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Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management.We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously. We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002).Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years.The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.Cite this article: Bone Joint J2015;97-B:1447–55.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation.We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.Cite this article: Bone Joint J2013;95-B:1083–7.

The dwindling number of organ donors is a major concern in transplantation.[1] As a result there has been a renewed interest in retrieving kidneys from asystolic or 'non-heart beating' donors [...]

Fenestrated endovascular repair of abdominal aortic aneurysms has been proposed as an alternative to open surgery for juxtarenal and pararenal abdominal aortic aneurysms. At present, the evidence base for this procedure is predominantly limited to single-center or single-operator series. The aim of this study was to present nationwide early results of fenestrated endovascular repair in the United Kingdom.

This meta-analysis of the three RCTs that have compared topical negative pressure with conventional treatment in patients with lower limb ulcers found that it significantly reduced healing times and increased the number of healed wounds

Non-vascular leg pain is a term used to describe pains in the leg or foot that suggest arterial occlusive disease but where specialist assessment shows that this is not the [...]

Objectives:to investigate the variables affecting the long-term outcome of infrainguinal vein bypass grafts that have undergone postoperative surveillance.Design:a retrospective analysis.Patients and methods:details of 299 consecutive infrainguinal vein grafts performed in 275 patients from a single university hospital were collected and analysed. All grafts underwent postoperative duplex surveillance. Factors affecting patency, limb salvage and survival rates were examined. These factors were gender, diabetes, hypertension, aspirin, warfarin, ischaemic heart disease, run-off, graft type, early thrombectomy, level of anastomoses and indication for surgery.Results:the 6-year primary, primary assisted and secondary patency rates were 23, 47, and 57%, respectively. Six-year limb salvage and patient survival were 68 and 45%, respectively. Primary patency was adversely influenced by the use of composite vein grafts. Early thrombectomy was the only factor that significantly influenced secondary patency. Limb salvage was worse in diabetic limbs, limbs with poor run-off and in grafts that required early thrombectomy. Postoperative survival was better in males, claudicants and in patients who took aspirin.Conclusions:although co-morbid factors did not influence graft patency rates, diabetes did adversely effect limb salvage. This study, like others before it, confirms that aspirin significantly reduces long-term mortality in patients undergoing infrainguinal revascularisation.

Objectivesdata from the STILE study have indicated that for patients with subacute limb ischaemia due to native vessel occlusion, surgery is both more effective and durable than thrombolysis. The purpose of this study was to evaluate the outcome of an aggressive surgical approach in patients presenting with acute limb-threatening ischaemia.Designdetails of patients presenting with salvageable acute limb ischaemia due to native artery occlusion over a 6-year period in a University hospital vascular unit setting were obtained from the vascular audit and the outcome of the surgical management of these patients was analysed.Resultsone hundred and seventy-four consecutive patients underwent surgery for acute native vessel limb ischaemia (76% lower, 24% upper limb). Fogarty thrombectomy or embolectomy was initially performed in 153 (89%) patients. Of these, 37 (24%) immediately underwent a further procedure: 28 (18%) had on-table thrombolysis and 14 (9%) underwent vascular reconstruction. Twenty-six patients (15%) underwent further limb salvage surgery within 30 days. Life table analysis demonstrated a limb salvage rate of 88% and 76% at 30 days and 2 years, respectively. Patient survival was 75% and 48% at the same time intervals.Conclusionsthese results demonstrate that a role for aggressive surgical intervention still exists, resulting in high limb salvage rates.

An organ culture of human saphenous vein was used as a model of vein graft intimal hyperplasia and the potential of Losartan, an angiotensin II receptor antagonist, to inhibit neointimal proliferation was investigated. Median (range) neointimal thickness was reduced from 17 (16–19) to 11 (8–18) μm in veins cultured with Losartan (median difference 5 (95 per cent confidence interval 2–8) μm). A similar decrease in the median neointimal proliferation index was seen from 21 (range 14–47) to 15 (range 5–31) per cent (median difference 8 per cent (95 per cent confidence interval 5–11 per cent)). These results demonstrate that angiotensin II receptor antagonists may be of therapeutic value for the modulation of vein graft intimal hyperplasia.

Over a 17-year period, 2930 vascular procedures were performed for chronic lower-limb occlusive disease. During this time, the total vascular surgical workload rose significantly as a result of an increase in the rates of arterial reconstruction and percutaneous transluminal angioplasty. Although the major lower-limb amputation rate did not change significantly, there was a decrease in the above- to below-knee ratio. In addition, there were significant increases in the percentage of patients treated over the age of 75 years and the proportion of attempted revascularizations before amputation. The mortality rates for arterial reconstruction, percutaneous transluminal angioplasty and amputation did not change significantly during the study period. The duration of hospital stay increased significantly for patients undergoing amputation and decreased significantly for those receiving arterial reconstruction.

A prospective study of all patients with critical limb ischaemia (CLI) who presented to a single vascular unit was undertaken for a 12-month period. There were 222 referrals in 188 patients, 80·2 per cent of which were emergency or urgent admissions. The majority (72·5 per cent) were initially investigated with colour duplex scanning to characterize the arterial lesion. Diagnostic angiography was performed in 35·1 per cent. An attempt at revascularization was made in 73·0 per cent of cases using percutaneous transluminal angioplasty (PTA) in 42·3 per cent, surgery in 24·3 per cent, and a combination of surgery and PTA in 6·3 per cent. Primary major amputation was required in 22 cases (9·9 per cent) and conservative treatments were used in 38 (17·1 per cent). The in-hospital mortality rate was 10 per cent with a limb salvage rate of 79 per cent. Diabetes was an independent risk factor for amputation (odds ratio 2·4, 95 per cent confidence interval 1·22–4·79, P= 0·012). Median hospital stay was much shorter for patients treated by PTA (4·5 days) than surgery (16 days) or primary amputation (18 days). The complication rate of PTA requiring surgery was 5·5 per cent. CLI represents a large non-elective workload for a vascular unit. The increasing use of non-invasive duplex assessment and angioplasty plays a major part in the successful management of these patients.

Percutaneous transluminal angioplasty (PTA) alone was used to treat 54 (23 per cent) of 232 lower limbs with critical ischaemia. Technical success was achieved in 49 cases (91 per cent) with an immediate symptomatic improvement in 47 (87 per cent). There was no death or limb loss attributable to PTA and three embolic complications were successfully treated by percutaneous aspiration. Symptomatic improvement and haemodynamic patency rates at 24 months were 77 and 78 per cent respectively; 27 of 34 limbs with ulceration or gangrene had healed with minor surgery by a median of 7.5 (range 3.0–18.0) months. Patient survival and limb salvage rates at the same time interval were 76 and 89 per cent respectively. These results demonstrate that, for a selected group of patients with lower-limb-critical ischaemia, PTA can be a highly successful therapeutic option with a low associated morbidity.

Vein wall morphology (intimal and medial thickness) was studied in a consecutive series of 100 veins before organ culture. The development of a proliferative neointima after 14 days in culture was quantified by measuring neointimal thickness, and the relationship between this and the original vein wall morphology was investigated. The correlation between the intimal or medial thickness before culture and neointimal thickness following culture was poor (rSintima/neointima = 0·21, rSmedia/neointima = 0·09). Long saphenous vein biopsies were obtained from 53 patients at the time of infrainguinal bypass surgery and their morphology was studied as above. Median intimal and medial thickness before grafting was 21 (range 2–208) and 245 (range 108–557) μm respectively. After 12 months in a colour duplex graft surveillance programme, 46 grafts were patent and 17 of these had developed a stenosis. There was no difference in intimal (28 versus19 μm, P = 0·1) or medial (247 versus245 μm, P= 0·47) thickness between stenosed and non-stenosed grafts respectively. Both the laboratory and clinical evidence from this study fail to support the hypothesis that pre-existing vein wall thickening is a key factor in the aetiology of vein graft stenosis.

Although knowledge of the biological processes involved in the development of intimal hyperplasia has increased markedly in recent years, the precise aetiology of infrainguinal vein graft stenosis remains undetermined. Current therapy is therefore directed at treatment of the established lesion rather than its prevention. There seems little doubt, however, that recent advances in understanding of the vascular biology of normal and pathological saphenous vein will eventually lead to specific targeted therapy that will allow the prevention of vein graft stenosis.

Objective:: The aim of this study was to assess and compare the efficacy of PTA and surgery in the treatment of severe lower limb ischaemia. Design:: Prospective 12-month study of 180 consecutive patients with severe chronic lower limb ischaemia. Methods:: PTA was used as first line therapy whenever possible and appropriate. Surgical revascularisation, primary amputation and conservative therapy were used in the remaining patients. Patient survival and limb salvage were derived using life table analysis. Results:: Revascularisation was attempted in 135 (75%) patients, with PTA in 82 (46%), surgery in 49 (27%) and a combination of both in four (2%). Overall 12-month survival and limb salvage was 75% and 71%, respectively. Surgery and PTA had significantly higher survival rates (91% and 78%) than primary amputation or conservative therapy (57% and 52%) (p<0.0001 log rank test). Revascularisation with either surgery or PTA achieved the same limb salvage rate of 76%. Conclusion:: A large proportion of patients with severe chronic lower limb ischaemia can be managed by PTA. This management strategy produces a clinically effective outcome at 1-year.

Objectives:: Although cell culture techniques and animal models of intimal hyperplasia have increased our current understanding of the aetiology of vein graft stenosis, the results of such studies have been difficult to relate to the human situation. Design:: The present study was designed to validate an organ culture of human saphenous vein by comparing the changes occurring in cultured vein with those seen in pathological vein graft stenoses and to identify a suitable marker of cell proliferation. Materials and methods:: Saphenous vein segments were cultured for 14 days, fixed in formalin and processed for immunohistochemistry. Freshly excised stenoses were fixed and processed similarly. A number of markers of cell proliferation were evaluated in the culture system in order to identify the one best suited to this particular model. Results:: Marked similarities were observed in the cellular and extracellular matrix composition, and electron microscopy revealed that both the neointima of the cultured vein and the pathological lesion contained an abundance of smooth muscle cells of a secretory phenotype. Bromodeoxyuridine proved to be the most reliable proliferation marker and revealed that early proliferation in the superficial layers of the vein intima gave rise to the formation of neointima. Both proliferation and neointimal thickness were maximal by day 14 in culture. Proliferation declined rapidly thereafter, and the neointima was maintained. Conclusions:: The changes occurring in cultured vein and graft stenoses bore many similarities, thereby justifying the use of organ culture as a valuable experimental tool.

Objectives:: To elucidate the incidence of significant vein graft stenosis in patients who have undergone bilateral infrainguinal vein grafts. Materials:: Between 1987 and 1996, 22 patients were identified from our vascular studies database as having undergone bilateral infrainguinal vein bypass grafting. Methods:: Data was obtained from the vascular studies database and by case note review. All patients had been part of a vein graft surveillance programme. Results:: Of the 22 patients with bilateral vein grafts, eight were excluded from further analysis because one or more of their grafts failed within 30 postoperative days. In the remaining 14 patients (28 vein grafts) there were 15 primary vein graft stenoses. Six patients (43%) had bilateral vein graft stenoses, which is significantly higher (p = 0.0008) than the predicted value of 9%, for developing bilateral vein graft stenoses. For those patients who developed a vein graft stenosis in their first grafted limb (9/14), 67% (6/14) subsequently developed a vein graft stenosis in their second grafted limb. Conclusion:: Patients who develop vein graft stenosis in one limb are at a greater risk of developing a contralateral vein graft stenosis if that limb is grafted. This may well be due to individual vein morphology or unidentified systemic factors that play a role in the aetiology of vein graft stenosis.

Aim:: To review outcome of 40 consecutive infrapopliteal percutaneous transluminal angioplasty (PTA) procedures performed over a 65 month period. Chief outcome measures:: The indication for PTA was intermittent claudication in 20 (50%) cases and rest pain, ulceration or gangrene in the remainder. Results:: There was one technical failure; the remaining 39 limbs were all clinically improved by 24 h and this improvement was maintained at 3 months in 36 (90%). There were no deaths nor limb loss related to PTA and 2 embolic complications were successfully treated percutaneously. The primary and secondary symptomatic patencies at 24 months were 59 and 79% respectively. The actuarial limb salvage rate at 1 year for the 20 limbs presenting with critical ischaemia was 77%, and 10 of the 14 procedures performed for ulceration or gangrene resulted in healing with only minor surgical intervention. Conclusions:: With modern endovascular techniques, infrapopliteal PTA is a safe, worthwhile and durable procedure.

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were: refused consent (n=13; 18%), relatives unavailable to ask for consent (n=9; 12%), technical problems with catheter insertion or perfusion (n=10; 14%), transplant staff unavailable (n=1; 1%), long asystolic period (n=8; 11%) and donor unsuitable for other reasons (n=8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.

Objective: To quantify the incidence and extent of structural changes present in the long saphenous vein of patients with arterial disease.Design: Observational study of saphenous vein morphology.Setting: Departments of Surgery and Pathology, Leicester Royal Infirmary.Patients: Sixty vein biopsies from patients undergoing arterial surgery.Main outcome measures: Intimal and medial thickness and morphology.Results: Smooth muscle cell hyperplasia, elastosis and fibrosis contributed to intimal thickening (> 10 μm) in 87% of veins. This was frequently associated with medial longitudinal muscle hypertrophy. Intimal thickness had a skewed distribution with a median (range) of 33 (8–381) μm, The upper limit of the normal range was 200 μm. The median (range) medial thickness was 293 (131–468) μm.Conclusions: Intimal thickening is common in the long saphenous vein of patients undergoing arterial surgery but is extensive in only a small proportion. The upper limit of the normal range was 200 μm.

The aim of this prospective study was to examine the long-term outcome of infrainguinal vein graft stenosis managed by percutaneous transluminal angioplasty (PTA) as first-line treatment. Thirty-three infrainguinal vein graft stenoses detected by graft surveillance during a 44-month period were treated initially by PTA. The median (range) follow-up after angioplasty was 39 (18–56) months. Although 19 stenoses were successfully treated by a single PTA, 14 stenoses recurred at a median (range) interval of 8·5 (1–39) months. Restenosis occurred more frequently in the distal third of a graft (P= 0·002) compared with that in the proximal or mid-grafts, and restenosis was more common in in situthan reversed vein grafts (P= 0·03). It is concluded that infrainguinal vein graft stenoses were successfully treated by single PTA. There was, however, a high restenosis rate after angioplasty of stenosis in the distal third of a vein graft and, while approximately one third of such stenoses can be treated by a single PTA, the optimal management of recurrent stenosis requires further investigation.

SUMMARYDysbaric symptoms following ascent from a scuba dive are due to symptomatic nitrogen or air emboli with clear patterns of associated injury. This case report highlights an unusual presentation of dysbaric injury treated successfully with a prostacyclin analogue.

Phospholipid synthesis in wheat aleurone tissue was found to be induced by imbibition. Radiotracer experiments using [Me-14C]choline precursor showed that the synthesized phospholipid was located in the microsomal fraction of the tissue. The most active period of phospholipid synthesis was during the first day of germination before gibberellic acid (GA3) responses were evident. GA3 was, in fact, without effect upon the rate of phospholipid synthesis, but evidence is presented which indicates that the hormone increased the rate of phospholipid breakdown. Abscisic acid (ABA) also induced phospholipid breakdown, and ABA did not inhibit the GA3-induced breakdown. The relationship of phospholipid synthesis and membrane formation to the induction of hydrolase production by GA3 is discussed.