Aneurysms occur throughout the length of the aorta, with a large proportion occurring in the infra-renal segment of the abdominal aorta (least 9 to 10 times more common than thoracic aortic aneurysms). Aneurysmal disease of the aorto-iliac segment which commonly occurs as a result of a degenerative process is invariably a progressive entity. Concomitant iliac artery aneurysms have been noted to occur in 15-40% of patients with abdominal aortic aneurysms (AAAs). As a result, following open AAA repair, there is a concern regarding the progressive enlargement of the iliac arteries. The aim of this study was to investigate the long term outcome of proximally excluded common iliac arteries (CIAs) following open bifurcated abdominal aortic aneurysm (AAA) repair. Baseline clinical and demographic data of 165 consecutive patients undergoing open AAA repair between April 2004 and April 2014 was collected. The aorta and iliac segments were measured in the 120 available preoperative Computed Tomographic (CT) angiograms. A single postoperative CT scan was performed and measurements recorded in 46 patients available for follow-up. The patients were grouped according to the type of surgical repair, open tube graft repair or bifurcated graft repair to the common iliac (CIA), external iliac artery (EIA) or common femoral artery (CFA). Entered into the study were 165 patients (133 men, 32 women) with a mean age of 66 years and a mean AAA diameter of 6.7cm (range 5.1 - 10.3cm). After a median follow-up of 49 months, 46 patients (88 CIAs) were available for a single postoperative CT scan.

Background: Peripheral arterial disease (PAD) is an established occlusive disease of the peripheral arteries and is not uncommon in the elderly. Atherosclerosis accounts for 90% of the pathology. Only 15% of affected individuals become symptomatic. Most symptomatic individuals present with intermittent claudication (IC). Only a small proportion (1%) of affected individuals present with critical limb ischaemia (CLI). Revascularization aimed at limb salvage, and recovery of ambulation and independent living is the ultimate therapeutic option for the advanced form of PAD (CLI). Traditionally, the success of revascularization for CLI has been defined by graft patency rates and limb salvage rates. Functional outcomes such as ischaemic wound healing and recovery of ambulatory function for independent living have been the focus in more recent publications. However, these assessments do not consider the patients' pre-operative metabolic profile as a predictor of postoperative outcomes. Purpose: The purpose of this study was to determine, in a prospective manner, the influence of preoperative metabolic profile on post-operative outcomes in contemporary patients with peripheral arterial disease presenting with critical limb ischaemia at a tertiary hospital in South Africa. Methods: All consecutive patients, ≥ 18 years, with CLI admitted to the vascular unit at Groote Schuur Hospital over a two-year period (1st January, 2015 to 31st December, 2016) with reconstructable disease were recruited for the study. Written informed consent was obtained from all participants. Revascularization entailed either open surgical revascularization, endovascular interventions or both (hybrid procedures). Data was analyzed according to the clinical level of disease and the type of surgical intervention. Post-operative outcome measures were determined. Primary endpoints (functional and technical outcomes) • Ambulatory recovery at six months and one year • Complete ischaemic wound healing at six months and one year • Limb salvage rate at six months and one year • Primary graft patency rate at six months and one year Secondary endpoint • The influence of pre-operative metabolic profile on the post-operative outcomes The association between pre-operative metabolic profile and post-operative outcomes was determined by Pearson Chi-square statistical test and logistic regression model. Results: A total of 73 consecutive patients were recruited for this study with a mean age of 58 ± 9 years (Range: 30 - 75 years). Seventeen patients (23.3%) had rest pain and 56 (76.7%) had tissue loss [Minor tissue loss was 47 (64.4%) and major tissue loss was 9 (12.3%)]. Current smokers and previous smokers constituted 86% of the sample population with a male to female ratio of approximately 1:1. Our study population was generally overweight based on the BMI. There was high prevalence of abdominal obesity and high body fat for both males and females. Recovery of ambulatory status was 69% and 67% at six months and one year follow-up respectively. The rate of ischaemic wound healing at six months and one year was 48.2% and 75.0% respectively. Surgical site sepsis was the most common local wound complication. Limb salvage rate was 78% and 79% at six months and one year respectively. Overall primary graft patency at six months was 69.0% but reduced to 60.0% at one year. Major amputation rate at one year was 21%. Most of the postoperative wound-related complications occurred among patients with diabetes. More diabetic patients had major amputations compared to non-diabetic patients (57.9% vs 42.1%). One year amputation-free survival (AFS) was 69.9%. There were no statistically significant associations between metabolic profile of patients and post-operative clinical outcomes. Conclusion: Demographics, co-morbidities, and procedural details of our study population, reflected a relatively younger population with CLI. The profile of this contemporary vascular surgery patients is that of overweight, high abdominal obesity, and high prevalence of smoking among both gender. The technical and functional outcomes observed in this study are consistent with available western literature. Diabetes was associated with prolonged ischaemic wound healing, higher risk of major amputation and local wound complications. A statistically significant association was not found between patients' metabolic profile and post-operative outcome but this could be due to the small sample size and short follow up period.

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Abdominal aortic aneurysms (AAA) are a pathological dilation of the aorta greater than 2.5cm and affect more than 4% of the male population and 1% of women aged 60 years or older. Screening is recommended among men and women older than age 65, and is covered by Medicare for patients with a family history and men with a history of smoking. Due to its asymptomatic nature, AAA is usually found incidentally during another radiological investigation. Many factors are associated with AAA development, but it is most commonly found in conjunction with atherosclerosis. There is currently no pharmacological intervention specifically for AAA, though statin therapy has shown some promise. The aneurysm will invariably grow, with an average rate of expansion of less than 0.5cm per year. As the aneurysm grows larger the chance of the rupture increases significantly with this outcome carrying an extremely high rate of mortality. Surgical intervention is recommended once the diameter reaches 5.5cm in men or about 5cm in women. There are two approaches to the repair of the aorta: the open surgical approach and the endovascular approach. The open surgical procedure replaces the affected portion of the aorta with a graft. The endovascular procedure places an endograft within the intact aneurysm, effectively excluding the affected section of vessel. The endovascular method carries a lower perioperative mortality rate than the open procedure, but over time can require additional surgeries to prevent continued aneurysm expansion due to blood flow in the aneurysm sac. Additionally, lifetime surveillance of the endograft is required to monitor its integrity and effectiveness. Lifestyle changes and possible pharmacological interventions in patients with AAA should focus on cardiovascular health changes to improve overall health and minimize risk factors for continued development of the aneurysm. In patients who will require repair particular attention should be paid to individual risks and preferences. The open repair procedure may be preferable in patients with better overall health and a longer life expectancy, while endovascular repair may be beneficial for more elderly or frail patients. Research and technology in this area are developing quickly, particularly for endovascular procedures, and the near future may see important changes in the risk-benefit analysis of AAA surgical interventions.

No abstract available. / Thesis (M.Med.)--University of KwaZulu-Natal, Durban, 2014.

Acute occlusion of the superior mesenteric artery (SMA) is a condition associated with high mortality and morbidity. The aim of this thesis is to evaluate diagnostic and therapeutic approaches for acute SMA occlusion. In a prospective study of patients with suspected intestinal ischemia, no biomarker was sufficiently accurate to detect this condition. In a second retrospective study, pancreatic amylase and troponin-I were elevated in a substantial proportion of patients with verified SMA occlusion. In an experimental animal model of acute SMA occlusion, microarray studies of ischemic small bowel wall were used to characterize the mRNA response to ischemia. Thrombospondin, Monocyte Chemoattractant Protein 1 and Gap Junction Alpha 1 were consistently up-regulated in all pigs with intestinal ischemia. Genes encoding previously proposed biomarkers for intestinal ischemia were either up-regulated, such as lactate dehydrogenase and creatine kinase, or down-regulated, such as intestinal fatty acid binding protein and glutathione S-transferase. In a study of the role of computed tomography in the diagnosis of SMA occlusion, it was shown that computed tomography with intravenous contrast was associated with improved survival. A retrospective analysis of all acute SMA revascularizations in Sweden 1999-2006 revealed that D-dimer was elevated in all 35 measured cases.  Endovascular surgery was associated with better outcome than open surgery, both in short and in long term. The presence of postoperative short bowel syndrome was a strong independent risk-factor for decreased long-term survival. Conclusions: Data affirm that D-dimer may serve as an exclusion test for acute SMA occlusion, whereas elevated troponin-I and pancreatic amylase are potential diagnostic pitfalls. Contrast-enhanced computed tomography of the visceral arteries seems to be the best diagnostic method. Endovascular surgery is an option to open surgery in selected cases, and was associated with favourable outcome.