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...

In diabetic patients, metatarsal excision may be better than transmetatarsal amputation.

The Commissioning for Quality and Innovation (CQUIN) indicators for 2022/23 were recently published by NHS England and for the first time include a vascular indicator, the “Achievement of revascularisation standards for lower limb ischaemia”.1 This is great news and will drive quality improvement for patients with chronic limb-threatening ischaemia (CLTI). In this editorial we describe what this means for English NHS organisations providing vascular services, vascular clinicians and patients.

modate large canal diameters and provide excellent pressurisation. TECHNIQUEThe technique involves the application of Spongostan ® foam on to a Surgicel ® mesh, which is rolled on to the Spongostan ® foam, forming a uniform cylindrical structure. The diameter of the restrictor is adjusted to the desired femoral canal diameter by increasing the thickness of the Spongostan ® foam. The restrictor is inserted into the medullary canal and guided to the appropriate position using a standard cement restrictor inserter, where it expands uniformly, creating an effective restrictor. Bone cement is applied and pressurisation commenced prior to implant insertion. The bespoke restrictor glides with minimal resistance and maintains its form during insertion. DISCUSSIONNumerous plug designs and materials are available, ranging from nonresorbable to resorbable. All restrictors should avoid intramedullary cement leakage and plug migration during cement and stem insertion to ensure adequate intramedullary pressures. The use of the Surgicel ® -Spongostan ® haemostatic restrictor overcomes some of the limitations of standard cement restrictors. These include the ability to bypass a narrow femoral isthmus, accommodate large femoral canals (particularly in revision procedures), and the flexibility of adjusting the restrictor to the desired diameter of the medullary canal, providing a bespoke cement restrictor.

The last decade has witnessed a number of changes in the delivery of vascular services nationwide. Vascular surgery attained speciality status in 2012, and is well recognised as an urgent and emergent speciality delivering time-dependent care for patients with aortic aneurysms, carotid surgery for stroke prevention and lower limb revascularisation for critical limb-threatening ischaemia. The National Vascular Registry (NVR), established in 2013, provides effective monitoring and reports on outcomes whilst also delivering a robust programme of quality improvement.1 The National Abdominal Aortic Aneurysm Screening Programme was fully implemented in 2014,2 and this coincided with a move towards centralisation of vascular services to a network model of care with elective and emergency arterial surgery concentrated in arterial hubs. In 2013, NHS England took full responsibility for all specialised commissioning which included all arterial surgery. Over the years, major vascular policy decisions make reference to the Vascular Clinical Reference Group (CRG), yet few clinicians are aware of who these groups are, who they are accountable to and how they are involved in organising, reconfiguring, delivering and monitoring of vascular services in England.