%) patients and limb salvage in 11 (26%) patients. Initial technical success was achieved in 17 (89%) of 19 patients who required iliac surgery and in 22 (92%) of 24 patients who required femoropopliteal balloon dilatations. There were four major complications (9%), all requiring surgical intervention. In two cases there was dissection with thrombosis and in two cases failure to improve the pressure gradient. Patients were followed up for up to 24 months. Two of the inflow angioplasties failed between 6 and 9 months. Two of the outflow angioplasties failed between 12 and 15 months. Three patients died in the follow-up period, two from myocardial infarction. In the authors' experience intraoperative balloon angioplasty has proven a worthwhile adjunct for tandem lesions in the iliac and femoropopliteal segments.

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Malignant tumours of the inferior vena cava (IVC) are rare. Secondary involvement of the IVC by adjacent retroperitoneal tumours is more common than the occurrence of leiomyosarcomas of the IVC. The authors present a case of a secondary neuroendocrine tumour of the infrarenal vena cava that presented with pulmonary emboli. To their knowledge this presentation has not been reported previously. The tumour was technically resectable and reconstruction of the IVC was not required. No primary tumour was identified. As palliative treatment, an aggressive surgical approach is recommended when the primary tumour is controlled or is not readily identified.

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There has been an explosion of technology in the field of vascular surgery in the latter half of the 1980s. Laser procedures, atherectomy catheterization, intra-arterial stenting and balloon angioplasty have all been demonstrated, with varied degrees of success, to play a role in the management of the patient with vascular disease. Vascular surgeons must be wary of unproven devices that come complete with extravagant claims of success. But, they should also show an interest in new technology as it comes along and should be prepared to become involved in its scientific evaluation. Some of these techniques, perhaps in a more refined state, will play an important role in patient care in the future. Vascular surgeons in Canada must also develop their interests and knowledge of circulatory hemodynamics by committing themselves to using duplex scanning equipment in their diagnostic vascular laboratories. Such laboratories must be staffed by thoroughly trained directors and technologists, and to do this, we must look to making vascular laboratory training part of the requirements for fellowship in the Royal College of Physicians and Surgeons of Canada.

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The authors describe their initial 18-month experience with laser-assisted balloon angioplasty (LABA) of femoral arteries in 44 patients. Primary patency was achieved in 28 patients, but within 30 days the artery became occluded in 9 of them. Perforation occurred much more frequently early in the study. Complications associated with antegrade femoral artery puncture have led to more liberal use of LABA through an operative approach in the femoral artery. Attention to technical detail is critical. When LABA fails it does not appear to worsen the patient's condition clinically or radiologically. Endovascular procedures are undergoing continued, rapid change, so ongoing development and assessment of results are necessary for those who perform LABA.

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Colonic ischemia after aortic reconstruction is rare, but when it occurs in its worst form it carries a 50% death rate. The etiology and pathogenesis of this condition demonstrate that in many instances it may be prevented. Early recognition, particularly of the transmural ischemic injury, is essential. Numerous techniques used during surgery for assessing the adequacy of colonic perfusion have been evaluated and found to be cumbersome and inaccurate in terms of predicting colonic ischemia. Recent experience with the use of the pulse oximeter appears promising in identifying patients with inadequate colonic perfusion who may then be candidates for reimplantation of the inferior mesenteric artery.

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In order to determine if serial, noninvasive evaluation of polytetrafluoroethylene (PTFE) vascular access grafts could identify a subgroup of patients at risk for thrombosis, the authors studied flow characteristics, using duplex ultrasonic scanning, in 18 hemodialysis patients with forearm loop grafts. On average, five examinations were performed per patient over the 10-month study period. Seven episodes of thrombosis occurred in six patients. The mean Doppler flow in grafts that subsequently thrombosed was significantly lower than in those that did not (544 +/- 218 ml/min versus 843 +/- 391 ml/min, p less than 0.001). The interval from last examination to thrombosis ranged from 13 to 58 days. At a defined cut-off flow of 450 ml/min, this test yielded a sensitivity of 83% and a specificity of 75% for episodes of thrombosis occurring within 2 to 6 weeks. The authors conclude that episodes of thrombosis in PTFE arm loop grafts are usually preceded by significantly lower Doppler-measured flow than grafts that do not thrombose and that it may be possible, by this means, to identify grafts at risk.

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