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When obtaining informed consent, simply describing patency and limb salvage rates does not provide an accurate picture of the outcome of femorofemoral grafting.

In cystic adventitial disease, a rare cause of claudication, most patients undergo operative or radiological intervention. There is little evidence to support either approach. CASE HISTORYIn 1991 a man aged 47 arrived at our casualty department with acute left calf pain. For the previous year he had been experiencing claudication in the left leg after walking about 500 m. Smoking was his only vascular risk factor. On examination he had a cold left foot and no pulses could be felt below the femoral artery on that side. All pulses were present in the right leg. Intravenous digital subtraction angiography showed external compression of the lumen of the left popliteal artery. The vessels in the right leg were normal. MRI (Figure 1) and CT imaging revealed a cystic swelling within the wall of the artery and cystic adventitial disease was diagnosed.The next day, without treatment, the foot was warm and the leg was pain-free. At two weeks, claudication distance was nearly 1 km and pulses were normal in both legs. MRI ( Figure 2) and CT scanning at five months, when he was still pain-free, showed spontaneous resolution of the cyst. A popliteal ultrasound scan at 10 years confirms the permanent resolution of the cyst and the patient remains symptom-free. COMMENTAdventitial cysts are synovial-like cysts in the adventitial layer of the artery wall. They most commonly affect the popliteal artery but have been reported also in the external iliac, brachial, radial and ulnar arteries. Occasionally they are found in association with saphenous veins in the ankle region. In all cases the diseased artery or vein overlies a joint.The most common presentation is claudication secondary to popliteal artery stenosis or occlusion. The disease predominantly affects men in the fourth and fifth decades (a male to female ratio of 5 to 1). The aetiology is unclear and is reflected by the changing nomenclaturecystic adventitial degeneration, cystic mucoid degeneration, cystic myxomatous adventitial degeneration, subadventitial pseudocyst and cystic adventitial disease. According to the ganglion theory, adventitial cysts are formed and maintained by communication with a synovial space. 1 The embryology theory proposes that mucin-secreting mesenchymal cells from the adjacent joint are included in the adventitia of the artery during development. 2 Treatment options are excision of the cyst and preservation of the artery, excision of the diseased artery with interposition grafting, CT or ultrasound guided percutaneous drainage or conservative management. Most experience is with the first two methods. In a review of 155 cases of cystic adventitial disease managed between 1954 and 1955, 3 69 were grafted and 68 treated by cyst evacuation and removal of the cyst wall. Both groups had an initial success rate of around 94% but little is known about the long-term outcomes of either. There are no controlled trial data or large single-centre series to show the superiority of any one technique. Long-term patency of vein or synthetic grafts used to bypa...

Sentinel lymph node biopsy (SNB) is now the standard of care in assessment of patients with clinically staged T1-2, N0 breast cancers. This study investigates whether there is a maximum number of sentinel lymph nodes (SLN) that need to be excised without compromising the false-negative (FN) rate of this procedure. Data were prospectively collected for 319 patients undergoing SNB between February 2001 and December 2006 at our institution. This data were analysed, both in terms of the order of SLN retrieval and relative isotope counts of the SLNs, in order to determine the maximum number of SLNs that need to be retrieved without increasing the FN rate. Furthermore, we investigated the relationship between SLN blue dye concentration and the presence of SLN metastases. The SLN identification rate was 97% with no false-negative cases amongst patients undergoing simultaneous axillary clearance historically during technique validation. In patients with SLN metastases, excision of the first 4 SLNs encountered results in the identification of a metastatic SLN in all cases. Although the majority (86%) of SNB metastases are in the hottest node, the SLN containing the metastasis is in the first 4 hottest nodes in 99% of patients with nodal metastases. The remaining 1% of SLN metastases were identified by blue dye. There was no statistically significant association between the SLN blue dye concentration and the presence of SLN metastases. A policy to remove a maximum of four blue and/or hot SLNs along with any palpably abnormal lymph nodes does not result in an increased false-negative rate of detection of SLN metastases.

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