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The work described in this paper focuses on the impact of thermal aging on NOx trap structure and functions. They were evaluated on a Synthetic Gas Bench (SGB) and correlated with the analysis of the structural and chemical evolution of the catalyst. A FTIR Operando study allowed to further analyse the mechanisms occurring on the catalyst surface and highlight the most critical points. NOx trap samples were hydrothermally aged in a furnace up to 900°C under an oxidising flow. The main following impacts on the material were highlighted: reduction of the surface area, sintering of Pt yielding a decrease of the NO oxidation efficiency and hence of the NOx storage capacity, and a loss of CO and HC conversion, barium structural evolution into BaAl2O4 also being partly responsible for the loss of NOx storage capacity. Other possibilities for loss of NSC are: the transition of -Al2O3 to -Al2O3 and the evolution of Ba crystalline structure which needs further analysis. Both XRD and surface IR Operando studies show that hydrothermal aging has a rather homogeneous impact on all materials: alumina phase transition and BaAl2O4 production, which all lead to a partial decrease of all storage sites. L’étude suivante porte sur l’impact du vieillissement thermique sur la structure et les fonctions d’un piège à NOx. Les essais ont été réalisés sur un banc gaz synthétiques (BGS) et les résultats ont été corrélés à des analyses structurale et chimique du catalyseur. Une étude FTIR Operando a permis de mieux analyser les mécanismes se produisant sur la surface du catalyseur et de mettre en évidence les points les plus critiques. Des échantillons ont été vieillis hydrothermiquement à 900 °C sous un flux oxydant. Les principaux impacts ont été les suivants : la réduction de la surface spécifique, le frittage du Pt qui mène à une diminution de l’efficacité d’oxydation de NO, CO, HC et de la capacité de stockage, la formation de BaAl2O4 est en partie responsable de la perte de capacité de stockage de NOx. D’autres possibilités pour la perte de NSC sont : la transition de la -Al2O3 à la -Al2O3 et l’évolution de la structure cristalline du baryum qui demande des analyses approfondies. Les études DRX et Operando IR montrent que le vieillissement hydrothermique a un impact assez homogène sur tous les matériaux : la transition de phase de l’alumine et la formation de BaAl2O4, qui toutes mènent à une diminution partielle de tous les sites de stockage.

The article discusses the approach of the researcher to revision stapes surgery and the outcomes from 49 procedures at a UK tertiary center. Revision stapes surgery are perceived to be difficult. Cases may harbor factors which include failure of primary surgery and including advanced otosclerotic disease and additional pathology such as lateral ossicular chain fixation, or difficult access due to anatomy.

The objective of the study was to determine risk factors for late skin flap failure following cochlear implantation. The study design was a retrospective case series. Data were collated from 371 implanted patients over a ten-year period. Of these patients, 1.3 per cent (n = 5) developed late skin flap failure. It is concluded that skin flap failure is a significant, though relatively uncommon, complication of cochlear implant surgery. What causes flap failure and why it should occur in such a variable fashion are still largely unknown, though infection undoubtedly plays an important role. The aetiological factors associated with flap failure and possible prevention strategies are discussed. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article focuses on ways to retract the chorda tympani anteriorly keeping held away while performing stapedectomy and mentions that the chorda, stapes and process of incus are identified and curettage of scutum is performed when necessary. Topics discussed include wick absorbs excess blood from all superior cut edges, placing Pope wick between the long process of incus, and the nerve and risk of traction or compression injury to the nerve.

Provides a corrected reprint to an article previously published in the 2000 issue of the 'Clinical Otolaryngology' journal.

Introduction: The aim of this study was to investigate whether radiological marker(s) of the inner ear can be detected in congenital cytomegalovirus (cCMV) patients with severe-profound sensorineural hearing loss., Methods: A retrospective imaging review of confirmed cCMV paediatric patients that had undergone consecutive cochlear implantation was performed at a tertiary hospital. Available pre- and postoperative imaging was examined, and abnormalities of the labyrinth were catalogued by a consultant neuroradiologist in the study group and control group., Results: Twenty-eight paediatric patients with cCMV having undergone cochlear implantation were identified between the ages of 1-15 years (mean 4.7 years) at the time of implantation. Increased density of the vestibule on computed tomography (CT) or filling defects of the vestibule on magnetic resonance imaging (MRI) were identified in 11 and 4 patients, respectively, of the 24 in the case series. No filling defects were identified in any of the 48 CT and MRI control group., Conclusion: This study demonstrates a potential novel radiological finding of the inner ear of patients with cCMV. With more research, greater onus placed on MRI and CT for inner ear assessment may facilitate early detection and treatment for patients at risk of significant hearing loss. Further prospective studies in this area will help to validate radiological markers in order to establish a comprehensive inner ear classification system for neuroradiological features in cCMV., (© 2022 S. Karger AG, Basel.)

Objective: To perform a matched cohort study to assess whether patients with Meniere's Disease (MD) require more intensive auditory rehabilitation following cochlear implantation (CI) and identify factors that may affect outcomes in patients with MD., Methods: A retrospective case review was performed. MD and control patients were matched for age, biological sex, implant manufacturer and electrode design. Outcomes measured were speech scores, number of visits to audiology department following switch-on, and post-operative active MD., Results: Forty consecutive implanted MD patients were identified between May 1993 and May 2019. Patients with active MD following CI required significantly more visits to the audiology department compared to controls (P < 0.01) and patients who had inactive MD post-operatively (P < 0.01). However, in MD patients, active MD was less likely following CI (P = 0.03). In patients who continued to experience active MD post-operatively, further medical and surgical ablative intervention was required to control ongoing Meniere's attacks., Conclusion: We present the largest case series of performance outcomes in CI patients with MD. Although speech outcomes in MD patients are comparable to controls, patients with active MD pre-operatively are more likely to experience variation in CI performance requiring a prolonged period of auditory rehabilitation compared to inactive preoperative MD.

Objectives: To assess whether bilateral otosclerosis renders pre-operative bone conduction more inaccurate by increasing the Carhart effect., Methods: Retrospective review of a database of pre and post-operative audiograms of 745 ears with otosclerosis treated with stapedectomy from 2013 to 2020 in a tertiary centre., Main Outcome Measures: Change in bone conduction after stapedectomy for otosclerosis in: unilateral otosclerosis (U1); bilateral otosclerosis undergoing first side surgery (B1); bilateral otosclerosis undergoing second side surgery (B2). The magnitude of change in bone conduction post-operatively within and between each group., Results: The average difference in pre and post-operative bone conduction was significant within in all groups (T-stat > 2 and P-value <0.05) with the greatest change observed in the U1 group. Analysis of average change in bone conduction between groups did not reach statistical significance (P-value = 0.37). Analysis of change per frequency demonstrated the greatest change in bone conduction post-operatively at 2000 Hz in all groups. The magnitude of change at 2000 Hz was the greatest in the bilateral groups; however, it did not reach statistical significance when compared to the unilateral group (P-value = 0.36)., Conclusions: This is the first study in the literature to assess the accuracy of pre-operative bone conduction in bilateral versus unilateral otosclerosis. There is no evidence that pre-operative bone conduction in bilateral otosclerosis is more inaccurate than in unilateral disease. In order to assess accuracy of pre-operative bone conduction in otosclerosis a reliable method of assessing post-operative bone conduction is required, without assumption of its equivalence to cochlear reserve., (© 2020 PLA General Hospital Department of Otolaryngology Head and Neck Surgery. Production and hosting by Elsevier (Singapore) Pte Ltd.)

Background: Stapes surgery is performed to treat hearing loss in patients with otosclerosis. Erosion of the long process of incus can occur postoperatively and requires demanding revision surgery to further improve the hearing. The authors describe a novel method of performing revision stapes surgery where there is erosion of the long process of incus., Methods: A retrospective case series analysis of a database of revision stapes operations performed by one surgeon between July 2013 and December 2017 at a tertiary center was carried out. 26 cases were identified where there was significant erosion of long process of incus. The ossicular chain in these cases was reconstructed using a novel technique of using cement to fix the piston prosthesis to the incus remnant. The full technique is described herein. The pre- and postoperative audiometric data were analyzed., Results: Mean preoperative air bone gap (ABG) was 29.3 dB and mean postoperative ABG was 9.9 dB. Of the 22 patients with recorded postoperative masked bone conduction thresholds, 16 had ABG closure to < 10 dB (72.7%)., Conclusion: We have shown highly favorable outcomes using this novel technique in addressing erosion of the long process of incus in revision cases for patients with otosclerosis.

Introduction: We have observed a small number of patients with cochlear implants who have a tendency to develop recurrent seromas overlying the implant package. Methods: Five patients with a current or previous history of recurrent seromas presenting for review over a three-month period were identified. A retrospective review of their case notes was undertaken. Results: All patients identified were children, with a mean age at first seroma of 5.0 years (range 1.9-10.4 years). The mean interval between implantation and first episode of seroma was 3.1 years (range 0.9-6.4 years). With the exception of imaging showing a fluid-density collection, investigations were generally unremarkable. Fluid aspirated from one patient was cultured and no organisms were grown. Antibiotics, most commonly amoxicillin / clavulanic acid, were commonly but not universally prescribed. Conclusions: Recurrent cochlear implant associated seroma appears to be an idiopathic process. Investigations are generally unhelpful, and whilst it is probably prudent to treat with antibiotics during an initial presentation, once a pattern of recurrent seroma is established, patients can be treated conservatively.

Objectives: It is recognised that CT can be used to determine the cochlear duct length (CDL) when selecting an electrode for cochlear implantation. It is the practice of our institution to routinely use MRI as the sole modality of pre-operative imaging in the assessment of children referred for consideration of cochlear implantation. We therefore wanted to determine whether MRI could be reliably used to determine cochlear duct length., Methods: An analysis of 40 ears that had undergone MRI and CT of the temporal bones was undertaken. The diameter of the basal turn was independently measured for each ear using the two modalities, and CDL was then calculated., Results: The mean error of measurement was 0.26 mm (range 0-0.8 mm), leading to a difference in calculated CDL of 0.96 mm (range 0-2.92 mm). CDL did not predict full insertion of 28 mm cochlear implant electrodes in 30 ears., Conclusions: MRI can be used to reliably determine cochlear duct length.

Objective: To examine inter-aural hearing preservation results in children undergoing simultaneous bilateral cochlear implantation (CI)., Methods: Retrospective case review in tertiary referral centre. All children undergoing simultaneous bilateral CI between January 2013 and June 2014 (18 months). Patients eligible for inclusion in the study had pre-operative hearing thresholds of <90 dB at 250 Hz and ≥100 dB at 500 Hz. Patients with anatomical cochlear anomalies or missing data were excluded. Seven patients were included, 1 male, 6 female, mean age of 12 years 11 months at the time of surgery. All patients had simultaneous bilateral cochlear implant surgery, using the same implant and technique. All patients had pre- and post-operative unaided pure tone audiometry. Inter-aural hearing preservation results were compared in each patient., Results: The achieved hearing preservation for 14 ears was complete in 5, partial in 7, and minimal in 2. Measurable hearing preservation was achieved in 86% overall. Inter-aural analysis revealed that only 2 (subjects 1 and 4) of the 7 patients had preservation results within the same preservation group (complete/partial/minimal). The mean inter-aural preservation difference was 30.7% with a range from 12.4% to 65.2%., Conclusions: Several factors and techniques have already been identified in the wider literature to explain differences in hearing preservation results in CI. However, despite controlling for known factors, we demonstrate variable inter-aural results. This suggests that there may be more factors beyond the surgeon's control influencing our ability to provide consistent results.

Background: Stapes surgery is performed for hearing restoration in patients with otosclerosis. Results from stapes surgery are good, although a small proportion will have a persistent conductive hearing loss and will consider revision surgery. The timing of such surgery depends on expected changes to hearing thresholds during the postoperative period., Methods: We performed a retrospective case series analysis of a database of outcomes from stapes surgery performed between July 26, 2013 and March 11, 2016 at one center. Hearing outcomes over the year subsequent to surgery were recorded., Results: There was a significant improvement in hearing outcomes between the postoperative visit at 6 weeks (mean air-bone gap 6.0 dB) and the hearing outcome at 6 months (mean air-bone gap 3.3 dB) (p < 0.01). This improvement was maintained at 12 months (mean air-bone gap 3.1 dB), although there were individual patients whose hearing outcome improved or deteriorated during this period. Improvements in air conduction thresholds mirrored improvements in air-bone gap measurements., Conclusion: Patients with an initial suboptimal or poor result after stapes surgery may observed improvement in their hearing thresholds in the year after surgery. These patients may have large preoperative air-bone gaps, and have a trend to have obliterated footplates. Revision surgery should not be considered until at least 6 months after primary surgery.

The objective of this study was to determine hearing outcomes in patients undergoing stapes surgery with a preoperative air-bone gap (ABG) <21.25 dB. Patients with a unilateral or bilateral preoperative ABG <21.25 dB undergoing primary stapes surgery were identified from a database of all stapes surgeries performed in a tertiary center over 15 years. A total of 254 ears met the inclusion criteria. The primary outcome measure was the degree of closure of the preoperative ABG. A secondary outcome measure was improvement in bone-conduction thresholds at 4 kHz. All patients underwent stapes surgery under local anesthesia. Ossicular reconstruction was achieved using a SMart 360 nitinol fluoroplastic piston (Gyrus ACMI, Inc.; Southborough, Mass.), and complete posterior crurotomy was performed with a KTP laser. Hearing was assessed with clinical voice testing immediately postoperatively and with pure-tone audiometry at 6 weeks postoperatively. A total of 248 ears (97.6%) demonstrated ABG closure to <10 dB. Bone-conduction thresholds showed an increase in 114 (44.9%), no change 74 (29.1%), and a decrease in 66 (26.0%). There is a slight increase in the risk of stapes mobilization in ears with a small ABG when compared to those with larger ABGs; however, this can be overcome by using a laser-assisted technique in combination with good surgical experience. The benefit in terms of hearing aid avoidance and the restoration of symmetrical hearing is both achievable and significant for the patient.

Hypothesis: Assess the clinical acceptability of direct acoustic cochlear implantation for patients with advanced otosclerosis and the support for conducting a controlled trial of its effectiveness in the United Kingdom., Background: Emerging evidence supports the efficacy of direct acoustic cochlear implantation in patients with advanced otosclerosis whose needs cannot be managed using the combination of stapes surgery and hearing aids. A controlled trial would provide evidence for its effectiveness and cost-effectiveness to healthcare commissioners., Methods: An online survey of clinical professionals was constructed to characterize current standard of care for patients with advanced otosclerosis and to assess whether clinicians would be willing to refer patients into a trial to evaluate direct acoustic cochlear implantation. A consensus process was conducted to define inclusion criteria for the future trial., Results: No survey respondent considered direct acoustic cochlear implantation to be inappropriate with a majority indicating that they would refer patients into a future trial. The consensus was that there is a lack of available treatment options for those patients with bone conduction thresholds worse than 55 dB HL and who did not meet current criteria for cochlear implantation., Conclusion: The present study confirms that a controlled trial to evaluate the effectiveness of direct acoustic cochlear implantation would have the support of clinicians in the United Kingdom. A feasibility study would be required to determine whether patients who meet the inclusion criteria could be recruited in a timely manner and in sufficient numbers to conduct a formal evaluation of effectiveness.

Acquired external auditory canal atresia is a rare complication of chronic inflammatory otitis, and is generally fibrous or soft tissue in nature. Here, we present the first reported case of heterotopic ossification within chronic fibrosing otitis externa in a 25-year-old male patient with a childhood history of granular myringitis and failed tympanoplasty. A calcified mass was demonstrated adjacent to the tympanic membrane on CT imaging, and surgical exploration revealed a cohesive bar of bone traversing the medial external auditory canal. Drill canaloplasty and split-thickness skin graft coverage of the lateral tympanic membrane resulted in an improvement in the pure tone average from 79 to 55 dB. As the treatment for chronic fibrosing otitis externa involves the surgical widening of the external auditory canal, we alert surgeons to the possibility of cohesive bone formation as a potential cause of navigational confusion and inadvertent over- or under-drilling of the canal stenosis., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.)

Objective: To compare audiometric and functional outcomes between two designs of heat-activated self-crimping stapes prostheses-a modified shape memory circumferential nitinol-Teflon piston versus its predecessor-in patients with otosclerosis., Study Design: A retrospective analysis of preoperative and postoperative hearing thresholds., Setting: Tertiary referral center and teaching hospital., Patients: One hundred sixty-three consecutive procedures of primary stapes surgery for clinically proven otosclerosis in 108 women and 55 men with an average age of 46 years., Intervention: Stapedotomy and insertion of either a standard or a circumferential stapes prosthesis., Main Outcome Measures: Four-frequency pure-tone average preoperative and postoperative air-bone thresholds were recorded. A secondary outcome measure was stability of the implant, as measured by failure rates., Results: Success of closure of the air-bone gap to within 10 dB was achieved in 97% and comparable in both groups (original prosthesis, 23.6; standard deviation, 7.3, with the average reduction seen in the circumferential prosthesis group being 22.6, standard deviation, 5.6). All the differences were not statistically significant using two-way analysis of variance. Failure rate for the original piston was 6%, with no failures seen with the circumferential piston., Conclusion: Both prostheses showed comparable postoperative hearing outcomes, with the circumferential prosthesis being found to be more stable.

Objectives/hypothesis: To evaluate the long-term (5-year) results of the shape-memory nitinol stapes piston in the surgical treatment of otosclerosis., Study Design: Retrospective case review in a tertiary referral center., Methods: The patients were adults with clinically proven otosclerosis undergoing stapedotomy. Stapedotomy and ossicular chain reconstruction using a shape-memory nitinol stapes piston were performed. The main outcome measure was masked air and bone conduction audiometry., Results: Forty-eight out of a potential 58 ears had complete audiometric data. The mean preoperative air-bone gap was 29.2 dB (standard deviation [SD] 9.4). The postoperative gap at 1 year was 4.6 dB (SD 3.1), and P at 5 years was 7.0 dB (SD 6.2)., Conclusions: These data suggest that the Smart piston provides a stable long-term hearing result in the surgical treatment of otosclerosis.

Taste change is a well documented but under emphasised complication of middle ear surgery and is usually related to damage to the chorda tympani nerve (CTN). However, the taste outcomes following cochlear implantation have not been previously recorded. One hundred and forty one patients who had received cochlear implants between January 1997 and April 2006 were questioned using a postal survey regarding changes in the sense of taste following cochlear implantation. Sixty seven per cent of questionnaires were returned. Forty three patients (45%) experienced changes in taste following their surgery. Eighteen patients (19%) said that their symptoms had not resolved by the end of the follow up period (mean 51 months). CTN division produced taste change in 86%. Fifty per cent of patients who had CTN preservation developed taste change, presumably related to occult trauma to the nerve. The difference in the number of patients describing taste change in the two groups was statistically significant (p < 0.05). Resolution of symptoms took a mean of 20 weeks. For those patients in whom taste change was noted, resolution of symptoms was more likely if the CTN was divided rather than preserved although the difference was not statistically significant (p < 0.5). This may reflect neuronal injury during surgery which then fails to heal normally. These results are comparable to taste outcomes in patients undertaking middle ear surgery for non-inflammatory disease such as stapedectomy. The symptoms can be extremely troublesome and may not resolve with time. Careful consideration of the CTN intra-operatively is recommended and in the event of injury, the taste outcome may be better if the nerve is divided rather than left in situ but damaged. These findings have significant implications for patients as bilateral implantation becomes more commonplace., (Copyright (c) 2007 John Wiley & Sons, Ltd.)

A patient who had previously undergone a modified radical mastoidectomy subsequently underwent cochlear implantation with good results. At surgery the mastoid cavity was partially obliterated to provide soft tissue cover for the implant cables. Following local infection the cable became exposed and we used a middle temporal artery local flap to provide cover for the cable. The anatomy of the flap and methods used are described here. The patient continues to have good hearing from the implant with a good coverage over the cable.

Helicobacter pylori is an accepted cause of chronic active gastritis and has a major causative role in peptic ulceration. It is a gastric carcinogen. Its role in non-ulcer dyspepsia (NUD) is less clear; yet 50 per cent of patients with NUD are infected with H pylori. H pylori has been investigated in several other organ systems, but has not been investigated extensively in squamous cell carcinoma of the upper aerodigestive tract, a region which could be directly exposed to the bacterium by gastro-oesophageal reflux (GOR). In this study 61 patients with severe laryngeal dysplasia or frank carcinoma of the head and neck are striated by age, investigated for the presence of antibodies to H pylori and compared to age and sex matched controls. In the age group of 46-61 years, the presence of H pylori antibodies was marginally greater in the experimental (63.0 per cent) than the control group (40.7 per cent) (Pearson Chi square p = 0.055, Fisher 2-sided exact test p = 0.066). When combining this age group with the younger age group and thereby creating two roughly equal groups (n = 31 and n = 30) there was also a statistical trend towards increased positivity in the experimental group. These findings are discussed in the light of other studies with gastro-oesophageal reflux disease (GORD).

Canalplasty is the surgical procedure whereby the external auditory meatus is widened. The indications include exostoses, stenosing external otitis and widening for surgical access. One hundred consecutive ears operated on by one surgeon are reported. The surgical technique is described in detail, paying particular attention to bone removal from the anterior canal wall. In this paper the majority of cases were occasioned by soft tissue rather than bony stenosis. The re-stenosis rate was four per cent and in each case this was associated with the use of a middle temporal artery flap. Partial, transient, delayed facial palsy occurred in two per cent, probably relating to thermal injury transmitted from the burr. A full, spontaneous recovery of facial function occurred in each case. This is a safe and effective technique for canal widening.

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.

Sudden onset sensorineural deafness is an otological emergency; subsequent recovery of hearing has been shown to correlate with early treatment. There have been few documented reports of this occurring in pregnancy, although the increased thrombogenic risk of the pregnant state is a proposed aetiological factor. The wide variation in outcome is demonstrated by these two cases, which are presented to raise awareness of this condition.

In a prospective study of 50 patients undergoing tonsillectomy the pain scores over the first 14 days were recorded. The scores for those patients 10 years or younger were compared with those older than 10. The results showed a significant difference between the distribution of pain over the course of time between the two groups. The mean pain scores on day 1 were similar in the two groups but in the older group the level of pain recorded daily remained fairly constant until day 9 when it fell to around half the initial score. In the younger children the pain scores peaked at day 2 but thereafter fell to approximately half the peak score by day 6. The analgesic intake in each group mirrored these findings.

As the prevalence of tuberculosis in the U.K. increases, uncommon clinical presentations of the disease may be encountered by the otolaryngologist. We describe just such a case, where a caucasian patient presented with laryngeal lesion, considered to be highly suspicious of a neoplastic process rather than an infective one. We discuss the pathogenesis of tuberculous laryngitis, and review the differential diagnosis and management of the condition.

Packing of the nasal cavity following intranasal surgery is still widely practised. The removal of this packing is invariably associated with a significant amount of pain. We designed a prospective randomised case-controlled study to look at the efficacy of 4% lignocaine solution as a potential analgesic in the removal of Merocel nasal packs. Each patient had bilateral packs and acted as his or her own control with one pack being rehydrated with lignocaine and the other with saline. We found that there was a reduction in the level of discomfort experienced on the side rehydrated with lignocaine, although this reduction did not reach significance. We emphasize the importance of rehydration of these packs prior to removal.

Epistaxis is a common problem amongst anti-coagulated patients. Application of first-aid principles can control the majority of bleeds. In our sample of 60 patients attending the anticoagulant clinic, 40% were unable to think of a single measure that would be helpful in controlling a nose bleed. 6 weeks after being given first-aid advice the proportion of patients able to recall at least three first-aid principles had improved from 8% to 50%. First-aid education in this respect was well received and there was a good recall rate. Provision of advice verbally backed up by a printed sheet gave best rates of recall.

After arterial reconstruction, patients have traditionally been followed up in clinic in the long term. We have pursued a policy of limited clinic follow-up, with an 'open access' service for suspected graft failure (and latterly duplex scanning surveillance for vein grafts). This policy was assessed by measurement of the success of self-referral, graft patency and patient satisfaction after operation for lower limb ischaemia in 173 patients. At median follow-up of 50 months, 61 (35%) patients had died and 45 (25%) had required amputation. Of those with salvaged limbs and available for follow-up, 55 (86%) patients reported continuing symptomatic improvement with a graft patency rate of 80%. During the review period, 27 (42%) patients had presented themselves on suspicion of graft occlusion and 14 (52%) of these had required surgical intervention. Of the patients, 45 (70%) found a single postoperative clinic visit helpful, and the majority thought that further visits would not have been helpful to them. Limited clinic appointments seem especially desirable for elderly patients for whom journeys are an imposition, as well as reducing travel costs, and giving surgeons more time to deal with new referrals. These results suggest that properly educated patients present themselves when signs of graft occlusion occur, and there is little to be gained by regular long-term clinic follow-up in vascular surgical practice.