Vascular Surgery Unit Research Articles

Mejoría de la calidad de vida y efectos adversos en pacientes con enfermedad arterial obstructiva crónica tratados con alprostadil-alfa-ciclodextrina por vía venosa periférica

Objectives To evaluate local and systemic complications in patients treated with alprostadil alpha-cyclodextrin (AAC) through the peripheral venous route, as well as changes in the quality of life of these patients. Method A descriptive, observational, prospective study was performed. All patients admitted to the Angiology and Vascular Surgery Unit of the University Hospital of Albacete who fulfilled the criteria for therapeutic indication of AAC administration between September 2001 and April 2002 were included. Each patient received the treatment according to a protocol previously established through consensus in the unit. Sociodemographic variables, associated disease, type and degree of arterial disease, local and systemic complications with administration of each of the cycles, and quality of life at the beginning and end of the treatment were studied. Results Forty-four patients were studied. A total of 65.5% had arterial disease in the most advanced stage. The most frequent systemic complications were allergic reactions and nausea; treatment had to be discontinued in 11.4% of patients. Local complications consisted of pain and erythema in the area of the venous line (mean 1.29 every 10 treatment doses); there was a mean of 0.97 line changes every 10 doses and 38.6% of the changes was due to phlebitis. The results of the EUROQOL questionnaire showed improvement in: mobility, ability to perform personal care, ability to perform daily activities, pain, and anxiety/depression. Conclusions Treatment with AAC according to the established protocol is safe and improves perceived quality of life.

Incidencia y factores de riesgo de las infecciones quirúrgicas de by-pass vasculares en el Hospital Juan Canalejo de a Coruña en el período 2000-2002

Vascular by-pass surgery is being used increasingly more frequently on elderly patients entailing several risk factors. Surgical infections in these procedures are a devastating complication which is related to high morbility and death rates. This study is aimed at ascertaining the incidence of surgical infections among patients having undergone a by-pass procedure with vascular prostheses, the risk factors associated thereto and the type or prosthesis entailing a lower infection rate. A retrospective cohort study was conducted at the Vascular Surgery Unit of the Juan Canalejo University Hospital throughout the 2000-2002 period. The Disease Control Center infection criteria were those applied. The frequency measurements calculated were cumulative incidence and relative risk as an association measurement. The statistical tests employed were the Chi-square and the Chi-square trend tests, the Student's-T for univariate analysis and logic regression for the multi-variate analysis. The cumulative incidence rate for the 2000-2002 period was 22.6% to 12.1%. The most frequent microorganisms were Staphylococcus aureus, meticilin-resistant Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli. The risk factors related to infection found were female sex (RR=1.8) anesthetic risk >2 (RR=1.7) and patient implanted with sapheneous vein vascular prosthesis (RR=3.8). The risk factors identified were the female sex, anesthetic risk and the type of prosthesis used, all of which condition infection-related complication in by-pass surgery.

Ruptured abdominal aortic aneurysm: prognostic factors

OBJECTIVE: To analyze the prognostic factors related to the mortality of ruptured abdominal aortic aneurysm. METHOD: Seventy-two patients who suffered ruptured abdominal aortic aneurysm and were operated in the period between 1976 and 2000 by the Vascular Surgery Unit of the Santa Casa de São Paulo - School of Medical Sciences were retrospectively analyzed. RESULTS: The descriptive analysis of the data shows a mean age of 67.93 years, with a standard deviation of 11.58, 32% female and 68% male. Of the total number, 28% had a previous history of aneurysm and 72% were not aware of the disease. Mean systolic blood pressure during hospital admission was 96.53 mmHg. Pain was present in 100% of the patients, as well as throbbing abdominal mass. In 93% of the cases the location of the aneurysm rupture was the retroperitoneum, 4% in the duodenum, and 2% in the free peritoneum. CONCLUSION: The prognostic factors related to mortality and morbidity that demonstrated statistical significance were: age, initial blood pressure at hospital admission, diuresis during surgery, volume infused, and creatinine levels.

Arterioureteric Fistula: Successful Treatment of Two Cases

Arterioureteric fistula is a rare condition mainly seen after extensive pelvic surgery for cancer, followed by radiation therapy, or after vascular surgery involving the iliac arteries. This complication causes massive and/or recurrent haematuria; symptoms are nonspecific and the diagnosis is made late and with difficulty. As with other uncommon conditions, physicians’ awareness can really make the difference and can significantly reduce mortality and morbidity. We report two cases of arterioureteric fistula observed in the last 7 years in the Vascular Surgery Unit of ‘A. Gemelli’ University Hospital in Rome.

Urgent Vascular Surgery For Trauma - Early Experience Of Dedicated Vascular Surgery Unit In A Teaching Hospital

Urgent Vascular Surgery For Trauma - Early Experience Of Dedicated Vascular Surgery Unit In A Teaching Hospital

Epidemiologic analysis of proximal deep vein thrombosis in thai patients: Malignancy, the predominant etiologic factor

From January 1995 to December 2000, 1555 patients (585 males, 970 females, with a mean age of 52.3 years) with acute limb swelling underwent diagnostic duplex venous ultrasonagraphy at the Vascular Surgery Unit, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand. Of these 1555 patients, 514 (188 males, 326 females, with a mean age of 53 years) were diagnosed with deep vein thrombosis (DVT). DVT was found mainly in the lower extremities, occurring in 506 of these 514 cases (98.4%). The affected vein in the lower extremity was found more commonly in the left side (359 limbs) than in the right side (184 limbs) (p < 0.001). DVT also occurred in the upper extremities in 8 of the 514 cases (1.6%). In this study, out of 308 patients with DVT in their lower limbs, DVT was associated with malignancy in 123 cases (39.9%), with postoperation in 48 cases (15.6%), and with limb immobilization in 38 cases (12.3%). Malignancy-related DVT was found to be more extensive and virulent and was associated with high morbidity and mortality. Further study should be conducted to investigate the role of anticoagulant drugs for the prevention of DVT in cancer patients. Perhaps the spectrum of DVT as presented in this series is characteristic not only of the Thai population but also of the populations of other Asian countries.

IS FIBRINOGEN AND D-DIMERS DETERMINATION USEFUL FOR PROGNOSIS OF DIABETIC POLYVASCULAR DISEASE

Claudication secondary to peripheral arterial disease leads to reduced mobility, limited physical functioning, and poor health outcomes. Disease severity can be assessed with quantitative clinical methods and qualitative self-perceived measures of quality of life. Limited data exist to document the degree to which quantitative and qualitative measures correlate. The current study provides data on the relationship between quantitative and qualitative measures of symptomatic peripheral arterial disease.This descriptive case series was set in an academic vascular surgery unit and biomechanics laboratory. The subjects were symptomatic patients with peripheral arterial disease patients presenting with claudication. The quantitative evaluation outcome measures included measurement of ankle-brachial index, initial claudication distance, absolute claudication distance, and self-selected treadmill pace. Qualitative measurements included the Walking Impairment Questionnaire (WIQ) and the Medical Outcomes Study Short Form-36 (SF-36) Health Survey. Spearman rank correlations were performed to determine the relationship between each quantitative and qualitative measure and also between the WIQ and SF-36.Included were 48 patients (age, 62 ± 9.6 years; weight, 83.0 ± 15.4 kg) with claudication (ABI, 0.50 ± 0.20). Of the four WIQ subscales, the ankle-brachial index correlated with distance (r = 0.29) and speed (r = 0.32); and initial claudication distance and absolute claudication distance correlated with pain (r = 0.40 and 0.43, respectively), distance (r = 0.35 and 0.41, respectively), and speed (r = 0.39 and 0.39 respectively). Of the eight SF-36 subscales, no correlation was found for the ankle-brachial index, initial claudication distance correlated with Bodily Pain (r = 0.46) and Social Functioning (r = 0.30), and absolute claudication time correlated with Physical Function (r = 0.31) and Energy (r = 0.30). The results of both questionnaires showed reduced functional status in claudicating patients.Initial and absolute claudication distances and WIQ pain, speed, and distance subscales are the measures that correlated the best with the ambulatory limitation of patients with symptomatic peripheral arterial disease. These results suggest the WIQ is the most specific questionnaire for documenting the qualitative deficits of the patient with claudication while providing strong relationships with the quantitative measures of arterial disease. Future studies of claudication patients should include both quantitative and qualitative assessments to adequately assess disease severity and functional status in peripheral arterial disease patients.

Control de la infección-colonización por Staphylococcus aureus resistente a meticilina en un Servicio de Angiología y Cirugía Vascular

Introduction. Nosocomial infection by methicillin-resistant Staphylococcus aureus (MRSA) has become an epidemic in recent years. One of the groups of patients most often affected, owing to the very characteristics of the group itself, is that involving patients who are hospitalised in a Vascular Surgery Unit. Aims. Our aim was to determine the rates of infection and colonisation by MRSA and to evaluate the effectiveness of steps taken to control this situation. Patients and methods. In a retrospective study, we analysed 157 cases in 155patients hospitalised in our service who had had at least one positive culture for MRSA between January 1993 and December 2002, together with the riskfactors. The annual rates of MRSA in the service were compared with the overall hospital rates. Cases coming from the community and those involving acquisition while in hospital were analysed. Results. There were 122 cases of infection and 35 of colonisation; 60.5% were cases of nosocomial acquisition and 39.5% came from the community and transfers. No differences were found in the riskfactors between the two groups. 27% of all cases of MRSA in the hospital occurred in our service. Since the introduction of control measures (hospital hygiene barrier, isolation, decontamination, detection of carriers) in 1994, there has been a 50% overall reduction in MRSA incidence (p < 0.05). Our service was not affected by the epidemic outbreaks that occurred in the hospital. Our analysis found that 20 patients died and 21 underwent major amputation. Conclusions. Infection and colonisation by MRSA is a serious problem in vascular surgery. The control programme, involving the nursing team and the Microbiology and Vascular Surgery services, has proved to be effective. [ANGIOLOGÍA 2004; 56: 561-70] Introducción . La infección intra-hospitalaria por Staphylococcus aureus resistente a meticilina (SARM) ha adquirido en los últimos años un carácter epidémico. Uno de los grupos de pacientes más afectados, por sus características, son aquellos ingresados en un Servicio de Cirugía Vascular. Objetivos. Determinar las tasas de infección-colonización por SARM y valorar la efectividad de las medidas de control. Pacientes y métodos. Estudio retrospectivo. Se analizan 157 casos en 155 pacientes ingresados en nuestro servicio que presentaron al menos un cultivo positivo para SARM entre enero 1993 y diciembre 2002, y los factores de riesgo. Se comparan las tasas anuales de SARM en el servicio con las globales hospitalarias. Se analizan los casos provenientes de la comunidad y los de adquisición hospitalaria. Resultados. 122 casos de infección; 35 de colonización. 60,5% de adquisición nosocomial y 39,5% procedentes de la comunidad y trasladados. No diferencia en factores de riesgo entre los grupos. El 27% de casos totales de SARM del hospital pertenecen a nuestro servicio. Desde la introducción en 1994 de las medidas de control (barrera e higiene hospitalaria, aislamiento, descontaminación, detección de portadores) hubo una reducción global del 50% de incidencia de SARM (p < 0,05). Los brotes epidémicos del hospital no afectaron a nuestro servicio. 20 pacientes fallecieron y 21 sufrieron amputación mayor. Conclusiones. La infección-colonización por SARM representa un grave problema en cirugía vascular. El programa de control se ha demostrado eficaz, implicando al equipo de enfermería, y a los servicios de Microbiología y Cirugía Vascular. [ANGIOLOGÍA 2004; 56: 561-70] Introdução. A infeccao intra-hospitalar por Staphylococcus aureus resistente á meticilina (SARM) adquiriu nos últimos anos um carácter epidémico. Um dos grupos de doentes mais atingidos, devido ás suas características particulares, é o dos doentes internados no Serviço de Cirurgia Vascular. Objectivos. Determinar as taxas da infecçõo-colonizaçõo por SARM e avaliar a eficacia das medidas de controlo. Doentes e métodos. Estudo retrospectivo. Analisaram-se 157 casos em 155 doentes que deram entrada no nosso servico e que apresentaram pelo menos uma cultura positiva de SARM entre Janeiro de 1993 e Dezembro de 2002, e os factores de risco. Compararam-se as taxas anuais de SARM no servico com as taxas globais hospitalares. Analisaram-se os casos provenientes da comunidade e os adquiridos na unidade hospitalar. Resultados. 122 casos de infeccao; 35 de colonização, 60,5% de aquisição nosocomial e 39,5% provenientes da comunidade e transferidos. Não há diferença quanto aos factores de risco entre os grupos. 27% do total de casos de SARM do hospital pertencem ao nosso servico. Desde a introdução, em 1994, de medidas de controlo (barreira e higiene hospitalar, isola mento, descontaminação, detecçõo de portadores) houve uma reduçõo global de 50% na incidência de SARM (p < 0,05). Os surtos epidémicos do hospital não afectaram o nosso serviço. Morreram 20 doentes e 21 sofreram amputação major. Conclusões. A infecção-colonização por SARM representa um grave problema na cirurgia vascular. O programa de controlo revelou ser eficaz, envolvendo a equipa de enfermaria, e os servicos de Microbiologia e Cirurgia Vascular. [ANGIOLOGÍA 2004; 56: 561-70]

Determination of amputation level in ischaemic lower limbs.

A properly performed amputation can not only be lifesaving for the patient, but may often be a better therapeutic alternative than an ill-conceived, futile attempt at a vascular reconstruction doomed to fail for lack of adequate recipient vessels. Currently there are no consistent criteria that can be applied before surgery. The purpose of the present investigation was to find a reliable method of determining the best amputation level in an ischaemic lower extremity. In the present study the author has tried to devise a 'score' for distal run-off vessel patency as shown by the preoperative angiogram to determine the most appropriate amputation level. The author has reviewed the level of amputation on ischaemic lower extremities in the vascular surgery unit of the Austin and Repatriation Medical Centre (ARMC) over the last 5 years. Two hundred and two patients have undergone 232 lower extremity amputations at ARMC. The author used chi2 corrected testing and found a good correlation between the score and the level of amputation. The lower the score, the higher the level of amputations (chi2 = 289.23, P < 0.005). The author could predict that with a score of <12 a patient would probably need an above-knee amputation; for a score from 12 to 19, a below-knee amputation; for a score of 20-25 a forefoot amputation would be sufficient and for a score of>25 a toe amputation would be all that was required. The use of a scoring system dependent on the preoperative angiogram to assess the run-off vessel situation provides a practicable and direct way to help predict the level of amputation in an ischaemic lower extremity. However, it is not totally reliable and should be used as one of the factors to be considered when an amputation is required.

Clinical management in a vascular surgery unit: results of the application of a clinical practice protocol

Clinical management in a vascular surgery unit: results of the application of a clinical practice protocol

Aneurysm of the Pancreaticoduodenal Arteries Associated with a Cœliac Artery Lesion

IntroductionA ruptured aneurysm of the pancreaticoduodenalarteries without acute or chronic pancreatitis butassociated with a median arcuate ligament divisionis an exceptional event described in only 11 cases. Thecase of a ruptured pancreaticoduodenal artery aneur-ysm, associated with a cœliac artery lesion which wedescribe, illustrates the difficulty in diagnosing theserare events promptly and in instituting urgent treat-ment to arrest the bleeding followed by an electiveprocedure to prevent recurrence.Case ReportA 54-year-old man with no history of vascular diseasewas admitted to a district hospital for investigation ofvague abdominal pain mainly affecting the rightabdomen, hypotension corrected by infusion ofcrystalloid and no fever. Laboratory blood chemicalfindings including a normal hemoglobin, raisedleukocyte count and high C-reactive protein concen-tration. This presentation raised the suspicion of a gallbladder infection and the patient was kept under closeobservation overnight. The next day, hypotensiondeveloped and the patient complained of pain in theright iliac quadrant. An abdominal ultrasound scanshowed a large iliac fluid collection, but no lesionsinvolving the gall bladder or liver. Appendicitis wasdiagnosed and the patient underwent a McBurneyoperation. During surgery blood was found in theabdomen. An exploratory laparotomy revealed a largeretroperitoneal hematoma. The patient was trans-ferred to our vascular surgery unit. A CT scan aftercontrast injection revealed an intact retroperitonealhematoma (16 £ 9 £ 15 cm), with no bleeding from theaorta or the visceral arteries, and a median arcuateligament division that compressed the origin of thecœliac trunk. Because these findings suggested aruptured pancreaticoduodenal artery aneurysm arter-iography was planned to confirm the diagnosis andtreat the aneurysm by embolization. The patient, whowas by now haemodynamically stable, was kept underobservation in the ITU and transferred to the vascularsurgical unit. On day 1, a CT scan showed that thehematoma had enlarged. The patient was kept undersurveillance in the vascular unit and arteriographywas planned for the following day. During the night,the patient collapsed but responded to more IVcrystalloid and was immediately transferred to theradiological unit. While the patient was being pre-pared for arteriography, a new CT scan showed thehematoma had now increased in size and had spreadto the intraperitoneal space, filling the peri-hepaticand peri-splenic areas as well as the pelvis.The patient underwent selective arteriography tovisualize the stenosis caused by compression of thecœliac axis, to localize the bleeding pancreaticoduo-denal artery aneurysm and to proceed to treatment byembolization. Under local anesthesia, a 5-F introducer

Spontaneous Rupture of the Uterine Artery in a Non-Pregnant Woman

Spontaneous rupture of the uterine artery is a rare event. Our Medline search revealed only 4 cases all of which occurred during pregnancy or puerperium. These haemorrhagic events present as acute abdomen with haemodynamic instability. In this report we describe a case of a non-pregnant woman with spontaneous rupture of the uterine artery. The aetiology of the condition is largely speculative. (excerpt)

Gestión clínica en un servicio de angiología y cirugía vascular. Resultados de la aplicación de algoritmos de manejo clínico

ObjectivesThe aim of this study was to analyze the impact of clinical management on quality indicators in a vascular surgery unit over a 10-year period. MethodsWe performed a retrospective analysis of quality indicators from 1990 to 2001 and of the influence of a clinical practice protocol and standards of quality on these indicators. ResultsComparison of both periods revealed improvement in all the quality indicators. The safety of surgical procedures was unaffected by the application of management protocols and clinical pathways. ConclusionsClinical management based on the cost-quality binomial can ensure the efficiency of a hospital unit without adversely affecting quality of care. Quality standards based on hospital resource use, morbidity and mortality can be defined for groups of procedures.

Satisfaction with care in vascular surgery inpatient units

Objective: to identify and solve problems concerning satisfaction of inpatients in three different vascular surgery units. Materials and Methods: a self-administered non anonymous questionnaire was submitted. Four dimensions of patients' satisfaction and a measure of overall satisfaction were evaluated. For each of them a logistic regression model was elaborated. Results: one hundred and fifty-six eligible patients agreed to participate. For the “overall satisfaction” 56% rated the care received as excellent; patients completely satisfied for “treatment and related information” were 76%; for the “availability of staff” 96%, for “helpfulness and communication by staff” 56% and for “management of patient's complaint by medical staff” 86%. Logistic regression analysis showed, after adjustment for relevant background factors, a statistically significant difference among units of care for the overall satisfaction. Conclusions: the study highlighted the importance of considering in vascular units the patients' satisfaction as an essential component of quality of care independently of the severity of cases. The hospital management recognised the low level of communication by the staff as one of the hospital bottle-necks and tried to solve a logistic problem identified as responsible for a low score in the overall satisfaction in one unit.Eur J Vasc Endovasc Surg 25, 48–52 (2003)

Thoracic outlet syndrome in paediatrics: Clinical presentation, surgical treatment, and outcome in a series of eight children

Background/Purpose: This report reviews the clinical presentation, surgical treatment, and outcome of 8 children treated for the thoracic outlet syndrome (TOS) during the last 3 years. Methods: From 1998 through 2001 31 patients were admitted to our Vascular Surgery Unit with TOS. Eight of them (25.8%) were in the paediatric age group, 8 to 16 years (mean, 13 years). No sex prevalence was found. The presenting symptoms were neurologic in 2 patients (25%) and secondary to venous flow impairment in 6 (75%). At phlebography, venous thrombosis was seen in 2 cases, and functional intermittent obstruction was seen in 4. Seven patients underwent decompressive surgical partial resection of the first rib with transaxillary or supraclavicular access. One patient was treated conservatively. Results: There were no major postoperative complications. Mean hospital stay was 2.7 days. In no patient were there signs of recurrence after a mean follow-up of 18 months (range, 3 to 36 months). Conclusions: In the authors' experience TOS in paediatric patients occurs with the same symptoms and thrombotic complications as in adults. The same surgical strategy adopted in adult patients is advisable for affected children. J Pediatr Surg 38:58-61. Copyright 2003, Elsevier Science (USA). All rights reserved.

The initial management of scapulothoracic dissociation: A challenging task for the vascular surgeon

The medical records of nine patients who had sustained a STD secondary to a blunt trauma during the last decade (1990±2000) were reviewed in the University of Crete Vascular Surgery Unit. Patients with penetrating or open trauma, and those with musculoskeletal or vascular or neurologic injury alone, were excluded from the study. The diagnosis of STD was made initially from the patients' history and the clinical presentation. All patients ± males with a median age of 30 years (range from 21 to 54 years) ± were victims of decelerating, high speed motorcycle or automobile accidents (Table 1) and presented with a pulseless and severely ischaemic upper limb, absence of motor and sensory function below the shoulder or arm, and a shoulder girdle or chest wall swelling or haematoma and ecchymoses with intact skin. On subsequent plain X-rays or CTs all patients were found to have disruption of the acromioclavicular or sternoclavicular joints and/or clavicular fracture (Table 1). Surgical exploration in three patients and an urgent arteriogram or CT scan in the remaining patients demonstrated the vascular injury in the thoracic outlet region. Innominate artery or aorta rupture was not found in our patient population. Active bleeding from the damaged subclavian arteries was recognised in five patients and from several perforator arteries and veins of the chest wall in all patients. Concomitant injuries of the trunks of the brachial plexus were identified in all patients. In all patients, head injury, hypovolaemic shock and upper extremity fractures or ischaemic neuropathy made detailed preoparative assessment of the neurological status of the upper extremity ipsilaterally to the injured shoulder girdle unreliable, if not impossible. The specific injuries of neurovascular structures identified during the operative intervention are outlined in Table 1. Additionally, all patients experienced multiple other moderate or severe local and remote injuries. After initial stabilisation of the patients' vital signs and general condition all patients were operated upon urgently. The surgical exploration was performed via a supraclavicular incision in five patients, a combined supraclavicular incision and sternotomy in three patients (Table 1: cases 1, 4 and 8), and a combined supraclavicular incision and left thoracotomy in one patient (Table 1: case 5). After controlling the actively bleeding sites and detailed investigation and identification of the injured trunks of the brachial plexus and other structures, our effort was directed to reestablishing arterial flow to the ischaemic arm. Arterial reconstruction was performed in eight patients, using the autologous great saphenous vein as an interposition arterial graft connecting the proximal Please address all correspondence to: N. Katsamouris, Vascular Surgical Unit, University of Crete Medical School, University Hospital of Heraklion, Crete, Greece. Tel.: ‡30 81 392 379 or ‡30 932 277 357; Fax: ‡30 81 542 063; E-mail: asterios@med.uoc.gr Eur J Vasc Endovasc Surg 24, 547±549 (2002) doi:doi:10.1053/ejvs.2002.1722, available online at http://www.idealibrary.com on

Second Best Medical Therapy

Background : best medical therapy (BMT) provides patients with peripheral arterial disease (PAD) substantial protection against future vascular events. Objective : to determine the quality of BMT received by PAD patients in this vascular surgery unit. Methods : retrospective case-note review of 50 consecutive patients in each of the following groups: intermittent claudication (out-patients), symptomatic carotid artery disease (out-patients), lower limb angioplasty, lower limb bypass surgery, carotid endarterectomy. Results : overall BMT use was poor. Fifteen percent of smokers had assistance with smoking cessation noted. Seventy-eight percent of patients were taking an antiplatelet agent, 38% cholesterol-lowering medication and 51% antihypertensive medication. Fifty-three percent of patients had a cholesterol measurement, 50% of out-patients had a blood pressure measurement and 53% of non-diabetics had a random blood glucose performed. Sixteen of the patients with lower limb disease were given advice about exercise. Patients with a history of coronary artery disease were more likely to be taking cholesterol lowering, or antihypertensive medication. Conclusions : BMT is poorly used in patients with PAD, which will result in an excess of cardiovascular morbidity and mortality. Strategies need to be developed to increase the use of BMT in our patients.

Patient Scoring Systems: Author's Reply

Many rural areas in Ireland, like the United KingI agree with authors that this process should be undertaken on a regular basis in a ‘‘blame-free’’ endom, are remote from large vascular units and have large elderly populations with a high incidence of vironment. In reality, all surgeons should now be trained to deliver the best quality of clinical care, given vascular disease. Non-specialist vascular units can only be justified in these areas provided the results the improved structure of surgical training. It is those same surgeons, trained in tertiary centres under the obtained are on par with larger centres. We are currently evaluating our results of extrasupervision of experts, that now are operating in district hospitals serving a sometimes skewed sample of cranial vascular reconstruction from a similar nonspecialist setting using POSSUM and P-POSSUM as the population. Cook et al. has noted that 14% of patients fell within the high-risk category (>50% morpredictors of outcome. The number of cases performed per year does not necessarily indicate excellence. Nontality predicted) at a district hospital compared with only 8% at a teaching hospital. specialist vascular surgery units, in particular, must be the subjects of regular and transparent audit in So why should a difference in morbidity and mortality outcome still exist among us? The current atorder to justify their existence and the service they give to their local population. tempts by the surgical community to answer such questions seems vital. I recommend that we should P. Brady and W. Joyce identify potentially confounding variables before adopting additional predictive variables. We should also Cavan, Ireland doi:10.1053/ejvs.2001.1505, recognise surgical errors as an important variable, with the potential for improved performance through available online at http://www.idealibrary.com on critical incident reporting. Toni Lerut, President of the European Surgical Association, has stated that ‘‘the quality of surgical training is the single most important References factor in reducing intra-surgeon variation’’. A welltrained and well-supervised trainee should obtain 1 Shuhaiber JH, Hankins M, Robless P, Whitehead SM. POSSUM for the prediction of mortality and morbidity in infra-renal abresults equal to a senior surgeon. dominal aortic aneurysm repair. The Hastings experience. Eur J Vasc Endovasc Surg 2001; 22: 180–182. J. H. Shuhaiber 2 Copeland GP, Jones D, Walters M. POSSUM: a scoring system Chicago, Illinois, U.S.A. for surgical audit. Br J Surg 1991; 82: 408–411. doi:10.1053/ejvs.2001.1515, 3 Amundsen S, Skjaerven R, Trippestad A, Soreide O. Abdominal aortic aneurysms. Is there an association between surgical volume, available online at http://www.idealibrary.com on surgical experience, hospital type and operative mortality. Acta Chir Scand 1990; 156: 323–328.

Basic science curriculum in vascular surgery residency

Recognizing the importance of basic science teaching in surgical education, the leadership of the Association of Program Directors in Vascular Surgery (APDVS) appointed a panel to gather information and to present its findings at the 1999 annual fall meeting of the Apdvs. A questionnaire was distributed to the program directors present. In addition, information was gathered from the American Board of Surgery regarding the basic science content in the vascular surgery item pool on the vascular surgery qualifying examination (VQE). The vascular surgery unit of the surgical resident curriculum was also analyzed. Fifty-three program directors (64%) completed the questionnaire. Although only two program directors felt that their residents were better prepared to answer basic science questions, the results of the Vqe showed that the examinees do not, as a group, perform differently on basic science items than on clinical management questions. In addition, only a minority of program directors (15%) use a specific method to monitor the learning process of their residents. The majority of the program directors responding (75%) felt that they were capable of teaching basic science to residents. Interestingly, almost half the 53 respondents (47%) said that a basic science curriculum should be comprehensive, not exclusively relevant to the clinical setting. Vqe content outline and the vascular surgery unit of the surgical resident curriculum revealed great emphasis on clinically relevant basic science information. The Apdvs panel recommends that a basic science curriculum should be comprehensive, yet clinically pertinent, and completely integrated with the clinical curriculum. In terms of how to teach basic science in vascular residencies, the panel supports teaching conferences that are problem-based with a faculty member acting as the “resource person” and with specific goals set for the conferences. The panel also suggested establishing a Web site that provides a series of questions, the answers of which could be readily available to trainees and program directors. such immediate feedback could be of great help to program directors to focus the learning process of their residents and monitor its progress. (J Vasc Surg 2001;33:854-60.)

The first two CABG Surgeries in Nepal

The cardiothoracic and vascular surgery unit of Bir Hospital made a landmark in the history of Nepalese surgery by performing two open heart coronary artery bypass graft surgeries under the leadership of Dr. D. P. Pokharel and an entirely Nepali team on 2057/3/4 an 2057/3/7.