Search

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified. [ABSTRACT FROM AUTHOR]

Introduction: The quality improvement framework for major amputation was developed with the aim of improving outcomes and reducing the perioperartive mortality to less than 5% by 2015. The aim of the study was to assess our compliance with the framework guidelines and look for the reasons for non-compliance. Method: All major amputations performed between 2008 and 2010 were included. The following data were collected: presence of infection ± tissue loss, status of arterial supply, revascularisation attempts, time to surgery, type of amputation, morbidity and mortality. Results: A total of 81 patients were included (42 BKAs, 39 AKAs). Ninety percentage had formal preoperative arterial investigations and 84% had an attempted revascularisation procedure. Patients who were transferred late from non-vascular units ( n = 12) had a 30-day mortality of 50% whereas patients who presented directly to our unit had a 30-day mortality of 7.2%. The number of amputations has decreased over the last 3 years from 34 to 21 per year, coinciding with the doubling of crural revascularisation procedures performed (from 60 to 120 per year). Ten patients underwent a revision from BKA to AKA because of an inadequate profunda femoris artery (PFA), whereas all those with a healed BKA stump either had a good PFA or a named crural vessel. Conclusion: The overall number of amputations is decreasing from year to year. By doubling our crural revascularisation procedures we are saving more limbs. Thirty-day mortality is higher than expected, particularly in patients who present late. Expeditious referral may potentially improve the mortality rate among this group of patients. [ABSTRACT FROM AUTHOR]

Objective Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital. Method Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed. Results Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10–65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2–162 months), local recurrences occurred in 13% ( n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections. Conclusion ETAR is simple and safe for managing rectal adenomas. [ABSTRACT FROM AUTHOR]

Background: The majority of renal transplant patients will sustain at least one acute rejection episode during the first 4 months, following transplantation. Clinical rejection is rarely an all-or-nothing reaction, and the first episode seldom progresses to complete renal destruction. The functional changes induced by rejection appear to be in large part reversible; therefore the recognition and treatment of the rejection episode, before the development of severe renal damage, are of extreme importance. Methods: This pilot study describes a technique of non-invasive wound assessment used to monitor 14 transplant patients, over a 3 week post-operative period. The technique involved the use of 20 MHz diagnostic ultrasound, in conjunction with fractal image analysis. Ultrasound scans of both wounded and adjacent uninjured tissue were taken 5, 7, 11, 14 and 21 days post-surgery. Results: When patients were divided into those who experienced allograft rejection and those who did not, a distinct trend appeared. In those who did not reject, the fractal signature of the wound progressed towards that of normal tissue in a linear fashion. In patients that did reject, the fractal signature initially progressed towards normal until day 11, then changed direction moving away from normal, between days 11 and 14. The patients experiencing allograft rejection were clinically diagnosed around a mean time of 14 days post-surgery. It is therefore possible that this shift in fractal signature may correlate with graft rejection. Conclusion: The results of this pilot study indicate that high frequency diagnostic ultrasound, coupled with appropriate image analysis, may be a useful adjunct to renal function assessment. [ABSTRACT FROM AUTHOR]

The polytetrafluoroethylene (PTFE) arteriovenous fistula allows vascular access for haemodialysis where a primary fistula or brachio-basilic vein transposition is not possible. We report patency rates and complications associated with these prosthetic grafts. Fifty-nine upper limb PTFE grafts in 48 patients were evaluated with a mean follow-up of 19 months (range 2–54 months). Three grafts (5%) were never used. The primary patency rate at 6 weeks was 90%. Cumulative secondary patency rates were 66% at 6 months, 36% at 12 months, 17% at 18 months, 3% at 24 months and 2% at 30 months. None of the grafts had remained patent at 3 years. Forty-six percent of the grafts studied thrombosed at least once and 32% became infected. Although the initial primary patency rate achieved compares favourably with that reported for brachio-basilic transposition fistulae, this study confirms that the use of prosthetic material is associated with a poor overall patency rate and high risk of complications. All options using autologous vein should be exhausted before considering prosthetic material. [ABSTRACT FROM AUTHOR]

A third of patients with critical limb ischemia (CLI) will eventually require limb amputation. Therapeutic neovascularization using unselected mononuclear cells to salvage ischemic limbs has produced modest results. The TIE2-expressing monocytes/macrophages (TEMs) are a myeloid cell subset known to be highly angiogenic in tumours. This study aimed to examine the kinetics of TEMs in patients with CLI and whether these cells promote neovascularization of the ischemic limb. Here we show that there are 10-fold more circulating TEMs in CLI patients, and removal of ischemia reduces their numbers to normal levels. TEM numbers in ischemic muscle are two-fold greater than normoxic muscle from the same patient. TEMs from patients with CLI display greater proangiogenic activity than TIE2-negative monocytes in vitro. Using a mouse model of hindlimb ischemia, lentiviral-based Tie2 knockdown in TEMs impaired recovery from ischemia, whereas delivery of mouse macrophages overexpressing TIE2, or human TEMs isolated from CLI patients, rescued limb ischemia. These data suggest that enhancing TEM recruitment to the ischemic muscle may have the potential to improve limb neovascularization in CLI patients., (Copyright © 2013 The Authors. Published by John Wiley and Sons, Ltd on behalf of EMBO.)