The incidence of incisional hernia was high after aortic aneurysm repair, but was lower in patients who had a transverse incision.

A nitinol stent may be suitable for aortic graft fixation, has characteristics similar to the Palmaz stent and has shape memory effect which may overcome the difficulties of introduction of wider diameter stents through narrow arteries.

Abdominal aortic aneurysm (AAA) can now be corrected by perfemoral introduction of a prosthetic tube graft with fixation using expandable metal stents. This technique requires a satisfactory iliac system, through which the graft can reach its destination, and suitable lengths of non-aneurysmal aorta below the renal arteries and above the aortic bifurcation for stent attachment. The feasibility for placement of endovascular grafts was assessed in 44 consecutive patients admitted for transabdominal AAA repair. The proximal and distal aneurysmal necks and the iliac arteries were assessed before operation by colour flow Doppler ultrasonography (duplex scanning), computed tomography and intravenous digital subtraction angiography, using intraoperative measurements as the 'gold standard'. At operation 32 of 44 patients had a suitable proximal neck and five of 44 a suitable distal neck for endovascular grafting. Duplex scanning was the most accurate modality for preoperative assessment of the aneurysm necks. According to this technique 32 of 44 patients had a satisfactory iliac system for introduction of an endovascular graft. Overall only four of 44 patients were considered suitable for endovascular correction of AAA using a tube graft-stent combination.

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A case is reported of acquired venous aneurysms in the superficial forearm veins of an oarsman. The aetiology, presentation and complications are discussed.

The chemotherapeutic agents used for cancer have a wide range of reported side-effects but these have so far not included critical limb ischaemia. We have seen three cases in women being treated for ductal carcinoma of the breast. CASE HISTORIES Case 1A woman of 56 was seen after her left foot had been cold and painful for 24 hours. In addition she said that for two months her fingers had been intermittently cold and blue. Her only risk factor for peripheral vascular disease was cigarette smoking, about ten a day. Recently an invasive ductal cancer of the breast had been treated with wide local excision and axillary clearance. One out of fifteen lymph nodes contained tumour but she was not thought to have metastatic disease elsewhere. She had undergone five cycles of cyclophosphamide, methotrexate and 5-fluorouracil (5-FU) chemotherapy (CMF) and was taking tamoxifen. The 5-FU was administered as an intravenous bolus of 987.5 mg at alternating one-week and three-week intervals. The last infusion had been 3 days earlier. On direct questioning, it was clear that the patient had first developed transient pain in her left foot after her first cycle of chemotherapy. When the pain recurred after the second cycle, deep venous thrombosis had been excluded by duplex scanning.On examination her left foot was cold and pulseless and the third and fourth toes were dusky blue. A doppler signal was just audible over the posterior tibial artery but anklebrachial pressure indices were not recordable. An arteriogram revealed a normal aorta and iliac vessels but the left superficial femoral artery was attenuated with occlusion of the popliteal just above the joint line (Figure 1).The chemotherapy was stopped and she was treated with an intravenous bolus of 5000 units of unfractionated heparin followed by an intravenous heparin infusion of 24 000 units over 24 hours. Three successive intravenous infusions of Iloprost (a prostacyclin analogue) 50 mg, in 250 mL 5% glucose, were given without improvement. Two days later a left chemical sympathectomy was performed and the foot became warmer though still painful. Aspirin 150 mg daily was then started. Over the coming weeks she improved clinically and the fourth toe returned to normal. However, the pain remained troublesome. Further duplex scanning revealed no distal popliteal or trifurcation vessels but the posterior tibial vessel was seen to re-form just above the medial malleolus as a reasonable sized vessel with very damped flow. She underwent a reverse autologous long saphenous vein left popliteo-posterior tibial bypass and the third toe was amputated. Postoperatively she was heparinized and subsequently warfarinized. The graft remains patent at one year. Case 2A woman aged 46 was seen when three months of increasing pain in the fingers and toes, with occasional discoloration, culminated in a long episode of pain and redness in the right foot. She was undergoing cyclical intravenous CMF chemotherapy for invasive ductal 444

Background: Transverse abdominal incisions are thought to be less painful and followed by fewer pulmonary complications than midline incisions, but reports remain controversial. This study compared midline and transverse incisions for elective transabdominal aortic aneurysm repair with respect to postoperative pain, respiratory function and pulmonary complications. Methods: Sixty patients were randomized to midline laparotomy and transverse incisions, and evaluated before and after operation for 7 days at regular intervals. Analgesia was provided via a thoracic epidural and pain scores were recorded by means of a visual analogue scale. Respiratory function (peak expiratory flow rate, forced expiratory volume in 1 s and forced vital capacity) and pulmonary complications were monitored as well as patient characteristics, operating time, blood loss, operative exposure, and length of stay on the intensive care unit (ITU) and in hospital. Results: The two groups included a similar number of patients (n = 30 per group) and basic characteristics such as age and preoperative risk factors. Linear analogue pain scores were significantly lower in the transverse group of patients (P < 0·001). There was no significant difference between the two groups with regard to postoperative ventilatory function and respiratory complications as well as analgesic requirements, operating time, blood loss, and length of ITU and hospital stay. Conclusion: The direction of incision does not seem to influence the incidence of respiratory complications. However, a transverse incision in combination with a high epidural analgesia seems to offer better postoperative pain control. © 2001 British Journal of Surgery Society Ltd

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