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Objective: The aim of this study was to evaluate the outcomes after semi-conversion (open conversion with graft preservation) after failed endovascular aneurysm repair (EVAR). The primary outcomes were 30-day mortality and semi-conversion failure. Secondary outcomes were 30-day major systemic complications, endoleak recurrence, reinterventions, and overall survival., Methods: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was prospectively registered on PROSPERO (CRD42023421153). All studies reporting the outcomes of semi-conversions for failed EVAR were eligible for inclusion. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) tool. A random effects meta-regression of proportions was conducted using the double arcsine-Tukey transformation, given the frequent zero event rate in the primary outcome. Heterogeneity was assessed with the I 2 statistic., Results: Eight studies were included in the review after full text screening. A total of 196 patients underwent semi-conversion at a mean time from EVAR of 47.4 months, 68.9% in an elective setting. Mean age at conversion was 78.1 years, and the main indication was isolated endoleak type II (70.1% of cases). Aortic clamping was not necessary in 92.3% of semi-conversions; the aortic sac was opened in 96.1% of cases; in 93.3% of cases, ligation/suture of one or more culprit arteries were performed; and aortic neck banding was executed in 29.2%. At 30 days from surgery, the pooled mortality and the major systemic complications rates were 5.3% (I 2  = 24.9%) and 13.4% (I 2  = 54.3%), respectively. At follow-up, endoleak recurred after 12.6% semi-conversions (I 2  = 83.2%), and the rate of reinterventions was 7% (I 2  = 50.1%); the semi-conversion failure rate was 5.5% (I 2  = 54.1%), and the overall survival was 84.6% (I 2  = 33.3%)., Conclusions: Semi-conversions have acceptable 30-day mortality rates, but the early and mid-term risks of complications, reinterventions, ruptures, and infections are not negligible. This procedure might be an alternative to complete or partial graft explant in patients whom aortic cross-clamping is not ideal., Competing Interests: Disclosures None., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear., Methods: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response., Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence., Conclusions: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research., Competing Interests: Disclosures D.P.M. has given talks, acted as a consultant or attended conferences sponsored by Amgen and Novo Nordisk. J.F.M. receives funding from the United States National Institute of Neurologic Disorders and Stroke for work related to running the CREST-2 clinical trial (U01NS080168) and the CREST-2 Long-term Observational Extension study (U01NS119169). E.A.S. has received research grants from the United States Food and Drug Administration, BD, Boston Scientific, Cook, CSI, Laminate Medical, Medtronic and Philips; has received consulting/speaking fees from Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, CSI, Inari, Infraredx, Medtronic, Philips, Shockwave and VentureMed. H.-H.E. is a local Principal Investigator for the ROADSTER 2 trial and a scientific committee member of SPACE-1, SPACE-2 and ACST-2. T.R. is funded by grants from the National Institutes of Health (R01 MD012467, R01 NS029993, R01NS040807, 1U24NS107267), and the National Center for Advancing Translational Sciences (UL1 TR002736, KL2 TR002737). J.S.M. has received institutional research grants from Abbott, Cook, Endologix, Gore and Medtronic., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: No agreement has been reached regarding which bedside test is the most useful for the diagnosis of peripheral arterial disease (PAD) in patients with diabetes. The aim of the present systematic review and meta-analysis was to evaluate the performance of bedside tests for the detection of PAD in individuals with diabetes., Methods: MEDLINE and EMBASE databases were systematically searched for studies providing data on the diagnostic performance of bedside tests used for the detection of PAD in those with diabetes. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for the diagnosis of PAD., Results: A total of 18 studies, reporting on a total of 3016 limbs of diabetic patients, were included in our qualitative review. Of these, 11 studies (1543 limbs) were included in the meta-analysis of diagnostic accuracy: ankle-brachial pressure index (9 studies and 1368 limbs; sensitivity, 63.5% [95% confidence interval (CI), 51.7%-73.9%]; specificity, 89.3% [95% CI, 81.1%-94.2%]); toe-brachial pressure index (3 studies and 221 limbs; sensitivity, 83.0% [95% CI, 59.1-94.3%]; specificity, 66.3% [95% CI, 41.3%-84.6%]); and tibial waveform assessment (4 studies and 397 limbs; sensitivity, 82.8% [95% CI, 73.3%-89.4%], specificity, 86.8% [95% CI, 75.5%-93.3%]). Overall, we found a high risk of bias across the studies, most frequently relating to patient selection and the lack of blinding., Conclusions: The toe-brachial pressure index, pulse oximetry, and tibial arterial waveform assessment demonstrated some promise, warranting further investigation., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Chronic exertional compartment syndrome (CECS) is an overuse injury typically seen in young and athletic patients. The five cardinal symptoms are pain, tightness, cramping, weakness, and paresthesia. These classically occur during exertion and disappear with cessation of the activity, with no permanent damage to tissues within the compartment; nonetheless, CECS presents a significant functional impairment to those affected. Regulating exercise has been shown to alleviate symptoms, but this may not be acceptable to some patients (eg, professional athletes). For patients who fail to respond to conservative management or where exercise reduction is unrealistic, fasciotomy can be considered. There are no established guidelines on the management of CECS, and it remains underdiagnosed. The aim of this systematic review was to compare the outcomes of patients suffering from CECS managed with either fasciotomy or nonoperative means by examining functional outcomes and resolution of symptoms., Methods: MEDLINE and Embase databases and clinical trial registries were searched comprehensively; 219 articles were identified, and 14 articles were included in the systematic review. Given the heterogeneity between the studies in terms of outcomes reported, a qualitative synthesis was performed., Results: The majority of included studies were retrospective cohort studies, with a single prospective cohort study. Studies included fasciotomies performed in the upper and lower limbs. The population of patients included military servicemen, motocross racers, and unselected patients. There is insufficient evidence in the literature to support conservative or surgical management over the other in the management of CECS. However, fasciotomy appears to be a safe approach, with satisfaction rates of 48% to 94%. Complications related to the fasciotomy included hematomas (2.7%-22.5%), nerve injuries (2.0%-18.6%), deep venous thrombosis (2.7%), and symptom recurrence (0.65%-8.4%). Up to 10.4% of patients required revision fasciotomy., Conclusions: There is no consensus on the optimal management of CECS and, as yet, no established international guidelines on treatment. This systematic review suggests that fasciotomy could be a safe and viable option in the management of patients suffering from CECS, with promising long-term results. Future research in the form of randomized controlled trials comparing conservative and surgical management would be beneficial., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Median arcuate ligament syndrome (MALS) describes the clinical presentation associated with direct compression of the celiac artery by the median arcuate ligament. The poorly understood pathophysiologic mechanism, variable symptom severity, and unpredictable response to treatment make MALS a controversial diagnosis., Methods: This review summarizes the literature pertaining to the pathophysiologic mechanism, presentation, diagnosis, and management of MALS. A suggested diagnostic workup and treatment algorithm are presented., Results: Individuals with MALS present with signs and symptoms of foregut ischemia, including exercise-induced or postprandial epigastric pain, nausea, vomiting, and weight loss. Consideration of MALS in patients' diagnostic workup is typically delayed. Currently, no group consensus agreement as to the diagnostic criteria for MALS exists; duplex ultrasound, angiography, and gastric exercise tonometry are used in different combinations and with varying diagnostic values throughout the literature. Surgical management involves decompression of the median arcuate ligament's constriction of the celiac artery; robotic, laparoscopic, endoscopic retroperitoneal, and open surgical intervention can provide effective symptom relief, but long-term follow-up data (>5 years) are lacking. Patients treated nonoperatively appear to have worse outcomes., Conclusions: MALS is an important clinical entity with significant impact on affected individuals. Presenting symptoms, patient demographics, and radiologic signs are generally consistent, as is the short-to medium-term (<5 years) response to surgical intervention. Future prospective studies should directly compare long-term symptomatic and quality of life outcomes after nonoperative management with outcomes after open, laparoscopic, endoscopic retroperitoneal, and robotic celiac artery decompression to enable the development of evidence-based guidelines for the management of MALS., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background/objective: Sport-related vascular trauma is an important consequence of increased physical activity. Repetitive, high-intensity movements predispose athletes to vascular disease, including arterial pathology, by exerting increased pressure on neurovascular structures. This is an important source of morbidity in an otherwise young and healthy population. Arterial pathology associated with repetitive trauma is often misdiagnosed as musculoskeletal injury. This article increases awareness of sport-related arterial disease by reviewing the symptomatology, investigation, and treatment modalities of this pathology. In addition, prognostic outcomes specific to the athlete are discussed., Results: Arterial thoracic outlet syndrome and vascular quadrilateral space syndrome are associated with athletes involved in overhead throwing exercises. Sport-related arterial pathology of the lower limb include external iliac artery endofibrosis (EIAE), popliteal artery entrapment syndrome (PAES), and adductor canal syndrome. Vascular stress and kinking secondary to vessel tethering are important contributors to pathology in EIAE. Chronic exertional compartment syndrome must also be considered, presenting with clinical features similar to PAES. In addition, athletes are predisposed to blunt mechanical trauma. Hypothenar hammer syndrome is one such example, contributing to a high burden of morbidity in this population., Conclusions: In arterial thoracic outlet syndrome and vascular quadrilateral space syndrome, surgery is advocated in symptomatic individuals, with postoperative outcomes favorable for the athlete. Acute limb ischemia may occur as a result of secondary thrombosis or embolization, often without preceding claudication. PAES and adductor canal syndrome are associated with functional entrapment in the athlete, secondary to muscular hypertrophy. Surgical exploration may be indicated. Poorer outcomes are noted when this process is associated with vascular reconstruction. Surgical treatment of EIAE follows failure of conservative management, with limited data available on postoperative prognosis. Investigations for all these conditions should be targeted based on clinical suspicion. A delay in diagnosis can have severe consequences on return to competition in these high-functioning individuals., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the clinical efficacy of a neuromuscular electrical stimulation (NMES) device to improve the absolute walking distance in patients with intermittent claudication as an adjunct to the local standard care available at the study sites compared with local standard care alone., Methods: This open, multicenter, randomized controlled trial included eight participating centers in England. Sites are equally distributed between those that provide supervised exercise therapy programs and those that do not. Patients with intermittent claudication meeting the eligibility criteria and providing consent will be randomized, depending on the center type, to either NMES and locally available standard care or standard care alone. The primary end point is change in absolute walking distance at 3 months (the end of the intervention period) by treadmill testing. Secondary outcomes include quality of life, compliance with the interventions, economic evaluation of the NMES device, and lower limb hemodynamic measures to further the understanding of underlying mechanisms. Recruitment commenced in March 2018 and will continue for a total of 15 months. The Neuromuscular Electrical Stimulation Improves the Absolute Walking Distance in Patients with Intermittent Claudication trial is funded by the UK Efficacy and Mechanism Evaluation Programme, Medical Research Council, and National Institute for Health Research partnership., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Stroke occurs in 3% to 8% and silent cerebral infarction in >60% of patients undergoing thoracic endovascular aortic repair (TEVAR). We investigated the utility of a filter cerebral embolic protection device (CEPD) to reduce diffusion-weighted magnetic resonance imaging (DW-MRI) detected cerebral injury and gaseous and solid embolization during TEVAR., Methods: Patients anatomically suitable underwent TEVAR with CEPD, together with intraoperative transcranial Doppler to detect gaseous and solid high-intensity transient signals (HITSs), pre- and postoperative DW-MRI, and clinical neurologic assessment ≤6 months after the procedure., Results: Ten patients (mean age, 68 years) underwent TEVAR with a CEPD. No strokes or device-related complications developed. The CEPD added a median of 7 minutes (interquartile range [IQR], 5-16 minutes) to the procedure, increased the fluoroscopy time by 3.3 minutes (IQR, 2.4-3.9 minutes), and increased the total procedural radiation by 2.2%. The dose area product for CEPD was 1824 mGy·cm 2 (IQR, 1235-3392 mGy·cm 2 ). The average contrast volume used increased by 23 mL (IQR, 24-35 mL). New DW-MRI lesions, mostly in the hindbrain, were identified in seven of nine patients (78%). The median number was 1 (IQR, 1-3), with a median surface area of 6 mm 2 (IQR, 3-16 mm 2 ). A total of 2835 HITSs were detected in seven patients: 91% gaseous and 9% solid. The maximum number of HITSs were detected during CEPD manipulation: 142 (IQR, 59-146; 95% gaseous and 5% solid). The maximum number of HITSs during TEVAR occurred during stent deployment: 82 (IQR, 73-142; 81% gas and 11% solid). Solid HITSs were associated with an increase in surface area of new DW-MRI lesions (r s  = 0.928; P = .01). Increased gaseous HITSs were associated with new DW-MRI lesions (r s  = 0.912; P = .01), which were smaller (<3 mm; r = 0.88; P = .02). Embolic debris was captured in 95% of the filters. The median particle count was 937 (IQR, 146-1687), and the median surface area was 2.66 mm 2 (IQR, 0.08-9.18 mm 2 )., Conclusions: The use of a CEPD with TEVAR appeared to be safe and feasible in this first pilot study and could serve as a useful adjunct to reduce cerebral injury. The significance of gaseous embolization and its role in cerebral injury in TEVAR warrants further investigation., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The cost of health care is increasingly becoming an international issue, with many health care systems requiring evaluation of cost when agreeing to fund health care. In the United Kingdom (UK), for example, the National Institute for Health and Care Excellence highlights the importance of using cost-effectiveness analyses to facilitate the effective use of resources. This study evaluates the use of cost-effectiveness analyses and the provision of vascular surgery., Methods: A systematic review of published literature was performed. UK-based studies assessing cost-effectiveness or cost-utility of superficial venous interventions, abdominal aortic aneurysm (AAA) repair, and carotid endarterectomy (CEA) were included. All included studies were quality assessed to determine the overall strength of UK economic evidence for each intervention., Results: Four superficial venous, six AAA, and two CEA studies met the inclusion criteria. After quality assessment, the UK evidence supporting the cost-effectiveness of superficial venous intervention was graded strong. The economic evidence for asymptomatic and symptomatic CEA was graded limited and insufficient, respectively, owing to a paucity of UK literature in this field. There was strong UK economic evidence affirming that endovascular aneurysm repair (EVAR) is unlikely to be a cost-effective alternative to open repair., Conclusions: There is strong economic evidence for symptomatic superficial venous intervention. However, funding for varicose vein treatments remains controversial. Future economic analyses are required for symptomatic and asymptomatic CEA to better advise national policy. Despite strong economic evidence, current UK guidance is for EVAR over open repair in the elective setting, with the majority of elective AAA repairs being EVAR., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Open repair is the gold standard management for juxtarenal aneurysms. Fenestrated endovascular aneurysm repair (FEVAR) is indicated for high-risk patients. The long-term outcomes of FEVAR are largely unknown, and there is no Level I comparative evidence. This systematic review and meta-analysis of case series compares elective juxtarenal aneurysm surgery by open repair and FEVAR., Methods: A systematic literature search was conducted for all published studies on elective repair of juxtarenal aneurysms by FEVAR and open repair. The MEDLINE, EMBASE, and Cochrane databases were searched from 1947 to April 2013. The exclusion criteria were case series of <10 patients or ruptured aneurysms. The primary outcomes were perioperative mortality and postoperative renal insufficiency. The secondary outcomes were secondary reinterventions and long-term survival., Results: We identified 35 case series with data on 2326 patients. Perioperative mortality was 4.1% in open repair and FEVAR case series (odds ratio for open repair with FEVAR, 1.059; 95% confidence interval, 0.642-1.747; P = .822). Postoperative renal insufficiency was not significantly different (odds ratio for open repair with FEVAR, 1.136; 95% confidence interval, 0.754-1.713; P = .542). FEVAR patients had higher rates of secondary reintervention, renal impairment during follow-up, and a lower long-term survival compared with open repair patients., Conclusions: FEVAR and open repair have similar short-term outcomes but have diverging long-term outcomes that may be secondary to the selection bias of FEVAR being offered to high-risk patients. FEVAR is a favorable option in high-risk patients, and open repair remains viable as the gold standard., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hypoxia may contribute to the pathogenesis of various diseases of the vascular wall. Hypoxia-inducible factors (HIFs) are nuclear transcriptional factors that regulate the transcription of genes that mediate cellular and tissue homeostatic responses to altered oxygenation. This article reviews the published literature on and discusses the role of the HIF pathway in diseases involving the vascular wall, including atherosclerosis, arterial aneurysms, pulmonary hypertension, vascular graft failure, chronic venous diseases, and vascular malformation., Methods: PubMed was searched with the terms "hypoxia-inducible factor" or "HIF" and "atherosclerosis," "carotid stenosis," "aneurysm," "pulmonary artery hypertension," "varicose veins," "venous thrombosis," "graft thrombosis," and "vascular malformation.", Results: In atherosclerotic plaque, HIF-1α was localized in macrophages and smooth muscle cells bordering the necrotic core. Increased HIF-1α may contribute to atherosclerosis through alteration of smooth muscle cell proliferation and migration, angiogenesis, and lipid metabolism. The expression of HIF-1α is significantly elevated in aortic aneurysms compared with nonaneurysmal arteries. In pulmonary hypertension, HIF-1α contributes to the increase of intracellular K(+) and Ca(2+) leading to vasoconstriction of pulmonary smooth muscle cells. Alteration of the HIF pathway may contribute to vascular graft failure through the formation of intimal hyperplasia. In chronic venous disease, HIF pathway dysregulation contributes to formation of varicose veins and venous thromboembolism. However, whether the activation of the HIF pathway is protective or destructive to the venous wall is unclear. Increased activation of the HIF pathway causes aberrant expression of angiogenic factors contributing to the formation and maintenance of vascular malformations., Conclusions: Pathologic vascular wall remodelling of many common diseases of the blood vessels has been found to be associated with altered activity of the HIF pathway. Therefore, understanding the role of the HIF pathway in diseases of the vascular wall is important to identify novel therapeutic strategies in the management of these pathologies., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Recurrent varicose veins (RVV) occur in 13% to 65% of patients following treatment, and remain a debilitating and costly problem. RVV were initially thought largely to be due to inadequate intervention, however, more recently neovascularization and other factors have been implicated. This review aims to provide an overview of the current understanding of the etiology and pathogenesis of RVV., Methods: A systematic search of the PubMed database was performed using the search terms including "recurrent," "varicose veins," and "neovascularization.", Results: Three types of RVV have been reported, namely residual veins, true RVV, and new varicose veins, although the definitions varied between studies. RVV are attributable to causes including inadequate treatment, disease progression, and neovascularization. Using duplex ultrasonography, neovascularization has been observed in 25% to 94% of RVV. These new vessels appear in various size, number, and tortuosity, and they reconnect previously treated diseased veins to the lower limb venous circulation. Histologically, these vessels appear primitive with incomplete vein wall formation, decreased elastic component, and lack of valves and accompanying nerves. Although the rate of RVV following open surgery and endovenous treatment appears similar, neovascularization seems less common following endothermal ablation. Other causes of RVV following endovenous treatment include recanalization and opening of collaterals., Conclusions: Recurrence remains poorly understood following treatment of varicose veins. Neovascularization is an established and common cause of RVV, although other factors may contribute., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To assess each of the scoring systems used to diagnose and classify post-thrombotic syndrome, a common chronic complication of deep vein thrombosis. The design of the study was a systematic review of the literature pertaining to post-thrombotic syndrome., Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by a search of PubMed (1948 to September 2011) using the search terms "post-thrombotic syndrome," "postthrombotic syndrome," "post-phlebitic syndrome," and "postphlebitic syndrome." A manual reference list search was also carried out to identify further studies that would be appropriate for inclusion. The various scoring systems in use were identified and assessed against a list of criteria to determine their validity for use. For outcome measures, each scoring system was assessed for specific criteria, including interobserver reliability, association with ambulatory venous pressures, ability to assess severity of post-thrombotic syndrome, ability to assess change in condition over time, and association with patient-reported symptom severity., Results: The Villalta, Ginsberg, Brandjes, Widmer, CEAP, and Venous Clinical Severity Score systems all were assessed for the stated outcome measures. From their use in the literature, only the Villalta score was able to fulfill all the criteria described. The main criticism of the Villalta score in the literature appears to be its use of subjective measures. To that end, we propose that use of a venous disease-specific quality-of-life questionnaire in combination with the Villalta score may help standardize the subjective criteria., Conclusions: The Villalta score, combined with a venous disease-specific quality-of-life questionnaire, should be considered the "gold standard" for the diagnosis and classification of post-thrombotic syndrome., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Robust guidelines exist for the treatment of carotid stenosis and intracranial aneurysms independently, however, the management of tandem carotid stenosis and intracranial aneurysms remains uncertain. Although the prevalence of tandem pathologies is small (1.9%-3.2%), treating carotid stenosis can alter intracranial hemodynamics potentially predisposing to aneurysm rupture. In this review, our aim was to assess the safety of intervention in this cohort, by analyzing outcomes from the published literature., Methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to conduct the review. Articles from 1947 to 2012 were searched using EMBASE Classic and EMBASE (November, 1947 -March, 2012) and Ovid MEDLINE(R) In-Process and other NonIndexed Citations and Ovid MEDLINE(R) on Ovid SP, http://ClinicalTrials.gov, http://controlled-trials.com and the Cochrane review database using a predefined search strategy., Results: One hundred forty-one patients from 27 articles were included. Interventions ranged from single (n=104, 74%), staged (n=26, 18%) to simultaneous procedures (n=11, 8%). The largest cohort of patients was treated by carotid endarterectomy alone (n=92, 66%). The majority of patients presented with a symptomatic carotid stenosis and an asymptomatic ipsilateral intracranial aneurysm (n=70, 50%). Five subarachnoid hemorrhages occurred (4% [5/140], three within 30 days of the procedure and two thereafter) of which two were fatal. All five occurred in patients who underwent carotid endarterectomy as a single procedure (5%). Two of the five patients presented with ruptured posterior communicating artery aneurysms., Conclusions: Published reports of perioperative aneurysm rupture are rare in individuals with tandem carotid stenosis and intracranial aneurysms. This is the first analysis of all published cases. However, it is limited by the small number of studies and the possible underreporting due to publication bias and underdiagnosis where angiography was not performed. Although we report a low incidence of subarachnoid hemorrhage, analysis of registry data with a larger cohort is warranted to confirm these findings., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Treatment of head and neck malignancy commonly involves radiotherapy, which is associated with the development of carotid artery stenosis. There is little evidence to guide clinicians on how to intervene in significant postradiotherapy carotid stenosis. This systematic review collated data pertaining to perioperative outcomes of carotid artery surgery and carotid stenting in postradiotherapy carotid stenosis to aid the clinical decision-making process., Methods: A systematic review of the literature, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines, was performed. We screened 575 articles related to carotid artery surgery or stenting in postradiotherapy carotid stenosis, from which 21 studies were included for quantitative analysis. The primary outcome was stroke or death ≤ 30 days of the procedure. Secondary outcomes included cranial nerve injury, restenosis, stroke, and death at >30 days., Results: Nine publications recorded 211 surgical procedures in 179 patients. In symptomatic patients, the 30-day mortality rate was 2.6% and the stroke or death rate was 2.7%. In asymptomatic patients, the 30-day mortality rate was 0% and the stroke or death rate was 1.1%. Permanent cranial nerve palsy was experienced by 0.6% of patients. Twelve publications recorded 510 carotid artery stenting procedures in 482 patients. In symptomatic patients, the 30-day mortality rate was 5.1%, and the stroke or death rate was 5.1%. In asymptomatic patients, the 30-day mortality rate was 1.4%, and the stroke or death rate was 2.1%. There was no statistically significant difference in 30-day stroke or death rate between surgical revascularization and carotid artery stenting in all (odds ratio [OR], 0.54; 95% confidence interval [CI] 0.17-1.70; P = .43), symptomatic (OR, 0.52; 95% CI, 0.14-1.98; P = .38), or asymptomatic patients (OR, 0.55; 95% CI, 0.06-5.42; P = .99)., Conclusions: The published outcomes from high-volume centers demonstrate that surgical revascularization and stenting are both technically feasible in postradiotherapy carotid stenosis and have similar safety profiles to nonirradiated necks. Radiation should therefore not be considered a contraindication to surgical intervention., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Doxycycline and micronized purified flavonoid fraction (MPFF) modulate vein wall remodeling that may be associated with hypoxia in varicose veins (VVs), vein graft stenosis, and deep venous thrombosis. We recently reported that in vitro exposure of non-VV (NVVs) and VVs to hypoxic conditions activates the hypoxia-inducible factor (HIF) pathway. This study investigated the in vitro effects of doxycycline and MPFF on the HIF pathway in hypoxic NVVs and VVs., Methods: Six NVVs and six VVs obtained from surgery were used to prepare vein organ cultures, which were exposed to hypoxia (1% O(2)), with and without MPFF (10(-5) mol/L) or doxycycline (5 μg/mL) for 16 hours. The veins were analyzed for HIF-1α, HIF-2α, and their target gene expression, with real-time polymerase chain reaction and Western blot. The differences between gene expressions were tested with one-way analysis of variance with repeated measures, followed by the Dunnett test for multiple comparisons. P < .05 was considered significant., Results: Treatment of NVV organ cultures exposed to hypoxia with doxycycline or MPFF did not significantly alter the expression of HIF-1α and HIF-2α messenger (m)RNA and protein compared with untreated. Doxycycline also did not significantly affect the expression of HIF-1α and HIF-2α mRNA and protein in VVs exposed to hypoxia compared with untreated VVs. However, MPFF significantly reduced the expression of HIF-1α but not HIF-2α mRNA in VVs exposed to hypoxia compared with untreated VVs. Interestingly, the reduction of the expression of HIF-1α mRNA in VVs by MPFF was not reflected at the protein level. The mRNA expression of HIF target genes, namely glucose transporter-1, carbonic anhydrase-9, vascular endothelial growth factor, B-cell lymphoma 2/adenovirus E1B 19-kDa protein-interacting protein 3, prolyl hydroxylase domain-2, and prolyl hydroxylase domain-3, was not significantly altered in NVVs and VVs exposed to hypoxia and treated with doxycycline or MPFF compared with those untreated., Conclusions: Doxycycline and MPFF at a concentration corresponding to a therapeutic dose do not alter the activation of the HIF pathway in NVV and VV organ cultures exposed to hypoxia. Our findings suggest vein wall remodeling actions in NVVs and VVs are likely not HIF-dependent., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Venous hypoxia has been postulated to contribute to varicose vein (VV) formation. Direct measurements of vein wall oxygen tension have previously demonstrated that the average minimum oxygen tensions were significantly lower in VVs compared with non-varicose veins (NVVs). Hypoxia-inducible factors (HIFs) are nuclear transcriptional factors that regulate the expression of several genes of oxygen homeostasis. This study aimed to investigate if hypoxia was associated with VVs by assessing the expression of HIF-1α, HIF-2α, HIF target genes, and upstream HIF regulatory enzymes in VVs and NVVs, and their regulation by hypoxia., Methods: VVs and NVVs were surgically retrieved and immediately snap-frozen or used for organ culture preparation. The relative expression of HIF-1α, HIF-2α, HIF target genes, and HIF regulatory enzymes in VVs and NVVs was analyzed with quantitative polymerase chain reaction (Q-PCR) and Western blot. VV and NVV organ ex vivo cultures were exposed to 16 hours of normoxia, hypoxia (oxygen tension 1%), or the hypoxia mimetic dimethyloxallyl glycine (DMOG) 1 mM in normoxia. The vein organ cultures were then analyzed for HIF-1α, HIF-2α, and their target gene expression with Q-PCR and Western blot., Results: HIF-1α and HIF-2α mRNA were significantly upregulated in VVs compared with NVVs (89.8 ± 18.6 vs 10.4 ± 7.2 and 384.9 ± 209.4 vs 8.1 ± 4.2, respectively). HIF target gene mRNA expression was also significantly elevated in VVs compared with NVVs, namely glucose transporter-1 (GLUT-1; 8.7 ± 2.1 vs 1.0 ± 0.3), carbonic anhydrase-9 (CA9; 8.5 ± 2.1 vs 2.8 ± 1.2), vascular endothelial growth factor (VEGF; 7.5 ± 2.1 vs 0.9 ± 0.2), and BCL2/adenovirus E1B 19-kDa protein-interacting protein 3 (BNIP-3; 4.5 ± 0.7 vs 1.4 ± 0.3). The upregulation of HIF-1α, HIF-2α, and HIF target genes in VVs was also reflected at protein level. Of the HIF regulatory enzymes, the expression of prolyl-hydroxylase domain (PHD)-2 and PHD-3 was found to be elevated in VVs compared with NVVs. Exposure of VV and NVV organ cultures to hypoxia or DMOG was associated with increases in HIF-1α and HIF-2α protein and HIF target gene expression compared with normoxia only., Conclusions: The study concluded, we believe for the first time, an increased activation of the HIF pathway, with upregulation of the expression of HIF-1α and HIF-2α transcription factors, and HIF target genes, in VVs compared with NVVs. Exposure of VVs and NVVs to hypoxic conditions was associated with increased expression of HIF-1α and HIF-2α protein and HIF target genes. The data suggest that the HIF pathway may be associated with several pathophysiologic changes in the VV wall, and that hypoxia may be a feature contributing to VV pathogenesis., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Sclerotherapy has been shown to be an effective and increasingly popular therapeutic strategy for the treatment of varicose veins. However, recent reports of serious side effects, including cerebrovascular accidents (CVA) and transient ischemic attacks (TIA), as well as speech and visual disturbances, have caused serious concern regarding its use. This review evaluated the reported incidences of neurological side effects associated with the use of sclerotherapy., Methods: A systematic search of the data bases MEDLINE, OVID Embase, and Google Scholar was undertaken by two independent reviewers. Articles reporting neurological side effects in humans following foam and liquid sclerotherapy were included; animal studies, laboratory studies, and review articles were excluded. Additional references were also obtained using the related articles function., Results: The search yielded 1023 articles, of which 41 studies were found to meet the inclusion criteria. A total of 10,819 patients undergoing sclerotherapy were reviewed. There were 12 case reports of CVA with confirmatory brain imaging and nine reports of TIA. There were 97 (0.90%) reports of neurological events overall, including TIA, visual and speech disturbances, and 29 cases of reported migraine (0.27%). Symptoms occurred at times ranging from minutes to several days following sclerotherapy. Eleven patients with TIA or CVA were found to have a right to left cardiac shunt, usually a patent foramen ovale., Conclusions: Neurological side effects following sclerotherapy are a rare occurrence; however, CVA associated with the use of sclerotherapy is clearly documented. The pathologic mechanisms resulting in CVA are likely to be different to those leading to migraine and visual disturbances; however, care should be exercised in patient selection, particularly in those with known cardiac defects., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Approximately 20% of strokes are attributable to carotid stenosis. However, the number of asymptomatic patients needed to prevent one stroke or death with endarterectomy is high at 17 to 32. There is a clear need to identify asymptomatic individuals at high risk of developing future ischemic events to improve the cost-effectiveness of surgery. Our aim was to examine the evidence for subclinical microembolization and silent brain infarction in the prediction of stroke in asymptomatic carotid stenosis using transcranial Doppler (TCD), computed tomography (CT), and magnetic resonance imaging (MRI)., Methods: The review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Articles regarding humans between 1966 and 2010 were identified through systematic searches of Pubmed, MEDLINE, and EMBASE electronic databases using a predetermined search algorithm., Results: Fifty-eight full text articles met the inclusion criteria. A median of 28% of microemboli positive patients experienced a stroke or transient ischemic attack during follow-up compared with 2% of microemboli negative patients (P = .001). The same was true for the end point of stroke alone with a median of 10% of microemboli positive patients experiencing a stroke vs 1% of microemboli negative patients (P = .004). A specific pattern of silent CT infarctions was related to future stroke risk (odds ratio [OR] = 4.6; confidence interval [CI] = 3.0-7.2; P < .0001). There are no prospective MRI studies linking silent infarction and stroke risk., Conclusions: There is level 1 evidence for the use of TCD to detect microembolization as a risk stratification tool. However, this technique requires further investigation as a stroke prevention tool and would be complemented by improvements in carotid plaque imaging., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Carotid stenosis accounts for 20% of ischemic strokes and can be managed with pharmacotherapy alone or in conjunction with carotid endarterectomy or stenting. The management of asymptomatic carotid stenosis is controversial amongst physicians. The aim of this study was to explore patient preferences for the potential management options using a standardized scenario to minimize clinician bias. These data will then be used to facilitate comparison with existing published data on physicians' preferences in the management of asymptomatic carotid stenosis., Methods: A patient information booklet and questionnaire was developed, validated, and distributed to patients who were identified as candidates for carotid screening duplex based on the presence of peripheral arterial, coronary, or aneurismal disease. Patients were asked to imagine their duplex revealed a 70% unilateral carotid stenosis. Five-year stroke or death risks of 11% were quoted for best medical therapy. The perioperative stroke or death rates quoted were 3% for endarterectomy and 3% to 5% for stenting, based on best current evidence. No physician interaction was allowed to minimize clinician bias. Responses for treatment preference and reasoning were analyzed using appropriate statistical methods. Results from this survey were then compared with a previously published poll of physician preference., Results: One hundred two questionnaires were analyzed with a 94% response rate: 48% chose pharmacotherapy alone, 30% selected carotid endarterectomy, and 22% opted for stenting. The preference for pharmacotherapy alone over either intervention, and for endarterectomy, over stenting was consistent in subgroup analyses by age, gender, prior stroke, family history of stroke, and smoking status., Conclusion: In this scenario, patients were split equally between medical and surgical treatment of asymptomatic carotid stenosis. This was identical to a recent poll of physicians. Tools for risk assessment and the results of the SPACE2, ACST2, and ACT1 trials would benefit patients and physicians making this important treatment decision., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Decreased venous tone and vein wall dilation may contribute to varicose vein formation. We have shown that prolonged vein wall stretch is associated with upregulation of matrix metalloproteases (MMPs) and decreased contraction. Because hypoxia-inducible factors (HIFs) expression also increases with mechanical stretch, this study tested whether upregulation of HIFs is an intermediary mechanism linking prolonged vein wall stretch to the changes in MMP expression and venous contraction., Methods: Segments of rat inferior vena cava (IVC) were suspended in tissue bath under 0.5-g basal tension for 1 hour, and a control contraction to phenylephrine (PHE, 10(-5)M) and KCl (96 mM) was elicited. The veins were then exposed to prolonged 18 hours of tension at 0.5 g, 2 g, 2 g plus HIF inhibitor U0126 (10(-5)M), 17-[2-(dimethylamino)ethyl] amino-17-desmethoxygeldanamycin (17-DMAG, 10(-5)M), or echinomycin (10(-6)M), or 2 g plus dimethyloxallyl glycine (DMOG; 10(-4)M), a prolyl-hydroxylase inhibitor that stabilizes HIF. The fold-change in PHE and KCl contraction was compared with the control contraction at 0.5-g tension for 1 hour. Vein tissue homogenates were analyzed for HIF-1α, HIF-2α, MMP-2, and MMP-9 messenger RNA (mRNA) and protein amount using real-time reverse transcription polymerase chain reaction and Western blots., Results: Compared with control IVC contraction at 0.5-g tension for 1 hour, the PHE and KCl contraction after prolonged 0.5-g tension was 2.0 ± 0.35 and 1.1 ± 0.06, respectively. Vein contraction to PHE and KCl after prolonged 2-g tension was significantly reduced (0.87 ± 0.13 and 0.72 ± 0.05, respectively). PHE-induced contraction was restored in IVC exposed to prolonged 2-g tension plus the HIF inhibitor U0126 (1.38 ± 0.15) or echinomycin (1.99 ± 0.40). U0126 and echinomycin also restored KCl-induced contraction in IVC exposed to prolonged 2-g tension (1.14 ± 0.05 and 1.11 ± 0.15, respectively). Treatment with DMOG further reduced PHE- and KCl-induced contraction in veins subjected to prolonged 2-g tension (0.47 ± 0.06 and 0.57 ± 0.01, respectively). HIF-1α and HIF-2α mRNA were overexpressed in IVC exposed to prolonged 2-g tension, and the overexpression was reversed by U0126. The overexpression of HIF-1α and HIF-2α in stretched IVC was associated with increased MMP-2 and MMP-9 mRNA. The protein amount of HIF-1α, HIF-2α, MMP-2, and MMP-9 was also increased in IVC exposed to prolonged 2-g wall tension., Conclusions: Prolonged increases in vein wall tension are associated with overexpression of HIF-1α and HIF-2α, increased MMP-2 and MMP-9 expression, and reduced venous contraction in rat IVC. Together with our report that MMP-2 and MMP-9 inhibit IVC contraction, the data suggest that increased vein wall tension induces HIF overexpression and causes an increase in MMP expression and reduction of venous contraction, leading to progressive venous dilation and varicose vein formation., (Copyright © 2011 Society for Vascular Surgery. All rights reserved.)

Objective: The wide variety of outcome measures to evaluate patients with varicose veins poses significant difficulties when comparing clinical trials. In addition, the relationship between different outcome measures is poorly understood. The aim of this study was to compare anatomical, hemodynamic, and clinical outcomes with disease-specific quality-of-life tools in patients undergoing treatment for varicose veins., Methods: Patients undergoing treatment for symptomatic veins in a single unit were studied. Assessments included duplex ultrasonography, digital photoplethysmography, evaluation of Venous Clinical Severity Scores and CEAP scores, generic (Short Form 12 [SF12]) and disease-specific (Aberdeen Varicose Vein Questionnaire [AVVQ], and Specific Quality-of-life and Outcome Response-Venous [SQOR-V]) questionnaires. Patients were reviewed at 6 weeks when hemodynamic, clinical, and quality-of-life assessments were repeated. The relationships between these outcomes were assessed., Results: The AVVQ showed a strong positive correlation with the SQOR-V (Spearman coefficient 0.702; P < .001) and weaker, but significant correlations with the SF12 physical and mental component scores and the Venous Clinical Severity Score (VCSS) (P < .001, P = .019, and P < .001, respectively, Spearman correlation). No correlations were observed between the AVVQ and photoplethysmography results (Spearman coefficient -0.042; P = .606), and weak correlations were observed with the AVVQ and anatomical reflux. At 6 weeks, functional, clinical, and hemodynamic measurements were all responsive to changes following interventions; however, correlations observed between changes in disease-specific quality-of-life and generic, clinical, and hemodynamic outcomes were weak., Conclusions: Both the AVVQ and SQOR-V questionnaire are sensitive and responsive disease-specific questionnaires, which correlate with generic and clinical outcomes to some extent. Anatomical and hemodynamic measurements correlated poorly with functional outcomes both preoperatively and following interventions., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

The case of a 49-year-old male patient who presented with recurrent pulmonary emboli secondary to a calcified lesion within his inferior vena cava is presented. The diagnosis and relevant literature is reviewed. This is the first time that calcification within the inferior vena cava has presented this way in adults, and it is important to consider this diagnosis in patients presenting with recurrent pulmonary emboli., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Maintenance of luminal area is essential for the optimal performance of venous bypass grafts. However, injury and response to the arterial circulation evoke vascular remodelling that favors intimal hyperplasia, with luminal encroachment and inward remodelling. Potassium channel-opening drugs reduce tissue workload and peripheral vascular resistance and through these mechanisms could favor outward or expansive remodelling of vein grafts. We tested the hypothesis that levcromakalim, a potassium channel opener, would enhance expansive remodelling in vein grafts., Methods: A randomized, double-blind, placebo-controlled trial was conducted in 33 rats with vena cava-to-aorta bypass grafts. Drugs were administered via osmotic pump for 7 days after surgery. Half the cohort had bromodeoxyuridine (BrdU) infused at day 6. Morphometric analysis was conducted of pressure perfusion-fixed grafts harvested at 1 week and 4 weeks., Results: At 1 week, lumen area was similar in both groups (1.82 +/- 0.39 mm(2) placebo vs 1.85 +/- 0.36 mm(2) levcromakalim), although medial cell density and BrdU staining were significantly increased in the placebo group. At 4 weeks, lumen area was unchanged in the placebo group (1.88 +/- 0.51 mm(2)) but had increased to 2.32 +/- 0.46 mm(2) in the levcromakalim group (P = .039 vs 1 week), with a very significant reduction in the intimal area (levcromakalim, 0.06 +/- 0.02 mm(2) vs placebo, 0.33 +/- 0.17 mm(2); P = .001)., Conclusions: Early, short-term treatment with levcromakalim favors expansive remodelling of experimental vein grafts to mimic the effect of external stenting. This expansive remodelling was associated with a reduction in medial cell proliferation at 1 week., Clinical Relevance: Critical limb ischemia can be treated by bypass surgery or angioplasty, but inward remodelling with restenosis is a common problem. There has been little previous experimental work to identify treatments associated with expansive remodelling, which would increase the chances of vessel patency. Here, in a randomized trial, we show that short-term treatment with a potassium channel opener (a class of drug that can be used to treat hypertension) results in strong, expansive remodelling, with increases the lumen area and graft size of experimental vein grafts by >25%.

Introduction: As yet, there is no patient-assessed, condition-specific instrument for the assessment of health-related quality of life in intermittent claudication. We evaluated the intermittent claudication questionnaire (ICQ) for properties required of a measure of health outcome., Methods and Results: Interviews with patients with intermittent claudication and vascular specialist opinion produced a pool of statements used to itemize a self-completed ICQ. This was piloted in 20 patients for practicality and then administered to 124 stable claudicants. Reliability was assessed through a retest in 63 (51%) patients at 14 days and analysis of Cronbach's alpha for internal consistency. Spearman's correlation coefficient was used to assess construct validity in comparisons between the ICQ and ankle brachial pressure index, treadmill-walking distances, the walking impairment questionnaire, the EuroQol, and the Short Form-36. Responsiveness of the ICQ to changes in health was assessed in 60 patients treated conservatively and 40 patients undergoing angioplasty. The standardized response mean was used to identify the most responsive instrument in the study. A 16-item ICQ with a test-retest intraclass correlation of 0.95 and Cronbach's alpha of.94 was produced. One hundred twenty-one (98%) patients completed the ICQ (mean time, 3.7 minutes). The ICQ correlated better with the EuroQol (r = 0.58) and 7 out of 8 subscales of the Short Form-36 (r = 0.33-0.68) compared with the walking impairment questionnaire. The ICQ demonstrated the largest standardized response mean in relation to health transition compared with the other instruments., Conclusions: The patient-assessed ICQ is a practical, reliable, valid, and responsive measure of patient health-related quality of life in intermittent claudication.

Purpose: Earlier studies have highlighted risk factors for perioperative stroke after carotid endarterectomy, such as female sex, preoperative symptoms, and cerebral infarction. In this study, we investigated the relationship between these factors and perioperative microembolization., Methods: A total of 235 patients were entered in the study at two centers. Transcranial Doppler ultrasound scanning was possible in 190 patients (81%) and was performed for 1 hour preoperatively and continuously intraoperatively as a means of detecting microemboli and monitoring mean middle cerebral artery velocity. The findings of transcranial Doppler ultrasound scanning were related to perioperative risk factors by means of univariate analysis., Results: Microemboli were detected in 28 (15%), 79 (42%), and 98 (52%) patients preoperatively, during carotid artery dissection, and after closure of the artery, respectively. Having 10 or more emboli after carotid artery closure was more common in women (P = .04) and in patients with symptomatic carotid artery disease (P = .04) and was demonstrated in three of the six patients who had a perioperative stroke. These three patients also had preoperative evidence of cerebral infarction and an intraoperative middle cerebral artery velocity less than 40 cm/s., Conclusion: In this study, perioperative microembolization was more common in women and patients with symptomatic carotid artery disease. These findings may explain the increased risk of carotid surgery in these patients.

Purpose: We investigated the hypothesis that fibrinogen increased DNA synthesis (and cell proliferation) of smooth muscle cells (SMCs) cultured from human saphenous vein and that the increased DNA synthesis was attenuated when cells were cultured on polymeric collagen., Methods: SMCs were cultured from human saphenous vein on plastic, fibronectin, monomeric, and polymeric collagen. Fibrinogen products were prepared by proteolytic digestion. DNA synthesis was measured by bromodeoxyuridine incorporation into DNA, cell proliferation by cell counting, cyclic adenosine monophosphate by enzyme-linked immunosorbent assay, and fibrinopeptide B labeled with iodine 125 used for binding studies., Results: Fibrin monomer (0.003-0.1 micromol/L) stimulated a concentration-dependent increase in DNA synthesis of up to 10-fold, which could be inhibited by the peptide Bbeta15-42. The stimulation of DNA synthesis was highest for cells cultured on plastic and lowest for cells cultured on type I collagen polymer. Much higher concentrations of fibrinogen (0.3-1 micromol/L) were required to effect similar increases in DNA synthesis. Fibrinogen had a particular effect to augment DNA synthesis, up to 14-fold, when cells were cultured on monomeric type I collagen. This augmented DNA synthesis was inhibited by a neutralizing antibody to urokinase-type plasminogen activator. Incubation of cells cultured on collagen monomer with fibrinogen resulted in production of fibrinopeptide B. Fibrinopeptide B (5 micromol/L) increased DNA synthesis by fourfold and had additive effects with fibrin monomer to increase DNA synthesis. Iodinated tyrosine fibrinopeptide B bound to SMCs (dissociation constant 0.6 micromol/L)., Conclusion: Cultured human saphenous vein SMCs appear to have high-affinity receptors for fibrin monomer and fibrinopeptide B, the engagement of which stimulates DNA synthesis. These mechanisms may be pertinent to the association between fibrinogen and vein graft stenosis in vivo.

Purpose: This prospective study aimed to validate a newly designed specific measure of quality of life for patients with venous ulcers., Methods: The study was set in a London teaching hospital and surrounding community clinics. Items for the questionnaire were selected by means of patient interviews, a literature review, and expert opinion. The questionnaire and the Short Form 36-item (SF-36) Health Survey were given to a prospective consecutive cohort of 98 patients with proven venous ulcers that were diagnosed by means of clinical and color duplex examination. Fifty-eight of the patients were women (60%), and the median age of patients was 76 years. The questionnaire was assessed for reliability, validity, and responsiveness., Results: The ulcer-specific questionnaire showed good reliability, as assessed by means of the internal consistency (Cronbach alpha = 0.93) and test-retest analysis (r = 0.84). Factor analysis identified four important health factors: social function, domestic activities, cosmesis, and emotional status. Validity was demonstrated by means of a high correlation with all eight domains of the SF-36 general health measure (r > 0.55, P <.001). Responsiveness was demonstrated by means of a significant reduction in the score on the ulcer questionnaire as ulcers healed at 6 and 11 weeks (P <.05)., Conclusion: Good evidence exists that a clinically derived measure for patients with venous ulcers has validity to measure the quality of life.

Purpose: We set out to assess the new Aberdeen Varicose Veins Questionnaire (Aberdeen Questionnaire) for the properties necessary for a valid measure of health outcome, to determine quality of life of patients with varicose veins, and to determine the effect of surgery on quality of life., Methods: A prospective consecutive cohort of 137 patients undergoing varicose vein surgery completed the self-administered SF-36 and Aberdeen Questionnaire and 25 questions relating to the symptoms and concerns of patients with varicose veins. Follow-up was done by repeated questionnaires 6 weeks after surgery. The Aberdeen Questionnaire was assessed for reliability, validity, responsiveness, and practicality. Quality of life of patients with varicose veins was compared with an age- and sex-matched sample of the general population., Results: Reliability estimates for the 8 scales short-form health survey (SF-36) and the Aberdeen Questionnaire were all above 0.7 (Cronbach's alpha). The Aberdeen Questionnaire had a highly significant correlation (r = 0. 74, P <.0001) with the patients' symptoms and concerns questionnaire, which is evidence of its validity. Patients with varicose veins score lower than United Kingdom norms (P <.001) in the physical domains of the SF-36, indicating worse health. After surgery, the SF-36 scores improved in all 8 domains of health, reaching significance in "Mental Health" (P <.05) and approaching significance in "General Health" (P =.066). The Health Transition Item of the SF-36 and the Aberdeen Questionnaire both showed a highly significant improvement in health (P <.001)., Conclusion: The Aberdeen Questionnaire is a valid measure of quality of life for patients with varicose veins. Persons with varicose veins have a reduced quality of life compared with the general population, and this discrepancy is significantly improved at 6 weeks by operating on them.

Objective: The aim of this study was the definition of the duplex scan parameters that best select patients for carotid endarterectomy., Methods: This study was set in a regional vascular unit. Duplex scanning and angiography were performed prospectively on 50 patients who were symptomatic (100 carotid bifurcation) to identify the most accurate and sensitive duplex scan criteria to identify an 80% to 99% stenosis according to the European Carotid Symptomatic Trial. With data from the European Carotid Symptomatic Trial, we estimated the effect of three different approaches used to select patients for carotid endarterectomy. The first approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with the most accurate duplex scan criteria (approach I). The second approach was the selection of patients for carotid surgery on the basis of duplex scanning alone with a 100% sensitive duplex scan criteria (approach II). The third approach was the selection of patients for angiography with duplex scanning (100% sensitive criteria) and then the use of angiography to define which patients should undergo surgery (approach III)., Results: All three approaches appeared to have a similar potential in stroke reduction. However, approach I, which minimized the number of patients who underwent surgery (19% less than approach II) or invasive imaging (65% less than approach III), appeared to be the most appropriate., Conclusion: These data support the selection of patients for carotid endarterectomy on the basis of duplex scanning alone. The duplex scan criteria should be validated against angiography.

Purpose: This study was performed to determine whether early duplex findings predicted restenosis after carotid endarterectomy., Methods: One hundred ninety-two symptomatic patients who underwent carotid endarterectomy were studied with color duplex imaging at 1 day and 1 week after surgery to identify minor residual disease (causing < 50% stenosis), arterial kinking, and suture stricture, and to measure the external and luminal diameters of the carotid bulb and distal internal carotid artery. Patients were then observed prospectively with duplex surveillance for a median of 24 months to identify > 50% restenosis., Results: Twenty-five stenoses > 50% of the operated carotid artery (13%) were identified, four at 1 day (residual) and 21 at a median follow-up of 6 months (restenosis). On multiple logistic regression analysis, > 50% restenosis was found to be associated with minor day-1 residual stenosis (p = 0.01) and with small luminal diameter of the distal internal carotid artery (p = 0.03) as measured 1 week after carotid endarterectomy. Life table analysis showed restenosis at 24 months to be more common for patients with below-median than patients with above-median carotid bulb external diameter (18% vs 5%, respectively; p = 0.01)., Conclusions: Duplex scanning within a week of carotid endarterectomy identifies > 50% residual stenosis, in addition to minor residual 25% to 50% stenosis and small carotid dimensions, which are good predictors of > 50% restenosis at 6 months.

Purpose: The value of duplex surveillance and the significance of contralateral carotid disease after endarterectomy have been assessed., Methods: Three hundred five patients were observed prospectively after carotid endarterectomy for a median time of 36 months (range, 6 to 96 months), with duplex surveillance performed at 1 day; 1 week; 3, 6, 9, and 12 months; and then each year after endarterectomy., Results: Thirty patients (10%) had ipsilateral symptoms (13 strokes, 17 transient ischemic attacks [TIAs]) at a median time of 6 months (range, 0 to 60 months). Life table analysis demonstrated that ipsilateral stroke was equally common for patients who had > or = 50% restenosis (3% at 36 months) and those who did not (6% at 36 months, p > 0.5). Twenty-three patients (8%) developed symptoms (stroke 5, TIA 14) attributable to the contralateral carotid artery at a median time of 9 months (range, 0 to 36 months) after endarterectomy. By life table analysis, 40% of patients with 70% to 99%, 6% with 50% to 69%, 1% with < 50% contralateral internal carotid stenosis, and 5% with contralateral carotid occlusion at the time of endarterectomy had a contralateral TIA in the 36 months after endarterectomy (p < 0.01). However, contralateral stroke was not significantly more common for patients with severe contralateral internal carotid stenosis demonstrated at the time of endarterectomy (< 50% stenosis, 0%; 50% to 69%, 3%; 70% to 99%, 7%; occlusion, 6% stroke rate at 36 months). Seven of the 32 patients who developed progression of contralateral disease had a TIA, compared with 11 of 227 patients who did not develop progression of contralateral disease (p < 0.01). None of the 12 patients who progressed from a < 70% to a 70% to 99% contralateral stenosis had a stroke., Conclusions: After carotid endarterectomy restenosis is rarely associated with symptoms; contralateral stroke is rare and is not associated with progressive internal carotid artery disease suitable for endarterectomy. This study has shown no benefit from long-term duplex surveillance after carotid endarterectomy. Selective clinical follow-up of patients who have high-grade contralateral stenoses would appear more appropriate.

Purpose: Variability in outcome after carotid endarterectomy is well recognized. This study examines the importance of patient-related factors in determining outcome., Methods: Four hundred and sixty consecutive patients undergoing carotid endarterectomy for symptomatic severe (60% to 99%) internal carotid stenosis performed by one vascular surgeon have been studied prospectively. Patients were followed-up at 3, 6, 9, and 12 months and then yearly. Pre-, intra-, and perioperative details and follow-up information were entered on a database., Results: Multiple logistic regression identified a number of factors significantly associated with death and stroke. A history of crescendo transient ischemic attacks (TIAs) (p = 0.003, p = 0.0002) and being female (p = 0.03, p = 0.0001) were associated with both perioperative death and stroke within 30 days of operation, respectively. Deaths between 1 and 36 months were associated with ischemic heart disease (p = 0.03) and diabetes (p = 0.04), whereas stroke was associated with small internal carotid diameter (p = 0.02). The importance of symptoms at presentation on outcome was further emphasized by life-table analysis. In 98% of patients with amaurosis fugax, only 67% of those with crescendo TIAs were alive at 18 months (p < 0.01). The survival of patients with amaurosis was significantly better than those with TIAs (p < 0.01), transient stroke (p < 0.01), and progressive, stroke (p < 0.05). Similarly, postoperative stroke was significantly more common for patients with crescendo TIAs than those with amaurosis (p < 0.01), established stroke (p < 0.05), and TIA (p < 0.05). Transient stroke was associated with a poor outcome, with only 66% of patients being alive in 36 months and 14% having suffered a stroke (p < 0.05 compared with established stroke)., Conclusion: Presenting symptoms significantly predict outcome after carotid endarterectomy. This should be considered both in patient selection and comparison of patient series.