These results suggest that overall primary patency rates for wrist and elbow fistulae are comparable to similar studies at 6, 12 and 24 months. Fistula survival after this period is dictated by poor patient survival. Our findings suggest that creation of primary vascular access at the elbow in older females and diabetics may be associated with better results.
CEA in patients aged 75 years and over is associated with a significantly increased risk of stroke and death. CEA may not benefit elderly patients with a reduced life expectancy.
Grade 0 No steal.Grade 1 Mild (cool extremity with few symptoms but demonstrable by flow augmentation with access occlusion) -no treatment required. The clinical assessment of steal syndrome is often difficult as other factors like concomitant peripheral vascular disease and peripheral neuropathy can influence the clinical picture. A warm hand with a palpable ipsilateral radial pulse distal to the fistula suggests a problem other than steal. However, the converse is not true. An absent radial pulse in a fistula patient does not necessarily indicate steal syndrome. This is supported by a study 7 in which one-third of the 180 patients included had an absent radial pulse yet only 7 developed clinical symptoms of ischaemic steal.The diagnosis of ischaemic steal has been a topic of much debate, with several methods suggested. The four main methods include photo-plethysmography, pneumaticplethysmography, Doppler ultrasonography and digital pulse oximetry. These all monitor the waveform produced by blood flow within the digital arteries. A pronounced increase in waveform amplitude following manual external fistula compression is described.8 This external pressure effectively removes the fistula from the systemic circulation and returns blood-flow along its 'natural' pathway, thereby confirming a diagnosis of fistula-induced steal.In considering interventional surgery for symptomatic steal, there are two requirements -the preservation of uninterrupted vascular access and resolution of the distal ischaemia.3 Current techniques aim to satisfy these requirements, in the most simplistic, readily available and reliable manner, with the exception of fistula ligation which sacrifices the fistula in order to eliminate steal, but with construction of a new fistula in an alternative location, either on the ipsilateral or contralateral arm. The approach to intervention can be divided into two groups, one based on reduction of fistula flow by increasing its resistance, and the other by increasing the blood supply to the artery distal to the fistula.Surgical approaches can include banding of the fistula, clipping, insertion of a tapered graft or undertaking the DRIL procedure.
Surgical techniqueThe DRIL procedure was first described in 1988 by Schanzer et al. 9 However, it has not been widely adopted because of concerns about its complexity and long-term efficacy.1 The DRIL procedure consists of two parts (Figs 1 and 2):1. Distal revascularisation is achieved with a bypass graft which has its origin from the graft artery, above the AVF, and ends with an end-to-side anastomosis, again to the graft artery but just distal to the AVF.2. Interval ligation is the simple cutting and tying of the graft artery distal to the AVF but proximal to the bypass graft anastomosis.The bypass graft provides a low-resistance pathway that runs in parallel to the artery, thus reducing the total system and more specifically, the peripheral resistance.
ResultsIn our unit, five DRIL procedures were completed with a further procedure in another unit followi...
17 Jass JR, Love SB, Northover JMA. A new prognostic classification for rectal cancer. Lancet 1987; i: 1303-6. 18 Enker WE, Laffer UT, Block GE. Enhanced survival of patients with colon and rectal cancer is based upon wide anatomic resection. Ann Surg 1979; 190: 350-60. 19 Sugihara K, Hojo K, Moriya Y, Yamasaki S, Kosuge T, Takayama T. Pattern of recurrence after hepatic resection for colorectal metastases. Br J Surg 1993; 80: 1032-5. 20 Goligher J. Treatment of carcinoma of the rectum. In: Surgery of the Colon, Rectum and Anus. 5th ed. London: 307-15.
We present the first case of a posttraumatic pseudoaneurysm of the axillary artery successfully treated with a stentgraft.A 89-year-old woman with a conservatively treated subcapital humeral fracture developed a pseudoaneurysm of the left axillary artery which was percutaneously successfully treated with a stentgraft. Endovascular repair of a traumatic axillary artery pseudoaneurysm should be considered especially in unfit patients.
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