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PURPOSE: To evaluate endovascular popliteal artery aneurysm repair using a an "off-label" abdominal endograft limb-module with nitinol-ring structure. MATERIALS AND METHODS: Retrospective observational study of 14 popliteal artery aneurysms in 12 male patients (mean age 76 years and median ASA grade 3) treated electively using the Anaconda™ endograft limb (Terumo Aortic) at a single teaching hospital. Eight limbs were treated percutaneously and 6 limbs required surgical arterial exposure. The mean popliteal artery aneurysm diameter treated was 3.6 cm (range 2.1-5.3 cm). Stent-graft diameters and lengths used were 10-15 and 60-140 mm, respectively. The median covered stented length was 218 mm (range 160-270 mm) and median duration of follow-up was 3.7 years. Outcomes assessed included technically successful aneurysm exclusion, primary patency, re-intervention and survival. RESULTS: All patients had successful stent-graft deployment and aneurysm exclusion, with no early complications or mortality at 30 days. Primary stent-graft patency at 1, 3 and 4 years was 93%, 75%, and 64%. By 8 years, patency had declined with 29% (2/14) stent-grafts patent. 7/14 limbs occluded; 3 underwent re-intervention (2 surgical, 1 endovascular). There were no deaths related to the procedure. Freedom from re-intervention and survival at 1/5 years was 93%/84% and 93%/67%, respectively. CONCLUSION: The Anaconda™ endograft limb for endovascular popliteal artery aneurysm repair offers good mid-term patency and acceptable long-term patency up to 4 years when compared with other grafts and open surgery. It may be considered in older comorbid patients unfit for surgery and can be performed percutaneously under local anaesthesia when anatomically feasible.

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Lung hernia, defined as protrusion of pulmonary tissue beyond the normal confines of the thoracic cage, is an unusual clinical entity. We describe radiographic and MDCT findings in a series of six cases. The diagnostic sign of intercostal lung hernia apparent on a chest radiograph and cross-sectional imaging is the detection of lung parenchyma or intra-thoracic contents beyond the rib cage. Multidetector computed tomography (MDCT) allows a detailed study of the underlying anatomy and is helpful in planning further management.

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PURPOSE: Stent migration into the right atrium is a potentially fatal complication of stenting in the venous system and is most likely to occur during the treatment of superior vena cava obstruction. Endovascular approaches that can salvage this hazardous situation are described and the keys to successful treatment are highlighted. MATERIALS AND METHODS: Four different strategies are reviewed: (1) snaring the stent directly, (2) angioplasty balloon-assisted snaring of the stent, (3) guide wire-assisted snaring of the stent, and (4) superior vena cava-to-inferior vena cava bridging stent. RESULTS: These techniques have been employed in the successful management of four cases. No short- or long-term complications as a result of these maneuvers have been identified. Additional treatment of the underlying disease was possible at the same time in each case. CONCLUSION: We conclude that prompt management of right atrial stent migration is essential and can be successfully achieved by a variety of "bale-out" techniques which are within the technical range of most interventional radiologists.

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OBJECTIVES: To study the value of a number of proposed prognostic factors in prediction of the risk of perioperative cardiac events after vascular surgery. DESIGN AND METHODS: Two hundred and ninety-seven patients undergoing peripheral vascular surgery were prospectively studied. Patients underwent preoperative 24 h ambulatory electrocardiography, measurement of haemostatic variables, myocardial assessment of perfusion by dipyridamole-thallium scintigraphy and radionuclide ventriculography. The primary endpoint was cardiac death or nonfatal myocardial infarction within 30 days of surgery. A combined endpoint included the primary endpoint plus occurrence of cardiac failure, unstable angina or serious arrhythmias. RESULTS: The primary endpoint occurred in 21 (7%), and the combined endpoint in 41 (14%) of patients. On multivariate analysis, increased age, previous myocardial infarction, aortic surgery, impaired heart rate variability and a positive thallium scan were independent predictors of primary end-points. Preoperative atrial fibrillation and increased fibrin D-dimer were additional predictors of the combined endpoint. Construction of receiver-operator characteristic curves to examine the incremental value of predictive models showed that sensitivity and specificity of clinical data alone for primary endpoints was 71% and 72% respectively, while for the full model (incorporating heart rate variability and thallium data) this rose to 84% and 80% (p=0.0001). CONCLUSIONS: Preliminary screening using clinical data has limited value in risk assessment prior to vascular surgery but preoperative heart rate variability, D-dimers and thallium scanning provide modest incremental predictive value.

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OBJECTIVE: To audit the surveillance programme of infrainguinal vein graft in a tertiary vascular unit, and find out how effective it was in preventing occlusion of grafts. DESIGN: Retrospective study. SETTING: Teaching hospital, Scotland. SUBJECTS: 59 consecutive patients who had 61 vein grafts between 1996 and 1998 for critical limb ischaemia. INTERVENTIONS: Grafts scanned at 3-monthly intervals for at least a year, and clinical review. MAIN OUTCOME MEASURES: Survival with an intact limb and patency of the graft. RESULTS: 52 of the 59 patients (90%) were alive at the time of follow up, and 55 of the 61 involved limbs (90%) were intact. Median follow up was 660 days (range 180-1995). 23 stenoses were detected by the surveillance programme. 17 grafts were revised, all of which were patent at follow up, and 8 other grafts occluded requiring 6 major amputations. One-year cumulative primary, primary-assisted, and secondary patency, and limb salvage rates were 63%, 88%, 88%, and 90% respectively. CONCLUSIONS: Surveillance of infrainguinal grafts by duplex scanning is effective and has resulted in high rates of limb salvage and secondary patency in patients who presented with critical ischaemia.

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OBJECTIVES: to determine the outcome of a policy of ligation with observation of infected false femoral aneurysms (IFFA) in intravenous drug abusers (IVDA), particularly with respect to the issue of limb preservation. DESIGN: a retrospective study. MATERIALS AND METHODS: thirty-seven consecutive cases of IFFA in 34 patients accrued over nine years were studied by case note review and by clinical or telephone interview. RESULTS: in 34 cases of ligation of primary IFFA there were no amputations, with patients describing claudication only in follow-up. In three cases of second IFFA in the same limb, repeat ligation resulted in two viable limbs with claudication only, and one above-knee amputation. At the nine year follow-up, all patients were still drug-dependent and considered unsuitable for late revascularisation. There were three deaths and all were drug-related. CONCLUSIONS: in our experience, ligation of IFFA is effective, safe and simple, and is the most appropriate method of dealing with these challenging cases.

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PURPOSE: The aim of this study was to prospectively evaluate the postoperative dilation of two types of knitted polyester arterial prostheses with the use of helical computed tomographic scanning. METHODS: Thirty-four patients who underwent aortoiliac or aortofemoral bifurcation grafting were randomized to receive a collagen-sealed warp-knitted polyester graft (n = 16 patients) or a gelatin-sealed Köper-knitted polyester graft (n = 18 patients). Alterations in size of all parts of the grafts were evaluated by helical computed tomographic scanning at postoperative day 8, at 3 months, and at 6 months. RESULTS: On postoperative day 8, the mean dilation of the Köper-knitted grafts was 18% +/- 8% for the stem and 15% +/- 12% for the limbs. At the same time period, the mean dilation of warp-knitted grafts was 27% +/- 13% for the stem and 33% +/- 18% for the limbs. No increase in graft dilation was observed at 3 and 6 months. Despite the wide range of values among patients with the same graft type, at each time interval, the Köper-knitted grafts dilated significantly less than the warp-knitted grafts (P <. 05). CONCLUSION: In this randomized study, helical computed tomographic scanning was an accurate technique with which to assess graft dilation. For a 6-month follow-up interval, the Köper-knitted polyester structure dilated less than the warp-knitted structure. Longer-term serial scans should allow a better understanding of the clinical significance of graft dilation.

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This is the first ever reported case of a radiation-induced aortic sarcoma. This patient had symptoms and signs initially interpreted as a pulmonary embolus. The extent of the disease was demonstrated with magnetic resonance imaging and magnetic resonance angiography, in particular, allowing rapid surgical intervention.

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PURPOSE: To determine the feasibility of diagnosing deep venous thrombosis (DVT) with direct three-dimensional magnetic resonance (MR) imaging of the thrombus. MATERIALS AND METHODS: Eighteen patients with proved DVT at conventional venography were evaluated with a magnetization-prepared three-dimensional blood- and fat-suppressed MR imaging sequence. The presence and extent of thrombosis on the MR images were compared with the findings at conventional venography. RESULTS: At MR imaging, DVT was visualized in 17 of the 18 patients. MR imaging demonstrated greater proximal extent of the thrombosis in four patients, asymptomatic contralateral thrombosis in one, involvement of the deep femoral vein in five, and involvement of the superficial venous system in three. CONCLUSION: Direct MR imaging of clots appears capable of demonstrating venographically diagnosed DVT. This MR imaging technique is noninvasive, quick, and repeatable and allows a survey of the whole lower-limb venous system. Detection of thrombosis relies on the formation of methemoglobin, which appears to be sufficiently rapid to allow use of this technique in the clinical setting. Changes in the signal from clot over time may allow estimation of the age of the thrombus.

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PURPOSE: The purpose of this study was to determine the effects of patient characteristics, blood rheology, and plasma biochemistry on the outcome of infrainguinal bypass grafting. METHODS: Blood rheology, plasma fibrinogen, cross-linked fibrin degradation products, von Willebrand factor (vWf) and other endothelial products, and clinical variables including smoking markers were determined before surgery in patients with 184 consecutive infrainguinal bypass grafts (90 vein, 94 synthetic grafts). RESULTS: Fifty (27%) graft occlusions and 17 (9%) deaths occurred within 1 year of surgery. On univariate analysis a poor outcome was associated with elevated preoperative plasma fibrinogen, fibrin degradation products, vWf, and platelet levels, reduced hemoglobin and systolic ankle pressure, a below-knee anastomosis, a decrease in patent calf vessels, and the presence of tissue necrosis (all p < 0.001). On multivariate analysis increased preoperative vWf levels were predictive of poor postoperative outcome (relative hazard for upper quartile versus lower quartile = 1.82), as were a low systolic ankle pressure (relative hazard = 2.51), presence of tissue necrosis (relative hazard = 2.73), and female sex (relative hazard = 1.9). None of the other variables studied was related to outcome. With a preoperative risk score derived from the results, graft patency rates within 3 months of surgery fell to less than 25% with risk scores in the upper quartile. CONCLUSIONS: Preoperative measurement of plasma vWf may enable more accurate prediction of the outcome of infrainguinal revascularization and when combined with other variables could assist in patient selection for these procedures. The association of vWf with graft occlusion supports a role for endothelial disturbance in graft occlusion.

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We investigated the relationships between the angiographic severity of peripheral arterial occlusive disease (PAOD) and haemostasis, fibrinolytic, and rheological variables in 219 patients with symptomatic peripheral arterial occlusive disease (PAOD). White cell count, fibrinogen, cross-linked fibrin degradation products (FDP), von Willebrand factor, and plasminogen activator inhibitor levels were all elevated in comparison with age-matched population controls (all p < 0.0001, Mann-Whitney U test), while fibrinogen (Spearman r = 0.30), von Willebrand factor (r = 0.40), and log (FDP) (r = 0.56), (all p < 0.0001) showed a strong correlation with the angiographic extent of PAOD. Multivariate analysis indicated that log (FDP) was a strong independent predictor of the angiographic severity of PAOD (p < 0.0001), in addition to increasing age (p < 0.0001), presence of tissue sepsis (p < 0.02), prior vascular surgery (p = 0.007), and other vascular pathology (p = 0.007). These results confirm that increase in fibrinogen, von Willebrand factor, plasminogen activator inhibitor and fibrin turnover, are strongly associated with the presence of symptomatic peripheral arterial disease, and suggest that there may be a causal link between fibrin turnover, as determined by FDP levels, and the extent of peripheral arterial occlusive disease.

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OBJECTIVES: To assess the effects of resolution of critical limb ischaemia on the elevated plasma fibrinogen, cross-linked fibrin degradation products (FDP), and von Willebrand factor antigen (vWF) levels, reported in peripheral arterial occlusive disease. DESIGN: A prospective study of patients undergoing surgery for chronic critical limb ischaemia. SETTING: Two vascular surgery units providing tertiary referral services for the West of Scotland. MATERIALS: Venous blood samples were assayed for plasma fibrinogen, FDP D-dimer, and vWF levels, prior to surgery, together with fibrinolytic and rheological parameters, in 82 patients. Sampling was repeated 4 months after resolution of critical limb ischaemia. OUTCOME MEASURES: Levels of these parameters following successful resolution of critical limb ischaemia were compared with pre-operative levels, and with an age-matched random population sample. MAIN RESULTS: Plasma fibrinogen and vWF levels were significantly lower (both p < 0.005, Wilcoxon matched pairs) following successful resolution of critical limb ischaemia in the 56 patients available for review, although levels remained higher than in population controls (p < 0.01, Mann-Whitney U-test). FDP levels were unchanged following surgery, remaining higher than in age-matched population controls (p < 0.01). CONCLUSIONS: Resolution of critical limb ischaemia fails to reduce plasma fibrinogen, fibrin turnover, and vWF levels to those seen in population controls. This implies that increased fibrinogen and fibrin turnover in peripheral arterial disease is not solely a consequence of tissue ischaemia, while the persisting prothrombotic state following resolution of critical limb ischaemia has potentially important implications for graft and patient survival.

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Seventy consecutive patients with infrainguinal bypass grafts entered a 1-year graft surveillance programme involving colour duplex scanning, direct graft insonation and computer-assisted impedance analysis. Graft patients with a positive duplex scan, high frequencies on graft insonation or an impedance value above 0.50 subsequently underwent arteriography. Sixteen patients were excluded before the initial surveillance visit. The 54 remaining patients with grafts (30 vein, 24 synthetic) underwent a total of 137 surveillance visits, with 21 grafts confirmed to be 'at risk'. The sensitivity of an impedance value above 0.55 in identifying these grafts was 86 per cent, rising to 95 per cent when combined with graft insonation. Duplex scanning did not identify any abnormalities in 11 grafts that were either shown by arteriography to be 'at risk' or occluded before arteriography. Impedance measurement and graft insonation are simple screening techniques with a high sensitivity (when combined), which identify 'at risk' infrainguinal grafts. Positive graft insonation or an impedance value over 0.55 will identify all 'at risk' vein grafts while minimizing the number of unnecessary arteriograms.

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We investigated the relationships between the angiographic severity of peripheral arterial occlusive disease (PAOD) and haemostasis, fibrinolytic, and rheological variables in 219 patients with symptomatic peripheral arterial occlusive disease (PAOD). White cell count, fibrinogen, cross-linked fibrin degradation products (FDP), von Willebrand factor, and plasminogen activator inhibitor levels were all elevated in comparison with age-matched population controls (all p < 0.0001, Mann-Whitney U test), while fibrinogen (Spearman r = 0.30), von Willebrand factor (r = 0.40), and log (FDP) (r = 0.56), (all p < 0.0001) showed a strong correlation with the angiographic extent of PAOD. Multivariate analysis indicated that log (FDP) was a strong independent predictor of the angiographic severity of PAOD (p < 0.0001), in addition to increasing age (p < 0.0001), presence of tissue sepsis (p < 0.02), prior vascular surgery (p = 0.007), and other vascular pathology (p = 0.007). These results confirm that increases in fibrinogen, von Willebrand factor, plasminogen activator inhibitor and fibrin turnover, are strongly associated with the presence of symptomatic peripheral arterial disease, and suggest that there may be causal link between fibrin turnover, as determined by FDP levels, and the extent of peripheral arterial occlusive disease.

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PURPOSE: A number of thrombotic mediators have been related to peripheral arterial disease in both epidemiological and pathological studies. METHODS: We measured preoperative levels of fibrinogen, cross-linked fibrin degradation products (FDP), and the endothelial markers, von Willebrand factor (vWF), tissue plasminogen activator (tPA), and plasminogen activator inhibitor (PAI), in the venous blood of 43 claudicants undergoing percutaneous transluminal angioplasty (PTA). Samples were repeated 4 months later, and changes in the levels of thrombotic mediators were compared with ten controls undergoing angiography alone. Additional perilesional arterial samples were obtained from 11 of the patients. RESULTS: Arterial sampling indicated that successful PTA led to an immediate fall in tPA levels and a rise in arterial vWF (p < 0.05), together with a trend toward a significant rise in cross-linked FDP levels. Only the increase in FDP following successful PTA (36 cases) (p < 0.05) was observed in 4-month postangioplasty venous samples, whereas all variables remained unchanged in cases of restenosis (4 patients) and in controls (all comparisons made by Wilcoxon matched pairs test). CONCLUSIONS: These findings suggest that successful PTA in patients with intermittent claudication results in acute endothelial disturbance and increased fibrin turnover at the site of angioplasty and in sustained increases in fibrin turnover (as reflected by FDP levels). The observation that this increase in fibrin turnover is absent in cases of restenosis within 4 months of PTA merits further study to determine whether increases in fibrin turnover are necessary to maintain patency following PTA.

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Massive systemic intra-arterial embolism of malignant lung cancer is a rare condition. When it occurs it usually follows pneumonectomy. Its occurrence is related to propagated tumour within a pulmonary vein and this may be suspected pre-operatively. Although the primary lung cancer may theoretically be curable, embolism is frequently widespread and is associated with a very poor prognosis. The importance of early intraoperative pulmonary vein interruption during lung cancer surgery is emphasized.

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