Endoluminal repair of anastomotic false popliteal aneurysm using the Wallgraft endoprosthesis.

The aim of this study was to present the endoluminal repair of a false anastomotic popliteal aneurysm on a previous polytetrafluoroethylene (PTFE) above knee bypass using a Wallgraft endoprosthesis. A 53-year-old man who underwent a left femoro-popliteal above knee PTFE bypass 13 years before was admitted with a painful pulsatile mass in the above knee area. Nine months previously he developed sudden pain around the knee extending to the foot associated with coldness and numbness after he was handling some fishing gear in a crouching position for about 1 hour, but this episode spontaneously resolved. Duplex scanning and angiography revealed a 3 x 2.5 cm false aneurysm, which was successfully treated by deploying a Wallgraft endoprosthesis as the patient declined surgical repair. The graft was detected as being occluded on the 3-month follow-up but no further action was taken because the patient experienced only non-limiting claudication and he refused again surgical treatment. Endoluminal repair of perianastomotic false aneurysms in the popliteal artery with Wallgraft endoprosthesis seems feasible and safe, but until its durability is validated in larger series surgical repair remains the treatment of choice.     

The importance of communication between physicians and patients. Special considerations in the era of endovascular therapy.

Most of the lawsuits in medical practice are the result of inadequate communication between doctors and patients and litigation has very little to do with errors. In the era of the technological development and the implementation of new techniques such as endovascular therapy, good communication between physicians and patients is essential. The purpose of this review is to elicit important considerations on challenging issues relating to the art of communication between physicians and patients and to provide information on what the vascular surgeon or interventionalist should bear in mind in obtaining an adequate informed consent from the patients.     

Clinical presentation and anatomic distribution of chronic venous insufficiency of the lower limb in a typical Mediterranean population.

BACKGROUND: The aim of this study was to demonstrate the characteristics of lower limb chronic venous insufficiency (CVI) in a homogeneous Mediterranean population. METHODS: Investigation of 694 patients with uni- or bilateral symptoms and signs of lower limb CVI using colour duplex scanning. Limbs with previous venous surgery were excluded. The limbs were classified according to history and ultrasonic findings into those with post-thrombotic and those with primary CVI. The clinical presentation according to the CEAP classification was correlated to the anatomic distribution of venous reflux. RESULTS: Most of the symptomatic limbs (537/656, 81.5%) with primary CVI belonged to classes 1 to 3. In these limbs reflux confined to superficial veins was very common (64.5%, 424/656) whereas the prevalence of deep and perforator vein reflux was 18.5 and 25.5%, respectively. In contrast most of the limbs (69.5%) with post-thrombotic CVI belonged to classes 4 to 6, had a complex pattern of reflux, and involvement of deep and perforator veins was common (86.5 and 48%, respectively). In about a quarter (24%) of patients with suspected primary CVI no reflux was found in either limb on duplex scanning. Most of them (48%) had telangiectasis. Bilateral reflux was found in 71% of the patients with primary CVI. CONCLUSIONS: The clinical presentation was worse in limbs with post-thrombotic CVI than in those with a primary disease. Post-thrombotic CVI was associated with a complex pattern of reflux, affecting mostly the deep and perforator veins, whereas superficial reflux was the most common pattern in limbs with primary CVI. Therefore, surgery aiming to eliminate superficial reflux would confer only a minimal benefit in limbs with post-thrombotic CVI but would treat the majority of the limbs with the primary CVI. The high prevalence of bilateral reflux found in patients with primary CVI suggests a bilateral predisposition, which supports the hypothesis of the existence of a generalised venous disease.     

Early thrombus remodelling of isolated calf deep vein thrombosis.

OBJECTIVE: this prospective study was designed to evaluate the evolution of thrombus propagation and lysis in relation to patterns and distribution of isolated calf DVT. METHODS: fifty-two limbs in 48 patients mean age 59+/-15, range 24-78 years, with isolated calf DVT that had at least one exam within 10 days of DVT detection were included in the study. Patients with a documented episode of prior DVT or evidence of post-thrombotic changes during the initial ultrasound exam were excluded. The initial thrombus length, patterns and location of the thrombi were recorded. On follow-up the propagation and lysis patterns of the clot were studied. RESULTS: remodelling of the thrombus, excluding echotexture and vein diameter changes on ultrasound, occurred in 23 limbs, (44%). Ascending propagation only was seen in seven limbs (13%) descending propagation only in two (4%) and in both directions in five (10%). Propagation at least to popliteal vein was detected in seven limbs (13%). Thrombus developed or extended to initially uninvolved veins in six limbs (12%). Pulmonary embolism developed only in one patient (2%; 95% CI: 0-11%). The site and the size of thrombus or the number of veins involved in the baseline exam did not correlate with the remodeling of thrombus. Soleal and gastrocnemial veins were comparable with the posterior tibial and peroneal veins in terms of thrombus propagation and lysis. CONCLUSIONS: early thrombus remodelling occurs in 44% of limbs with isolated calf DVT. This includes ascending and descending thrombus propagation and lysis. Thrombus development or propagation to initially uninvolved calf veins is found in 12%. Thrombus remodelling does not appear to be related to size, site and patterns of thrombosis.     

Confidentiality Governing Surgical Research Practice

Healthy subjects or patients volunteering to participate in trials expect that their privacy and autonomy will be protected. The aim of this article is to highlight issues related to confidentiality governing surgical research practice. A search of the current relevant literature was undertaken. Consent to the disclosure of any information should be sought wherever practicable, but disclosures should be kept to the minimum necessary. The data should be made anonymous where unidentifiable data serve the purpose. Where the previously described actions are not practicable for various reasons, data may be disclosed for research, provided participants have been given information about access to their records and about their right to object. Personal information may only be disclosed without individuals consent when it is for the protection of the public interest, but this has proved too ambiguous a rubric to be useful without proper clarification. Hampering of noncommercial medical research should also be avoided, as it may cause serious damage to public health. Confidentiality in research is an important issue in the protection of the participants rights to privacy and autonomy, and it should be considered in the design of each study. Breach of confidentiality is legally justifiable for the sake of the public interest, but proper clarification of the law is required in order to avoid hampering noncommercial medical research that is vital for the public health.This paper was presented at the 39th Congress of the European Society for Surgical Research, 12-15 May 2004, Athens, Greece.     

Medical litigation in cosmetic plastic surgery

AIM: This article aims to highlight issues related to malpractice in plastic surgery and to point out the importance of good understanding of the law and the value of a patient's written informed consent as measures of professional protection. METHODS AND MATERIAL: Search of relevant literature from PubMed. RESULTS: The demand for cosmetic plastic surgery increases despite the increasing cost, in contrast to other traditional goods for which demand typically declines as price increases. Cosmetic plastic surgery has moved beyond the stage of being an exclusive privilege of the rich and famous. Nevertheless, cosmetic plastic surgery is one of the medical specialties exposed to a substantially high risk of malpractice claims. Most malpractice claims in cosmetic plastic surgery are not consequences of technical faults but because of inadequate patient selection criteria and lack of adequate communication between patient and surgeon. Proven efficient training, careful utilization of computer imaging techniques in association with the adoption of simple precautions and guidelines and adequate communication along with a completed patient's consent form are important essentials in case of medical litigation. CONCLUSIONS: In today's litigious society, maintenance of high standards in daily practice with continuous training and appropriate documentation of every procedure are all a sufficient defense of the plastic surgeon in case of medical litigation. Written patient's informed consent remains an integral part of the communication between physicians and patients, and importantly is facilitating professional protection.     

Primary superficial vein reflux with competent saphenous trunk.

OBJECTIVES: because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD). PATIENTS AND METHODS: eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD. RESULTS: the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux. CONCLUSIONS: these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.     

Can Ultrasound Replace Arteriography in the Management of Chronic Arterial Occlusive Disease of the Lower Limb?

OBJECTIVES: to investigate whether colour duplex scanning can be used as the sole diagnostic investigation prior to lower limb revascularisation. PATIENTS AND METHODS: the results of angiography and duplex were compared in 80 limbs (69 claudication, 11 critical limb ischaemia [CLI]) from 68 patients. RESULTS: excellent diagnostic agreement (kappa value 0.89, 95% CI 0.85-0.93) was achieved at the femoropopliteal segment. Agreement was good for the aorto-iliac segment (kappa value 0.69, 95% CI 0.61-0.77) and moderate for the infrapopliteal segment (kappa value 0.59, 95% CI 0.55-0.63). Similarly, in the decision-making process excellent agreement was achieved for the femoropopliteal segment (kappa value 0.91, 95% CI 0.88-0.94), good for the aortoiliac segment (kappa value 0.62, 95% CI 0.56-0.68), and moderate for the infrapopliteal segment (kappa value 0.46, 95% CI 0.42-0.50). Duplex detected patent 12 tibial arteries in 10 limbs that were not opacified on arteriography. In four limbs duplex revealed significant disease in the above knee popliteal artery that was missed on arteriography. CONCLUSIONS: treatment of femoropopliteal disease can be based upon duplex alone in the great majority of cases. However, where there is disease in the aortoiliac segment, or where infrapopliteal revascularisation is long considered both duplex and angiography should be performed to maximise pre-operative information.     

Endofibrosis of Iliac Arteries in High-Performance Athletes: Diagnostic Approach and Minimally Invasive Endovascular Treatment

The aim of this article is to report our experience in the diagnosis of two cases of iliac artery endofibrosis or arteriopathy, a rare entity occurring in high-performance athletes, presenting with intermittent claudication (right-sided in both) after maximal exercise. External iliac artery endofibrosis or arteriopathy is a likely diagnosis in competitive athletes free of cardiovascular risk factors who present with leg claudication. Arteriography and a papaverine-assisted mean pressure gradient across the iliac arteries of more than 10 mmHg is a useful diagnostic approach. Moreover, balloon angioplasty of the iliac artery in that patient, in whom a pressure gradient was detected, resulted in symptomatic relief for 2 months followed by mild symptom recurrence. Thus, although balloon angioplasty is feasible and safe, it might not be adequate to treat this entity and, thus, its value remains undefined.