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The article presents a study which investigates the use of baseline factors in predicting complications and reinterventions after endovascular repair (EVAR)in patients suffering from abdominal aurtic aneurysm. The results show that the use of these baseline factors created a higher complications rate in patients with abdominal aortic aneurysm. It was conclude that complications and reintervention rates were common factirs after EVAR in patients with aneurysm.

Background Endovascular aneurysm repair (EVAR) is a new technology to treat patients with abdominal aortic aneurysm (AAA) when the anatomy is suitable. Uncertainty exists about how endovascular repair compares with conventional open surgery. EVAR trial 1 was instigated to compare these treatments in patients judged fit for open AAA repair. Methods Between 1999 and 2003, 1082 elective (non-emergency) patients were randomised to receive either EVAR (n=543) or open AAA repair (n=539). Patients aged at least 60 years with aneurysms of diameter 5.5 cm or more, who were fit enough for open surgical repair (anaesthetically and medically well enough for the procedure), were recruited for the study at 41 British hospitals proficient in the EVAR technique. The primary outcome measure is all-cause mortality and these results will be released in 2005. The primary analysis presented here is operative mortality by intention to treat and a secondary analysis was done in per-protocol patients. Findings Patients (983 men, 99 women) had a mean age of 74 years (SD 6) and mean AAA diameter of 6.5 cm (SD 1). 1047 (97%) patients underwent AAA repair and 1008 (93%) received their allocated treatment. 30-day mortality in the EVAR group was 1.7% (9/531) versus 4.7% (24/516) in the open repair group (odds ratio 0.35 [95% CI 0.16-0.77], p=0.009). By per-protocol analysis, 30-day mortality for EVAR was 1.6% (8/512) versus 4.6% (23/496) for open repair (0.33 [0.15-0.74], p=0.007). Secondary interventions were more common in patients allocated EVAR 9.8% vs 5.8%, p=0.02). Interpretation In patients with large AAAs, treatment by EVAR reduced the 30-day operative mortality by two-thirds compared with open repair. Any change in clinical practice should await durability and longer term results. [ABSTRACT FROM AUTHOR]

Presents an abstract of the article 'Risk Factors for Aneurysm Rupture: Results From the UK Small Aneurysm Study and Trial,' by R.M. Greenhalgh, L.C. Brown and J.T. Powell.

Discusses the need for surgical research to settle debates in medical opinion and alter clinical behavior. Publication of the European Carotid Surgery Trail; Minimal support from grant-giving bodies; Problems in screening programs.

Not the full answer [ABSTRACT FROM AUTHOR]

Objective: This Medical Research Council funded trial was set up to investigate whether venous surgery provided any additional benefit in the healing and recurrence rates of venous ulcers over compression bandaging alone. Methods: Ulcer surgery as adjuvant to compression bandaging for leg ulcers (USABLE) was a multicentre, randomized controlled trial, which planned to recruit 1000 venous ulcer patients to receive either compression bandaging alone or compression bandaging plus venous surgery. Follow up recorded ulcer healing, recurrence and patient quality of life. Results: Recruitment was slow, and involved screening a large number of patients (759) with only 75 randomized over an 18-month recruitment period. Conclusions: The results would infer that surgery is unlikely to be a management option for the majority of patients presenting to a hospital with a gaiter area leg ulcer. [ABSTRACT FROM AUTHOR]

Discusses the abstract of a study demonstrating simple venous surgery benefits healing or maintenance of healing of venous ulcers in randomized controlled trials. Co-morbidity and pattern of venous incompetence; Comparison of healing rate in conservatively-treated group versus operated group.

Discusses the abstract of a study evaluating mortality rates of abdominal aortic aneurysm (AAA) in England. Sex comparison on the rise in elective surgery and emergency AAA repair.

SummaryBackground: Proteolytic degradation of the aortic wall by matrix metalloproteinases (MMPs) is considered important in the pathogenesis of abdominal aortic aneurysms (AAAs). Many of these MMPs are inhibited by tetracycline derivatives, which may have the potential to retard aneurysm growth. Methods: Patients undergoing elective repair of an AAA (n = 5) received an intravenous bolus of tetracycline (500 mg) on induction of anaesthesia and levels of tetracycline in serum, aneurysm wall and mural thrombus were assessed by microbiological assay. In a separate series of patients (n = 7) aneurysm biopsies were placed into explant culture (with and without tetracyline) and the accumulation of protein, hydroxyproline, MMP-9, interleukin (IL) 6 and monocyte chemoattractant protein (MCP) 1 in the medium was assessed by colorimetric assay or immunoassay. Results: At aortic cross-clamping the median concentration of tetracycline was 8·3 μg/ml in serum, 2·9 μg per g tissue in aortic wall and zero in mural thrombus. Tetracycline inhibited, in a concentration-dependent manner, both MMP-9 and MCP-1 secretion (P = 0·022 and P = 0·018 respectively), but did not alter hydroxyproline or IL-6 secretion. At the highest concentration of tetracycline (100 μg/ml) median MMP-9 secretion was reduced from 27 to 5 ng/ml (P = 0·007) and median MCP-1 secretion was reduced from 50 to 10 ng/ml (P = 0·008). Conclusion: Tetracycline rapidly penetrates the aortic wall, but the concentration achieved may be insufficient to alter collagen turnover through limitation of MMP production or activity. [ABSTRACT FROM AUTHOR]

Background: Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture‐preventing reintervention) to enable the development of personalized surveillance intervals. Methods: Baseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR‐1 and EVAR‐2 trials were used to develop the model, with external validation in a cohort from a single‐centre vascular database. Longitudinal mixed‐effects models were fitted to trajectories of sac diameter, and model‐predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. Results: Some 785 patients from the EVAR trials were included, of whom 155 (19·7 per cent) experienced at least one rupture or required a rupture‐preventing reintervention during follow‐up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2 years (C‐index 0·68), 3 years (C‐index 0·72) and 5 years (C‐index 0·75) after operation and had excellent external validation (C‐index 0·76–0·79). More than 5 years after operation, growth rates above 1 mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2 years. Conclusion: Secondary sac growth is an important predictor of rupture or rupture‐preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow‐up. [ABSTRACT FROM AUTHOR]

Background The erosion of the early mortality advantage of elective endovascular aneurysm repair ( EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation. Methods An individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention. Results The analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization. Conclusion The early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575. [ABSTRACT FROM AUTHOR]

Background A number of published economic evaluations of elective endovascular aneurysm repair ( EVAR) versus open repair for abdominal aortic aneurysm ( AAA) have come to differing conclusions about whether EVAR is cost-effective. This paper reviews the current evidence base and presents up-to-date cost-effectiveness analyses in the light of results of four randomized clinical trials: EVAR-1, DREAM, OVER and ACE. Methods Markov models were used to estimate lifetime costs from a UK perspective and quality-adjusted life-years ( QALYs) based on the results of each of the four trials. The outcomes included in the model were: procedure costs, surveillance costs, reintervention costs, health-related quality of life, aneurysm-related mortality and other-cause mortality. Alternative scenarios about complications, reinterventions and deaths beyond the trial were explored. Results Models based on the results of the EVAR-1, DREAM or ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to £30 000 per QALY). EVAR seemed cost-effective according to models based on the OVER trial. These results seemed robust to alternative model scenarios about events beyond the trial intervals. Conclusion These analyses did not find that EVAR is cost-effective compared with open repair in the long term in trials conducted in European centres. EVAR did appear to be cost-effective based on the OVER trial, conducted in the USA. Caution must be exercised when transferring the results of economic evaluations from one country to another. [ABSTRACT FROM AUTHOR]

Background Single-centre series of the management of patients with ruptured abdominal aortic aneurysm ( AAA) are usually too small to identify clinical factors that could improve patient outcomes. Methods IMPROVE is a pragmatic, multicentre randomized clinical trial in which eligible patients with a clinical diagnosis of ruptured aneurysm were allocated to a strategy of endovascular aneurysm repair ( EVAR) or to open repair. The influences of time and manner of hospital presentation, fluid volume status, type of anaesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality were investigated according to a prespecified plan, for the subgroup of patients with a proven diagnosis of ruptured or symptomatic AAA. Adjustment was made for potential confounding factors. Results Some 558 of 613 randomized patients had a symptomatic or ruptured aneurysm: diagnostic accuracy was 91·0 per cent. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio ( OR) 1·47, 95 per cent confidence interval 1·00 to 2·17). Mortality rates after primary and secondary presentation were similar. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51 per cent among those with pressure below 70 mmHg). Patients who received EVAR under local anaesthesia alone had greatly reduced 30-day mortality compared with those who had general anaesthesia (adjusted OR 0·27, 0·10 to 0·70). Conclusion These findings suggest that the outcome of ruptured AAA might be improved by wider use of local anaesthesia for EVAR and that a minimum blood pressure of 70 mmHg is too low a threshold for permissive hypotension. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study on the cost-effectiveness of endovascular abdominal aortic aneurysm repair (EVAR). It reveals that older patients should benefit more from EVAR in terms of absolute risk reduction, however, EVAR will be cost-effective in this group only if patients maintain such early survival advantage over open surgery.

Objectives: No randomized controlled trials exist to show whether varicose vein surgery improves healing of venous ulcers. In this study we investigated whether superficial venous surgery gave additional benefit to compression therapy in terms of healing rate, time to healing and quality of life of patients with venous ulcers. Methods: A total of 121 consecutive patients with venous ulceration were identified, of which 45 were unfit/unwilling to be included. The remaining 76 (aged 38-89, 39 female) were randomized to receive either four-layer bandaging (n =39) or superficial venous surgery (long and short saphenous with or without perforator surgery) and four-layer bandaging (n =37). Ulcer healing and health-related quality of life (HRQL) were assessed. Results: The healing rate was 64% (25/39) in the compression treatment group and 68% (25/37) in the surgical treatment group. This difference was not statistically significant (Pearson χ2 P=0.75). There was no significant difference between the time to ulcer healing in the two treatment groups (log rank statistic=0.69, P value=0.41): median time 83 days for surgery vs 98 days for compression. After adjusting for duration of ulcer, size of ulcer and previous deep vein thrombosis, there was still no significant difference between time to healing for the two treatment groups (adjusted hazard ratio=0.79, 95% confidence interval 0.45-1.39). There was no difference in HRQL between the two groups, using the scores of a disease-specific questionnaire (CXVUQ). Conclusions: This study suggests that for venous ulceration, superficial venous surgery gives no additional benefit to compression therapy from the point of view of healing rate and quality of life. [ABSTRACT FROM AUTHOR]

Background: Two clinical trials, one British and one American, have shown that early, prophylactic elective surgery does not improve five-year survival among patients with small abdominal aortic aneurysms. We report long-term outcomes in the United Kingdom Small Aneurysm Trial.Methods: We randomly assigned 1090 patients, 60 to 76 years of age, with small abdominal aortic aneurysms (diameter, 4.0 to 5.5 cm) to one of two groups: 563 were assigned to undergo early elective surgery, and 527 were assigned to undergo surveillance by ultrasonography. Patients were followed in the trial until June 1998 and thereafter until August 2001; the mean duration of follow-up was 8 years (range, 6 to 10).Results: The mean duration of survival was 6.5 years among patients in the surveillance group, as compared with 6.7 years among patients in the early-surgery group (P=0.29). The adjusted hazard ratio for death from any cause in the early-surgery group as compared with the surveillance group was 0.83 (95 percent confidence interval, 0.69 to 1.00; P=0.05). The 30-day operative mortality in the early-surgery group (5.5 percent) led to an early disadvantage in terms of survival. The survival curves crossed at three years, and at eight years, mortality in the early-surgery group was 7.2 percentage points lower than that in the surveillance group (P=0.03). There was no evidence that age, sex, or the initial size of the aneurysm modified the hazard ratio or that delayed surgery in the surveillance group increased 30-day postoperative mortality. Death was attributable to a ruptured aneurysm in 19 of the 411 men who died (5 percent) and in 12 of the 85 women who died (14 percent) (P=0.001). The rate of early cessation of smoking was higher in the early-surgery group than in the surveillance group.Conclusions: Among patients with a small abdominal aortic aneurysm, we found no long-term difference in mean survival between the early-surgery and surveillance groups, although after eight years, total mortality was lower in the early-surgery group. This difference may be attributed in part to beneficial changes in lifestyle adopted by members of the early-surgery group. [ABSTRACT FROM AUTHOR]

Discusses the abstract of a study testing the hypothesis that high concentrations of plasma interleukin-6 (IL-6) on prognosis of abdominal aortic aneurysms. Median concentration of plasma IL-6; Association of IL-6 with aneurysm growth rate; Plasma IL-6 concentration in patients with IL-6 genotype.

Discusses the abstract of a study evaluating the pharmacotherapy and outcome in intermittent claudication. Risk for vascular death; Patient characteristics; Prescription rate for statins and antiplatelets; Mortality.

Presents an abstract of the article 'Initial Management od Cerebrovascular Disease by General Practitioners,' by R.G. Gibbs, J.C. Todd, R. Newson, R.M. GreenHalgh and A.H. Davies.

SummaryBackground: The association between raised levels of homocysteine, fibrinogen and lipoprotein (a), and the presence of pre-existing intimal hyperplasia (IH) in vein has not been assessed. The positive association between such hyperplasia and graft failure following infrainguinal arterial reconstruction, and between lipoprotein (a) and graft failure, is disputed. The influence of homocysteine on outcome has not been investigated prospectively. Methods: Fifty-seven patients (63 grafts) undergoing infrainguinal arterial reconstruction with saphenous vein were studied. Homocysteine, fibrinogen and lipoprotein (a) levels were measured, and a vein biopsy was taken at operation. Patients underwent graft surveillance and outcome at 12 months was determined. Results: Fifty-seven per cent of patients had hyperhomocysteinaemia. Patients with pre-existing IH had significantly higher homocysteine levels. There was no association between homocysteine and outcome, or between fibrinogen and pre-existing IH or outcome. Lipoprotein (a) levels were significantly lower in patients with pre-existing disease, and were lower, but not significantly, in those whose grafts failed. The correlation between pre-existing IH and vein graft failure was highly significant. Conclusion: Hyperhomocysteinaemia is associated with peripheral vascular disease and the development of pre-existing IH in vein, which itself is associated with vein graft failure. Presented to the Surgical Research Society, in Dublin, UK, July 1998. [ABSTRACT FROM AUTHOR]

Aim: To determine whether recurrent varicose veins affect patient quality of life. The health-related quality of life (HRQL) scores of patients with recurrent varicose veins were compared with those of patients presenting with primary varicose vein disease. Methods: HRQL among patients attending outpatient appointments for recurrent and primary varicose veins was measured using the Aberdeen Varicose Vein Questionnaire (AVVQ) and the Short Form-36 General Health Survey (SF-36). Results: Questionnaires were given to 211 patients (150 primary, 61 recurrent), and 194 (133 primary, 61 recurrent) completed them. For the AVVQ, patients with recurrent varicose veins had significantly worse symptom scores compared with those with primary disease (24.87 ± 12.28 vs 17.77 ± 9.68, Mann-Whitney, P <0.01). The SF-36 recorded significantly worse HRQL (Mann-Whitney, P <0.05) for patients with recurrent varicose veins compared with those with primary varicose veins in all but one of the eight domains (role limitation attributed to emotional problems, RE, P = 0.073). Conclusion: Varicose vein recurrence is associated with a significantly worse HRQL than is found among patients with primary varicose veins. [ABSTRACT FROM AUTHOR]

SummaryBackground: Previous studies have related deep venous incompetence to reduced venous ulcer healing rates. The aim of this study was to determine the relationship between the pattern of venous incompetence and ulcer healing. Methods: A total of 198 legs with venous ulceration were investigated with colour venous duplex imaging to determine the presence and site of venous incompetence. All were treated initially with the four-layer bandage technique. Results: At 6 months, 74 per cent of the venous ulcers had healed using the four-layer bandage technique. There was no significant correlation between the pattern of incompetence and the healing rate of the ulcer. Previous deep vein thrombosis (DVT), increased size of the ulcer and previous episodes of ulceration were associated with a poor healing rate. Conclusion: The four-layer bandage technique achieved an ulcer healing rate of 74 per cent after 6 months, irrespective of the pattern of venous incompetence. Patients with a large ulcer, previous DVT or previous episodes of ulceration had delayed healing, supporting the previous literature. [ABSTRACT FROM AUTHOR]