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Katherine J Williams, Hayley M Moore, Mary Ellis, Alun H Davies Academic Section of Vascular Surgery, Imperial College London, London, UKCorrespondence: Alun H DaviesAcademic Department of Vascular Surgery, 4th Floor, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UKTel +44 20 3311 7320Email a.h.davies@ic.ac.ukIntroduction: Neuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease.Methods: Forty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4– 6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8.Results: The mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p< 0.05), which was enhanced at week 6 (PV and TAMV p< 0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p< 0.01). Leg swelling was reduced by mean 252.7 mL (13%, p< 0.05) overall; 338.9 mL (16%, p< 0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10.Conclusion: NMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life.Clinical Trials: This trial was registered with www.clinicaltrials.org.uk (NCT02137499).Keywords: neuromuscular, electrical, stimulation, venous disease, venous insufficiency

Amjad Belramman,1 Roshan Bootun,1,2 Sarah Onida,1,3 Alun H Davies,1,3 Tristan RA Lane1,31Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK; 2East of England Deanery Vascular Surgery Training Programme, Cambridge, UK; 3Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UKCorrespondence: Tristan RA LaneSection of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, 4N12A, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UKEmail tristan.lane@imperial.ac.ukAbstract: The American Venous Forum and the National Institute for Health and Care Excellence recommend endothermal ablation (ETA) techniques as the first line treatment for superficial venous incompetence. However, these techniques require the use of tumescent anaesthesia prior to energy delivery, which may be a source of discomfort for the patient and can prolong procedure time. Recently, nonthermal, nontumescent (NTNTs) techniques such as mechanochemical ablation (MOCA) have been developed to address some of the negative aspects associated with ETA. This article reviews this technique from a patient selection and perspective point view.Keywords: endovenous ablation, varicose veins, venous disease, mechanochemical ablation

The American Venous Forum and the National Institute for Health and Care Excellence recommend endothermal ablation (ETA) techniques as the first line treatment for superficial venous incompetence. However, these techniques require the use of tumescent anaesthesia prior to energy delivery, which may be a source of discomfort for the patient and can prolong procedure time. Recently, nonthermal, nontumescent (NTNTs) techniques such as mechanochemical ablation (MOCA) have been developed to address some of the negative aspects associated with ETA. This article reviews this technique from a patient selection and perspective point view.

BACKGROUNDVenous disease is the most common cause of leg ulceration. Although compression therapy improves venous ulcer healing, it does not treat the underlying causes of venous hypertension. Treatment of superficial venous reflux has been shown to reduce the rate of ulcer recurrence, but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear.METHODSIn a trial conducted at 20 centers in the United Kingdom, we randomly assigned 450 patients with venous leg ulcers to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life.RESULTSPatient and clinical characteristics at baseline were similar in the two treatment groups. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group; more patients had healed ulcers with early intervention (hazard ratio for ulcer healing, 1.38; 95% confidence interval [CI], 1.13 to 1.68; P=0.001). The median time to ulcer healing was 56 days (95% CI, 49 to 66) in the early-intervention group and 82 days (95% CI, 69 to 92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85.6% in the early-intervention group and 76.3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrollment was 306 days (interquartile range, 240 to 328) in the early-intervention group and 278 days (interquartile range, 175 to 324) in the deferred-intervention group (P=0.002). The most common procedural complications of endovenous ablation were pain and deep-vein thrombosis.CONCLUSIONSEarly endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. (Funded by the National Institute for Health Research Health Technology Assessment Program; EVRA Current Controlled Trials number, ISRCTN02335796.)

BACKGROUND: Peripheral arterial disease (PAD) is common and symptoms can be debilitating and lethal. Risk management, exercise, radiological and surgical intervention are all valuable therapies, but morbidity and mortality rates from this disease are increasing. Circulatory enhancement can be achieved using simple medical electronic devices, with claims of minimal adverse side effects. The evidence for these is variable, prompting a review of the available literature. METHODS: Embase and Medline were interrogated for full text articles in humans and written in English. Any external medical devices used in the management of peripheral arterial disease were included if they had objective outcome data. RESULTS: Thirty-one papers met inclusion criteria, but protocols were heterogenous. The medical devices reported were intermittent pneumatic compression (IPC), electronic nerve (NMES) or muscle stimulators (EMS), and galvanic electrical dressings. In patients with intermittent claudication, IPC devices increase popliteal artery velocity (49-70 %) and flow (49-84 %). Gastrocnemius EMS increased superficial femoral artery flow by 140 %. Over 4.5-6 months IPC increased intermittent claudication distance (ICD) (97-150 %) and absolute walking distance (AWD) (84-112 %), with an associated increase in quality of life. NMES of the calf increased ICD and AWD by 82 % and 61-150 % at 4 weeks, and 26 % and 34 % at 8 weeks. In patients with critical limb ischaemia IPC reduced rest pain in 40-100 % and was associated with ulcer healing rates of 26 %. IPC had an early limb salvage rate of 58-83 % at 1-3 months, and 58-94 % at 1.5-3.5 years. No studies have reported the use of EMS or NMES in the management of CLI. CONCLUSION: There is evidence to support the use of IPC in the management of claudication and CLI. There is a building body of literature to support the use of electrical stimulators in PAD, but this is low level to date. Devices may be of special benefit to those with limited exercise capacity, and in non-reconstructable critical limb ischaemia. Galvanic stimulation is not recommended.

INTRODUCTION: The prevention and management of venous disease is a therapeutic challenge. Movement of blood through the venous system is augmented by the action of muscles on the deep veins, and can be achieved through the application of electrical current. The efficacy of currently available clinical devices for this purpose is unknown, and is investigated here. METHODS: A literature search of the EMBASE and Medline databases was performed, and studies were included if they were full text articles, written in english, pertaining to venous disease and neuromuscular electrical stimulation (NMES). RESULTS: NMES devices increase venous haemodynamic parameters such as peak velocity and volume flow. Studies report them to be non-inferior to intermittent pneumatic compression. They are effective in the prevention of venous thromboembolism, though inferior to low molecular weight heparin. NMES can reduce symptoms of chronic venous disease. DISCUSSION: NMES is an important tool in the prevention and management of venous disease, and avoids the significant risks associated with heparin administration. Data explored here is heterogenous in device, protocol, and reported end-points, therefore should be interpreted with care. Long term effects of treatment with NMES have not been explored.

SummaryBackgroundIf carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.MethodsBetween 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3–2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6–11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.Findings1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1% vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4–3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0–7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7–9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43–0·68, p

Objectives We sought to investigate whether positron emission tomography/CT angiography using [11C]-PK11195, a selective ligand for peripheral benzodiazepine receptors expressed in activated macrophages, can be used to image vascular inflammation.Background Activated macrophages and T lymphocytes are fundamental elements in the pathogenesis of large vessel vasculitides.Methods Fifteen patients (aged 52±16 years) with systemic inflammatory disorders (6 consecutive symptomatic patients with clinical suspicion of active vasculitis and 9 asymptomatic control patients) underwent PET with [11C]-PK11195 and CT angiography. [11C]-PK11195 uptake was measured by calculating target-to-background ratios (TBR) of activity normalized to venous blood. Results Co-registration of PET with contrast-enhanced CT angiography facilitated localization of [11C]-PK11195 arterial wall uptake. Visual analysis revealed focal [11C]-PK11195 uptake in the arterial wall of all 6 symptomatic patients, but in none of the asymptomatic controls. Whilst serum inflammatory biomarkers (C-reactive protein, erythrocyte sedimentation rate, white cell count) did not differ significantly between the 2 groups, symptomatic patients had increased [11C]-PK11195 vascular uptake (TBR 2.41±1.59 versus 0.98±0.10; p=0.001). Conclusions By binding to activated macrophages in the vessel wall, [11C]-PK11195 enables noninvasive imaging of vascular inflammation. Alternative longer lived radioligands for probing peripheral benzodiazepine receptors are being tested for wider clinical applications.

Objective: To systematically review temporal changes in perioperative safety of carotid endarterectomy (CEA) in asymptomatic individuals in trial and registry studies. Methods: The MEDLINE and EMBASE databases were searched using the terms “carotid” and “endarterectomy” and “asymptomatic” from 1947 to August 23, 2014. Articles dealing with 50%–99% stenosis in asymptomatic individuals were included and low-volume studies were excluded. The primary endpoint was 30-day stroke or death and the secondary endpoint was 30-day all-cause mortality. Statistical analysis was performed using random-effects meta-regression for registry data and for trial data graphical interpretation alone was used. Results: Six trials (n = 4,431 procedures) and 47 community registries (n = 204,622 procedures) reported data between 1983 and 2013. Registry data showed a significant decrease in postoperative stroke or death incidence over the period 1991–2010, equivalent to a 6% average proportional annual reduction (95% credible interval [CrI] 4%–7%; p < 0.001). Considering postoperative all-cause mortality, registry data showed a significant 5% average proportional annual reduction (95% CrI 3%–9%; p < 0.001). Trial data showed a similar visual trend. Conclusions: CEA is safer than ever before and high-volume registry results closely mirror the results of trials. New benchmarks for CEA are a stroke or death risk of 1.2% and a mortality risk of 0.4%. This information will prove useful for quality improvement programs, for health care funders, and for those re-examining the long-term benefits of asymptomatic revascularization in future trials.

Introduction Varicose veins are a common problem with 25-50% of the population symptomatically affected, and chronic venous disease leads to significant impairments in quality of life with substantial health system cost implications. Significant variability exists in the symptoms suffered by patients, the treatment offered and the outcomes achieved. Identification of the optimal treatment pathways for patients remains difficult. Aims i. To ascertain primary care disease knowledge. ii. To assess what affects treatment and identify which patients benefit most. iii. To generate a predictive model of varicose vein outcomes. iv. To assess the impact of altering treatment of varicosities in the context of endovenous truncal vein ablation v. Toinvestigatetheearlyimpactofnewtechnologies Methods i. Two survey studies were completed: ⁃ 21 questions assessing venous disease management pathways was disseminated to General Practitioners. ⁃ 19 questions assessing the management of superficial venous thrombosis and was distributed to General Practitioners and Vascular Surgeons. ii. A cohort of consecutive patients with symptomatic chronic venous disease were assessed and completed quality of life questionnaires pre and post- intervention. iii. Uni-variable and multi-variable analysis of patient cohort data to facilitate the creation of generalised model of venous treatment outcomes iv. A randomised clinical trial assessing the timing of varicosity avulsion in the context of local anaesthetic endovenous truncal ablation. ⁃ Ambulatory Varicosity avUlsion Later or Synchronised (AVULS) trial. v. Assessmentofnewtechnologies ⁃ The European Sapheon Closure system Observed ProspectivE (eSCOPE) study a multi-site cohort observational study of cyanoacrylate glue occlusion of truncal vein incompetence ⁃ The VNUS Versus Clarivein for Varicose Veins (VVCVV) multi-centre randomised clinical trial comparing the procedural pain profile of radiofrequency and mechanochemical ablation. Results i. Education outcomes ⁃ 138 responses were received. The management of chronic venous disease in the primary care setting is disparate and knowledge of current techniques is poor, despite extensive guidance. ⁃ 369 responses were received, from 197 vascular specialists and 172 primary care physicians. Superficial thrombophlebitis management is shown to be diverse and does not adhere to recent evidence. ii. 461 patients were recruited. Patients suffering from chronic venous disease suffer from substantial quality of life impairment, including previously under-recognised depressive symptoms. Treatment of the underlying venous condition provides relief from venous symptoms and improves quality of life. ⁃ Patient symptoms and quality of life do not correlate with anatomical vein diameter, however clinical severity scores do. iii. Predictive modelling produces models that account for 30-41% of the variability in post-operative scores for disease specific quality of life tools, generic quality of life tools, and clinical severity scores. iv. The AVULS trial recruited 101 patients. Simultaneous treatment leads to improved clinical outcomes at up to 1 year and early quality of life improvement. Delayed treatment has a significantly increased risk of requiring further treatment (Odds Ratio 27.78, Relative Risk 18.36, p