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Minimally invasive treatment of varicose veins is becoming increasingly popular with both patients and physicians. Endovenous laser therapy has been shown to be safe and effective but the rare complication of iatrogenic creation of arteriovenous fistulas has been described. One case of fistulation between the external iliac artery and vein has been published. We report two further cases and describe their management.

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OBJECTIVES: to measure quality of life in patients with intermittent claudication and evaluate the ability of patients and vascular surgeons to make a similar assessment. DESIGN, MATERIALS AND METHODS: in this prospective study patients with intermittent claudication attending two vascular clinics were asked to complete a generic health-related quality of life instrument (MOS SF-36). Patient quality of life and vascular surgeons' assessment of patient quality of life were further evaluated using a single question/adjectival scale response combination. RESULTS: patients' self-assessment of their quality of life correlated better with the SF-36 score than did the surgeons' assessment. There was little correlation between the surgeons' and patients' own assessment of quality of life. The surgeons differed significantly from each other in their assessments. Claudicants had lower SF-36 scores than population norms in pain and physical aspects of quality of life. CONCLUSIONS: claudicants have worse quality of life than the general population, with pain and physical limitations being the most important domains. Surgeons predict the quality of life of claudicating patients less accurately than patients do themselves, and may differ from their colleagues in such assessments. Objective quality of life assessment in claudicants should be undertaken before treatment is decided.

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Peripheral vascular occlusive disease is initiated with a genetic risk factor component compounded by patient-controlled contributions including obesity, diabetes, hypertension, and smoking. Medical management of these factors may delay or obviate surgical intervention. Angiography may be used to perform angioplasty (+/- stents) or to guide various interventional procedures. The major contribution to pre- and post-operative assessment is the noninvasive laboratory.

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The creation of a temporary axillofemoral bypass in a patient undergoing surgery for an 8.1 cm symptomatic infrarenal aortic aneurysm is described. This adjunctive procedure, rarely used in abdominal aortic surgery, may have contributed to minimizing variations in afterload in a patient with a 20% ejection fraction and severe mitral regurgitation.

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A patient undergoing radical retroperitoneal lymphadenectomy for metastatic embryonal cell testicular carcinoma is presented. Tumor resection required removal of the inferior vena cava due to transmural invasion. The inferior vena cava was replaced using externally stented polytetrafluoroethylene (PTFE) graft. Patency was documented by postoperative Doppler studies, duplex scanning, and computed tomographic scanning. Stented PTFE is currently the graft of choice for inferior vena caval replacement.

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OBJECTIVE: To assess the value of intra-arterial urokinase infusion in the management of acute, critical ischemia of the lower limb. DESIGN: A prospective study. SETTING: A vascular surgery department within a university hospital. PATIENTS: Twenty-five consecutive patients with acute, critical ischemia of the lower limb, excluding those requiring immediate surgical intervention. Follow-up ranged from 1 to 18 months. INTERVENTION: Angiography followed by intra-arterial infusion of urokinase. MAIN OUTCOME MEASURES: Angiographic and clinical evidence of clot lysis and limb reperfusion, any surgical procedures required and final clinical outcome. RESULTS: Urokinase was technically successful in lysing clot in 19 patients: 7 required no further treatment; in 8 an underlying lesion was identified and repaired by either percutaneous angioplasty or surgery; in the remaining 4 patients, although the clot was lysed, the limbs remained ischemic and, since reconstruction was considered impossible, amputation was required. Two patients improved clinically with little angiographic evidence of clot lysis. A total of nine patients required amputation, seven of these as a "primary" procedure after urokinase infusion. There were four episodes of significant morbidity but no deaths. CONCLUSION: Urokinase has a place in the management of acute vascular occlusion of the lower limb, not only in treating the occlusion but, equally importantly, in facilitating identification of lesions that require surgical intervention.

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Inferior pancreaticoduodenal aneurysms are uncommon. A 77-year-old woman was seen with a 1-week history of sharp pain in the right lower abdominal quadrant radiating to the back, associated with malaise, anorexia, vomiting and nonbloody diarrhea. Appendicitis was diagnosed, but at laparotomy a large retroperitoneal hematoma was found; no aneurysm was identified. The abdomen was closed and aortography was done. An aneurysm of the inferior pancreaticoduodenal artery arcade was demonstrated, with occlusion of the celiac artery at its origin. The arc of Buehler was patent and enlarged and supplied the hepatic and splenic arteries. Embolization with Gianturco coils placed proximal to the aneurysm was successful.

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OBJECTIVE: To compare critically by meta-analysis the postoperative outcomes after truncal vagotomy and pyloroplasty (TVP) and after highly selective vagotomy (HSV). DATA SOURCES: A search was conducted on MEDLINE with the keywords "peptic ulcer" and "vagotomy". Bibliographics of the articles retrieved and review articles pertaining to the subject were scanned further. STUDY SELECTION: Included were only published prospective, randomized controlled trials comparing TVP and HSV in the English-language literature up to April 1991. Twelve studies were found. DATA EXTRACTION: Two authors, working independently, abstracted raw data on mortality, recurrence, dumping, diarrhea and postoperative Visick grading. DATA SYNTHESIS: A ratio greater than 1.0 indicates a higher proportion occurring with TVP and less than 1.0 a higher proportion with HSV. [Table: See Text] CONCLUSION: The results suggest that the likelihood of adverse long-term sequelae is higher with TVP whereas the likelihood of recurrence is higher with HSV.

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A case of nonanastomotic pseudoaneurysm of a unilateral axillofemoral bypass graft is reported. The graft material used in this particular instance was an 8 mm, reinforced, thin-walled, fluorinated ethylene-propylene-ringed, expanded polytetrafluoroethylene (ePTFE). The pseudoaneurysm occurred 1 year after insertion of the graft and was not associated with any direct trauma. It manifested with a painful tender mass at the top of the body of the axillofemoral bypass graft at the level of the nipple line. There were no symptoms of localized or diffuse sepsis. Immediate surgical exploration confirmed the diagnosis of a pseudoaneurysm of the ePTFE graft. Successful repair of the disrupted segment was accomplished by use of an interposition, nonringed, reinforced, thin-walled, 8 mm ePTFE graft. To our knowledge this is the first case of a nonanastomotic pseudoaneurysm of a ringed, ePTFE, axillofemoral bypass graft not associated with direct trauma.

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Three consecutive patients with ruptured Baker's cysts, verified by duplex scan, were found to have ecchymosis on the dorsum of the foot. The appearance of ecchymosis can be helpful in differentiating a ruptured cyst from cellulitis or deep-vein thrombosis.

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The proper teaching of operative skills to surgical residents is increasingly constrained by operative time, complex procedures and medicolegal concerns. A technical-skills program was developed and introduced over a 3-year period to 28 1st-year residents in general surgery. To introduce the residents to the principles of surgical techniques in a simulated environment outside the operating room, the program consisted of a combination of two didactic sessions and six "wet labs" taking 3 to 4 hours per week for 8 weeks between January and March each year. The didactic sessions included instruction on suture material and the use of stapling devices; the "wet lab" used a "hands-on" approach. Educational objectives in the "wet lab" included instruction on preparation of the patient and draping, aseptic technique, principles of bowel anastomosis, incisions, instrument use and handling, principles of hemostasis, intraoperative surgical emergencies, surgical assisting and overall conduct in the operating room. The residents' surgical technique and skills improved over the course period. The overall value, teaching and understanding of surgical principles were rated highly. Problems cited during resident feedback were the use of live animals and insufficient time to practise. The efficacy of a surgical-skills program has been demonstrated, but its effectiveness requires further evaluation.

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We present a case with findings suggestive of popliteal artery entrapment in a patient with intermittent claudication and localized muscle hypertrophy in the calf muscles after removal of a herniated disk. Angiography failed to demonstrate popliteal artery entrapment but instead revealed compression of the tibial vessels caused by calf muscle hypertrophy. The concept of muscle hypertrophy caused by denervation is also discussed.

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Scrubbing, gowning, gloving and aseptic technique are currently the only formal teaching 4th year medical students receive at the beginning of an 8-week surgery rotation. Teaching is often delegated to junior house staff and early bad habits are difficult to unlearn in post-graduate training. A study population of 4th year medical students from three hospitals were examined. At the beginning of an 8-week surgery rotation technical skills were tested with a simulation appendectomy model at the beginning and end of the surgery rotation. On day one, after a pre-test, a teaching intervention was alternated between two hospitals. A control group received only a post-test. The outcome measure was a cumulative score of the students' performance in technical stations in the simulation model. A comparison was made of the mean post-test scores in the teaching, non-teaching and control groups. An analysis of variance of all post-test scores rejected the null hypothesis at the 0.05 level. Duncan's multiple range test demonstrated a significant difference between the teaching and non-teaching group. Feedback from 25 students indicated the teaching model was practical and relevant. A formal teaching intervention of basic technical skills with 4th year medical students improved their performance on a simulated appendectomy model.

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