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Biomedical subjects

M S Whiteley

Publications and source records attributed to M S Whiteley.

At least 19 recordsLinked to original sources
PubMed2000

Remote superficial femoral artery endarterectomy: medium-term results.

BACKGROUND: the aim of this study is to determine the medium-term results following successful remote superficial-femoral endarterectomy (RSFE). SETTING: district general hospital in United Kingdom. METHODS: RSFE comprises a single incision over the origin of the superficial femoral artery. The endarterectomy is carried out in a closed fashion from above. The cut end of distal atheroma is secured with a stent. Twenty-five limbs were followed up with three monthly duplex scans and angiography if any abnormality was suggested. All patients presented with intermittent claudication; in addition three had rest pain and three ulceration or gangrene. The length of atheromatous core removed was 10-30 cm. RESULTS: all patients had a follow-up of at least one year (range 12-27 months). Eleven arteries developed 14 stenoses. Nine became apparent within nine months of RSFE. The cumulative risk of stenoses developing in patent arteries was 24% at 6 and 63% at 12 months. Eleven angioplasties (PTA) of these stenoses were undertaken. Nine of these remain patent at a median of 12 months after PTA. At one year primary patency was 10 of 25 (40%), primary-assisted patency 18 of 25 (72%) and secondary patency 19 of 25 (76%) and at two years 29%, 57% and 57% respectively. CONCLUSIONS: RSFE is worth considering for superficial femoral artery occlusive disease, particularly in high-risk patients without suitable vein and with limited life expectancy. Careful duplex surveillance is important. Until stenoses can be prevented, the widespread use of RSFE cannot be recommended.

Aged↗
PubMed1999

Acute upper limb ischemia: a complication of coronary artery bypass grafting.

We present the case of a patient with acute upper limb ischemia after radial artery harvest for coronary artery bypass grafting. This occurred despite adequate preoperative and intraoperative assessment with the Allen test, hand-held Doppler and radial artery backbleeding. A successful outcome was achieved by performing brachioradial bypass grafting using reversed cephalic vein.

Acute Disease↗
PubMed1999

Assessing arterial inflow before infra-inguinal bypass grafting: a survey of the members of the Vascular Surgical Society of Great Britain and Ireland.

The optimal assessment of arterial inflow is controversial. We investigated current preferences of inflow assessment prior to infra-inguinal bypass grafting. A questionnaire was sent to 364 members of the Vascular Surgical Society of Great Britain and Ireland asking about inflow assessment in different clinical situations, access to resources, size of hospital and number of grafts performed each year. Questionnaires analysed = 169. Angiography was used by 89.5%, most single view. Two views angiography was used more often by surgeons performing more than 20 femoro-distal grafts each year (79.3 versus 37.6%). Routine use of iliac duplex was < 20%; poor femoral pulse increased this to near 30%. About 90% of respondents had access to colour flow duplex. Most respondents use single-plane angiography to assess inflow before infra-inguinal grafting. Two views and functional tests are used more commonly by surgeons working in larger or teaching hospitals and those performing more grafts.

Arterial Occlusive Diseases↗
PubMed1999

Physiological comparison of open and endovascular aneurysm repair.

BACKGROUND: This prospective study compared morbidity and mortality rates following conventional and endovascular abdominal aortic aneurysm (AAA) repair using a physiological scoring system. METHODS: Between December 1994 and November 1997, 104 elective open aneurysm repairs and 49 endovascular aneurysm repairs were performed. These patient cohorts were compared using the Portsmouth predictor equation (P-POSSUM) scoring system. Data collected prospectively from patient notes were used to obtain physiological and operative severity scores which were analysed to compare expected and observed mortality and morbidity rates. RESULTS: There were three deaths (6 per cent) in the endovascular AAA repair group and 17 (16 per cent) in the conventional aneurysm repair group, whereas the P-POSSUM formulae predicted mortality rates of 8 and 19 per cent respectively. Although the mean physiological scores were similar for both groups (endovascular 20.8 versus conventional 20.1), the operative severity score was significantly greater in the conventional group (26.3 versus 19.7; P < 0.001). CONCLUSION: In this study open aortic aneurysm repair had a higher operative severity than endovascular repair, which was reflected in the increased mortality rate.

Aged↗
PubMed1999

The effect of autoclave resterilisation on polyester vascular grafts.

OBJECTIVES: polyester grafts are expensive, single-use items. Some manufacturers of uncoated, woven grafts include instructions for autoclave resterilisation to be performed at the surgeon's own request. Others warn against such manipulation. Theoretically, the glass transition point of polyester at 70-80 degrees C and the possible acceleration of hydrolysis suggest that autoclave resterilisation at 135 degrees C might be a problem. MATERIALS AND METHODS: a DeBakey Soft Woven Dacron Vascular Prosthesis (Bard) and a Woven Double Velour Dacron Graft (Meadox) were autoclave-resterilised 0 to 20 times, having been weighed before and after sterilisation. Tactile testing was performed. Mechanical properties were examined by probe puncture and single-filament testing, the surface was examined by scanning electron microscopy and the degree of hydrolysis by infra-red spectroscopy. RESULTS: tactile testing revealed a change of feeling with increasing cycles of resterilisation. Investigation of weight, textile strength, single-filament strength, electron microscopy of the surface and infra-red spectroscopy showed no change of the material. CONCLUSIONS: changes felt are presumably a surface phenomenon, not measurably affecting strength or chemistry of material after autoclave resterilisation. We therefore feel that it is safe to use once-autoclave-resterilised surplus uncoated polyester grafts, provided that sterility is guaranteed.

Blood Vessel Prosthesis↗
PubMed1999

Surgical patients with methicillin resistant staphylococcus aureus infection: an analysis of outcome using P-POSSUM.

The significance of MRSA infection in surgical patients was studied using the P-POSSUM scoring system. All surgical patients undergoing operation between 1/10/96 and 30/09/97 were prospectively scored using P-POSSUM. A subset of these patients with MRSA infection was analysed using P-POSSUM predicted mortality. Physiological and operative severity scores were compared with non-MRSA surgical patients and length of hospital stay with P-POSSUM matched non-MRSA controls. Thirty of the 1,132 patients were MRSA positive and of these five died, giving a P-POSSUM observed/expected deaths ratio of 1.7 (not significant; 95% CI -0.24 to 0.10). The P-POSSUM physiology score of 30 MRSA positive patients, compared with the non-MRSA group (n = 1102), was significantly more severe (20.9 v/s 17.4; 95% CI 1.09 to 5.95) as was the operative severity score (15.6 v/s 9.2; 95% CI 4.40 to 8.42). The length of stay for surviving MRSA positive patients was significantly longer than P-POSSUM matched controls. MRSA infection in surgical patients does not increase mortality. However, patients who contract MRSA infection are more debilitated and have undergone a greater surgical insult.

Adult↗
PubMed1999

Calman, venous surgery and the vascular trainee.

BACKGROUND: Surgical training in Great Britain is undergoing inevitable changes to accommodate the processes of Higher Surgical Training. Junior surgeons have long argued that their training experiences have been haphazard or without satisfactory supervision. With the advent of changes following the Calman Report and the implementation of the Vascular Surgical Society recommendations, we have audited the venous surgical experience of vascular trainees in Great Britain. METHODS AND RESULTS: Questionnaires were sent to 90 vascular surgical trainees achieving an overall 76.7% response rate (n = 69). Just under half of the trainees had spent more than 12 months on a pure vascular firm. The majority of trainees had received formal training in sapheno-femoral junction ligation and sapheno-popliteal junction ligation. However, several areas of training were deemed insufficient at both the junior and senior trainee levels. Very few trainees gain instruction on deep venous surgery and the techniques of microsclerotherapy. CONCLUSIONS: Despite the participation of trainees in specialised vascular units, current training schedules fail to cover the field of venous surgery adequately. Training by vascular specialists needs greater focus and should be tailored to the trainee's experience on entry to their firm.

Health Care Surveys↗
PubMed1998

Scoring systems.

Explore the source record for details and available documents.

Graft Occlusion, Vascular↗
PubMed1998

The fate of patients undergoing surveillance of small abdominal aortic aneurysms.

OBJECTIVES: Increasing numbers of patients with small abdominal aortic aneurysms (AAA) are being diagnosed. The aim of this paper is to define the fate of those patients undergoing surveillance of small AAAs. SETTING: U.K. district general hospital. METHODS: A prospective study has been carried out of all patients undergoing surveillance. At the time of the first consultation the patient was assessed, a Detsky score calculated and the referral source noted. End points of the study were elective repair of the aneurysm, aneurysm rupture or death of the patient. RESULTS: Details of 267 patients were analysed. The referral source was general practitioner in 39%, patients with peripheral vascular disease in 32% and department of urology in 21%. None were referred from population screening. The cumulative 5-year risks of rupture, elective repair or non-AAA related deaths were 15%, 26% and 46% for all patients, 4%, 13% and 38% for patients initially presenting with AAA less than 4 cm diameter and 21%, 42% and 54% for patients presenting with an AAA 4-5.5 cm diameter. All but one of 11 patients whose aneurysm ruptured were unfit or had declined elective repair. There were 56 non-AAA related deaths, the majority due to cardiovascular causes. Those patients with low Detsky scores had a 5-year survival of 62%, those with high scores 44%. The age/sex matched survival or a normal population at 5 years in 80%. CONCLUSION: Overall the non-AAA related mortality was greater than the risks of rupture or elective repair. It is important to bear in mind the poor prognosis of this group of patients compared with a normal population when considering elective repair of small AAAs.

Actuarial Analysis↗
PubMed1998

Full-dose and half-dose Klean Prep produce clearer images with iliac duplex examination than picolax.

OBJECTIVES: Iso-osmotic bowel preparation (Klean Prep) improves the accuracy of iliac duplex examination and reduces the time of each examination. Full-dose Klean Prep entails 4 l of fluid. We studied the effect of 2 l of Klean Prep (half-dose) and Picolax on image quality. DESIGN: Prospective study comparing clarity of duplex examination after three different bowel preparation regimes with that after 12 h starvation. MATERIALS AND METHODS: Thirty patients underwent iliac duplex examination after 12 h starvation. Scans were scored subjectively for grey scale and colour image quality, and Doppler signal-to-noise ratio. Patients were allocated blindly to: (a) full-dose Klean Prep, (b) half-dose Klean Prep, or (c) Picolax. After out-patient preparation, the scan was repeated and scored by the same observer, blinded to the preparation. RESULTS: Both full- and half-dose Klean Prep produced significant improvements in image quality for all three modalities; Picolax produced minimal change. There was minimal advantage of full-dose over half-dose Klean Prep. Patients preferred half-dose Klean Prep to full-dose. CONCLUSION: Klean Prep significantly improves the image obtained by iliac duplex examination; Picolax does not. Half-dose Klean Prep is an acceptable preparation to patients.

Aged↗
PubMed1998

Minimally invasive superficial femoral artery endarterectomy: early experience with a modified technique.

OBJECTIVES: To describe our experience of a modified technique for carrying out remote endarterectomy for superficial femoral artery occlusive disease. METHODS: A 4-French arterial dilator is inserted using a Smart needle into the popliteal artery below the occlusion. A remote endarterectomy is carried out through an arteriotomy in the proximal superficial femoral artery. The atheroma is cut distal to the lower extent of disease using a Moll ring cutter. The lower flap of atheroma is secured with an intraluminal stent inserted from the arteriotomy in the superficial femoral artery. The arteriotomy is extended into the common femoral artery and closed with a vein patch. RESULTS: The procedure was completed in 21 of 26 limbs. In 18 cases the superficial femoral artery remained patent at 30 days. Of the 21 cases all but four stayed in hospital for one night. A successful femoropopliteal bypass was carried out in the five patients in whom the procedure was not completed. CONCLUSION: Insertion of the dilator into the popliteal artery distal to the occlusion before carrying out the remote endarterectomy has two advantages. Firstly, the stent insertion is carried out in the correct plane and prevents dissection of the distal cut atheroma when attempting to pass the guidewire from above. Secondly, the procedure can be carried out under simple image intensification without sophisticated radiological equipment. The early results are encouraging and further evaluation of the technique is justifiable.

Arteriosclerosis↗
PubMed1998

POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity.

BACKGROUND: There is a need for an accurate measure of surgical outcomes so that hospitals and surgeons can be compared properly regardless of case mix. POSSUM (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) uses a physiological score and an operative severity score to calculate risks of mortality and morbidity. In a previous small study it was found that Portsmouth POSSUM (P-POSSUM; a modification of the POSSUM system) provided a more accurate prediction of mortality. METHODS: Some 10000 general surgical interventions (excluding paediatric and day cases) were studied prospectively between August 1993 and November 1995. The POSSUM mortality equation was applied to the full 10000 surgical episodes. The 10000 patients were arranged in chronological order and the first 2500 were used as a training set to produce the modified P-POSSUM predictor equation. This was then applied prospectively to the remaining 7500 patients arranged chronologically in five groups of 1500. RESULTS: The original POSSUM logistic regression equation for mortality overpredicts the overall risk of death by more than twofold and the risk of death for patients at lowest risk (5 per cent or less) by more than sevenfold. The P-POSSUM equation produced a very close fit with the observed in-hospital mortality. CONCLUSION: P-POSSUM provides an accurate method for comparative surgical audit.

England↗
PubMed1998

Combined fascia and mesh closure of large incisional hernias.

Large incisional hernias of the abdominal wall represent substantial defects of supportive tissues. The repair of these requires the mobilization of fascia or the use of a prosthetic mesh. A method for closing large midline incisional hernias using both the fascia and a mesh was described in 1979. This repair was used for six midline hernias and four large incisional hernias in the right subcostal region. No wound complications and no recurrences (median follow-up 1 year 5 months) were seen. The combined fascia and mesh repair can be successfully used for large incisional hernias of the anterior abdominal wall in areas other than the midline.

Fasciotomy↗
PubMed1998

Photoplethysmography can replace hand-held Doppler in the measurement of ankle/brachial indices.

Ankle/brachial pressure index (ABPI) using hand-held Doppler and sphygmomanometer is a standard assessment for patients with peripheral arterial occlusive disease (PAOD). Good Doppler technique is difficult to master and so we investigated replacing Doppler with photoplethysmography (PPG). Two investigators examined 52 legs in 32 vascular patients. Both used standard sphygmomanometer cuff occlusion. Restoration of flow was detected by either an 8 MHz Doppler ultrasound probe or a PPG transmitter/receiver on index finger or great toe. Doppler-derived ABPIs were compared with PPG-derived ABPIs. Excellent correlation was found between both indices (correlation coefficient 0.875). Four lower limbs had unrecordable PPG traces, one also having an unrecordable Doppler signal. Excluding these four patients, the correlation coefficient rose to 0.975. PPG placed on the pulp of a digit can replace the hand-held Doppler in measuring ABPIs.

Ankle↗
PubMed1998

Subfascial endoscopic perforator vein surgery (SEPS): current practice among British surgeons.

Subfascial endoscopic perforator vein surgery (SEPS) has recently caused considerable interest among British surgeons. There are no data indicating which, if any, patients benefit from SEPS. A series of 47 British surgeons, identified as having taken up SEPS, were sent a questionnaire asking about their current practice; 26 were returned completed (55% response rate). Of those surgeons replying, 22 (85%) had performed their first SEPS procedure within the previous 21 months, 18 (69%) within the previous 9 months. Most surgeons had performed five procedures (range 1-52). The most common indication for SEPS was venous ulceration with proven incompetent perforators (eight surgeons), but there was a wide diversity of other indications used to select patients for SEPS. Only nine surgeons had changed their indications for surgery with the advent of SEPS, yet their predicted number of SEPS procedures was far greater than the number of open procedures they currently performed. Out of 26 surgeons, 25 intend to continue performing SEPS. Prospective studies are needed to identify which patients might benefit from this new procedure.

Attitude of Health Personnel↗