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Background: The short form 36 (SF36) questionnaire is used for assessment of generic quality of life. Responses to the individual question in SF36 are also used for calculation of the SF6D index score. This score is used for calculation of quality adjusted-life years (QALYs) in economical analyses. As the individual patient questionnaires are not always available for performing systematic reviews and meta-analyses, a new formula has been developed for derivation of SF6D index score from the reported SF36-domain scores. This study aimed to evaluate the validity of this formula for use in patients with intermittent claudication., Methods: A retrospective review of a prospectively collected database of a randomized controlled trial was performed. A total of 178 patients were recruited. Clinical indicators of ischemia were recorded. All patients completed SF36 questionnaires. Response and domain-based SF6D scores (R-SF6D and D-SF6D) and QALYs were calculated. Correlation and agreement analysis were performed., Results: Response rate was 88% (n = 781) over a 1-year follow-up period. Domain-based SF6D score (mean, 0.684; standard deviation [SD] 0.110) was significantly higher (paired t-test, P = 0.001) than the response-based score (mean, 0.627; SD, 0.110) with a mean difference of 0.056 (95% confidence interval, 0.053-0.060). Mean QALY calculated using D-SF6D score (0.503; SD, 0.116) was also significantly higher than the QALY calculated from the R-SF6D score (0.467; SD, 0.121). Bland-Altman comparison showed strong agreement (limit of agreement -0.167 to 0.054) between the 2 methods with equal variances (Pitman's test, P = 0.629). D-SF6D scores showed stronger correlation with clinical indicators of ischemia (r = 0.246-0.602) compared with that of R-SF6D scores (r = 0.233-0.549)., Conclusions: Domain-based estimation of SF6D score is a valid and reliable method with strong agreement to the gold standard response-based scores in claudicants. However, adjustments may be required in studies using a mixture of D-SF6D and R-SF6D scores for QALY calculation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Aerobic fitness is an important predictor of postoperative outcome in major surgery. In this study, we assess the effects of a period of preoperative exercise on aerobic fitness as measured by cardiopulmonary exercise testing (CPET) in patients scheduled for abdominal aortic aneurysm (AAA) repair., Methods: As part of a randomized trial, the first patients recruited in the intervention group were enrolled in a supervised exercise program of six week duration. Treadmill CPET parameters were measured before and after exercise preoperatively for these patients. These parameters were as follows: peak oxygen uptake (VO2 peak), anaerobic threshold (AT), and ventilator equivalents for oxygen and carbon dioxide (VE/VO2 and VE/VCO2, respectively). Total exercise time and the time at which AT was achieved were also recorded. A comparison between pre- and postexercise parameters was made to detect for a possible improvement in aerobic fitness., Results: Twenty patients with AAA (17 men; mean age: 74.9 ± 5.9 years) were included in this study. Thirty-five percent of patients had a history of ischemic heart disease, 25% of obstructive airway disease, and 15% of cerebral vascular events. Seventy percent were previous smokers, and 15% were current smokers. Fifty-five percent of patients were taking aspirin and 75% were undergoing statin therapy. The median (interquartile range) VO2 peak at baseline was 18.2 (15.4-19.9) mL/kg/min, and after exercise was 19.9 (17.1-21.1; P = 0.048). Median AT at baseline was 12.2 (10.5-14.9), and 14.4 (12.3-15.4) after exercise (P = 0.023). Time of exercise tolerated also improved from a median of 379 to 604 sec (P = 0.001). No significant changes were seen in VE/VO2, VE/VCO2, or the time at which AT was achieved., Conclusion: This study shows that cardiopulmonary aerobic fitness improves after a period of supervised exercise in patients scheduled for AAA repair. This is justification for a randomized trial to assess whether this affects morbidity and mortality after AAA repair., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The influence of intraluminal thrombus (ILT) on the proteolytic environment within the wall of an abdominal aortic aneurysm (AAA) is unknown. This is the first study to examine the correlation between ILT thickness and the levels of matrix metalloproteinases (MMPs) and their natural inhibitors (tissue inhibitors of matrix metalloproteinases [TIMPs]) within the adjacent AAA wall., Methods: Thirty-five patients undergoing elective repair of AAAs were studied. A single full-thickness infrarenal aortic sample was obtained uniformly from the arteriotomy site from each patient. All samples were snap frozen and analyzed for total and active MMP 2, 8, and 9 and TIMP 1 and 2. Thrombus thickness at the specimen site was measured on the preoperative contrast computed tomographic angiograms., Results: There was a statistically significant correlation between ILT thickness, concentration of TIMP 1, and active concentration of MMP 9. MMP 2 (active and total) and TIMP 2 demonstrated a positive correlation with ILT thickness, although not statistically significant., Conclusion: In this novel study, we found a significant positive correlation of ILT thickness with active MMP 9 and TIMP 1 concentration in the adjacent AAA wall, and this may have implications for AAA expansion and eventual rupture., (Copyright © 2012 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: To evaluate patients' awareness, functional outcome, and satisfaction after abdominal aortic aneurysm (AAA) repair., Methods: A study-specific questionnaire was developed with collaboration of a multidisciplinary team. Lists of patients who underwent elective open AAA repair and endovascular aneurysm repair (EVAR) between January 2006 and December 2008 were obtained from the departmental database and cross-checked against hospital database for survival status. Emergency AAA repairs were excluded. Study questionnaires were posted to 138 patients (113 open, 25 EVAR) with self-addressed stamped return envelopes. Statistical analysis was performed using SPSS v16.0., Results: Response rate was 89% (n = 123; 102 open, 21 EVAR). Seventy-one percent (n = 88) were unaware of this condition before diagnosis. Ninety-seven percent (n = 120) indicated their understanding of the need for surgery. Ninety-two percent (n = 113) stated that the operation was adequately explained to them. Ninety percent (n = 111) reported full recovery after surgery, with 60% (n = 74) recovering within 6 months. Eighty-seven percent (n = 108) were satisfied with the overall experience, and 85% (n = 105) stated that they would recommend the operation to family and/or friends if required., Conclusions: There is a lack of awareness regarding AAA in elderly population. However, after being diagnosed, patients understand the implications and are satisfied with the overall results and would recommend AAA repair to family and/or friends if required., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: A double-blind, randomized controlled trial was carried out to study the effects of statins on matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in areas of peak and low abdominal aortic aneurysm (AAA) wall stress., Methods: A total of 40 patients undergoing elective open AAA repair were randomized to receive either atorvastatin 80 mg (n = 20) or placebo (n = 20) for 4 weeks preoperatively. Finite element analysis was used to determine AAA wall stress distribution. Full thickness aortic samples were obtained at surgery from areas of low and peak wall stress, snap-frozen, and stored at -80°C for subsequent MMP-2, -8, and -9 and TIMP-1 and -2 analyses. Statistical analysis was performed using SPSS 16.0 (SPSS Inc, Chicago, IL)., Results: Both groups were well matched (p > 0.05) regarding age, gender, comorbidities, and duration of hospital stay. There were no statistically significant differences in levels of MMPs and TIMPs between the statin and placebo group and between areas of low and peak AAA wall stress., Conclusion: The short-term use of statins is not associated in reducing levels of MMP 2, 8, and 9 and TIMP-1 and -2 in areas of low and peak wall stress in patients with AAA., (Copyright © 2011. Published by Elsevier Inc.)

Objectives: To establish the relationship between quality of life (QOL) index scores and clinical indicators of lower limb ischemia., Methods: One hundred seventy-eight patients (108 men, median age 70 years) with femoropopliteal lesions suitable for angioplasty were recruited. Assessments were performed prior to and at 1, 3, 6, and 12 months following intervention (angioplasty and/or supervised exercise program). Clinical indicators of lower limb ischemia (treadmill walking distances, ankle pressures), generic (SF36, EuroQol), and disease-specific (Kings College VascuQol) quality of life questionnaires were analyzed. Correlation analysis was performed for index scores (SF-6D, EQ-5D, VascuQol) and individual domain scores using nonparametric tests., Results: All clinical indicators of lower limb ischemia and quality of life index scores showed a statistically significant improvement as result of intervention (Friedman test, P < .001). Both generic QOL index scores (SF-6D, EQ-5D) showed moderate but statistically significant correlation (Spearman's rank correlation, P < .001) with treadmill walking distances (SF-6D r = 0.533, EQ-5D r = 0.500) and weak but significant correlation to resting and postexercise ankle-brachial pressure index (SF-6D r = 0.253, EuroQol r = 0.214). Disease-specific index scores (VascuQol) showed similar moderate correlation to treadmill walking distances (r = 0.584, P < .001) and weak but statistically significant correlation with resting and postexercise ABPI (r = 0.377, P < .001). All index scores showed strong and statistically significant (P< .001) correlation with patient-reported walking distance (SF-6D r = 0.604, EQ-5D r = 0.511, VascuQol r = 0.769). All domains of SF36 showed similar correlation with clinical indicators except general health. The strongest correlation was seen with treadmill walking distances in the domains of physical function (r = 0.538) and bodily pain (r = 0.524)., Conclusion: All generic and disease-specific QOL scores show statistically significant improvement with angioplasty and/or supervised exercise in patients with claudication due to femoropopliteal atherosclerosis. However, the degree of improvement seen in clinical indicators of lower limb ischemia is not reflected in these scores. These findings support the use of composite outcome measures with mandatory, independent assessment of QOL as an independent outcome measure in intervention studies in these patients., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: To compare angioplasty (PTA), supervised exercise (SEP) and PTA + SEP in the treatment of intermittent claudication (IC) due to femoropopliteal disease., Methods: Over a 6-year period, 178 patients (108 men; median age, 70 years) with femoropopliteal lesions suitable for angioplasty were randomized to PTA, SEP, or PTA + SEP. Patients were assessed prior to and at 1 and 3 months post treatment. ISCVS outcome criteria (ankle pressures, treadmill walking distances) and quality of life (QoL) questionnaires (SF-36 and VascuQoL) were analyzed., Results: All groups were well matched at baseline. Twenty-one patients withdrew. Results are as follows: Intragroup analysis: All groups demonstrated significant clinical and QoL improvements (Friedman test, p < 0.05). SEP (60 patients, 8 withdrew)-62.7% of patients (n = 32) improved following treatment [20 mild, 9 moderate, 3 marked], 27.4% (n = 14) demonstrated no improvement, and 9.8% (n = 5) deteriorated. PTA (60 patients, 3 withdrew)-66.6% patients (n = 38) improved following treatment [19 mild, 10 moderate, 9 marked], 22.8% (n = 13) demonstrated no improvement, and 10.5% (n = 6) deteriorated. PTA + SEP (58 patients, 10 withdrew)-81.6% of patients (n = 40) improved following treatment [10 mild, 17 moderate, 3 marked], 14.2% (n = 7) demonstrated no improvement, and 4.0% (n = 2) deteriorated. Intergroup analysis: PTA + SEP produce a much greater improvement in clinical outcome measures than PTA or SEP alone, but there was no significant QoL advantage (Kruskal-Wallis test, p > 0.05)., Conclusion: SEP should be the primary treatment for the patients with claudication and PTA should be supplemented by an SEP., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Abdominal aortic aneurysm (AAA) rupture occurs when wall stress exceeds wall strength. Engineering principles suggest that aneurysm diameter is only one aspect of its geometry that influences wall stress. Finite element analysis considers the complete geometry and determines wall stresses throughout the structure. This article investigates the interoperator and intraoperator reliability of finite element analysis in the calculation of peak wall stress (PWS) in AAA and examines the variation in PWS in elective and acute AAAs., Method: Full ethics and institutional approval was obtained. The study recruited 70 patients (30 acute, 40 elective) with an infrarenal AAA. Computed tomography (CT) images were obtained of the AAA from the renal vessels to the aortic bifurcation. Manual edge extraction, three-dimensional reconstruction, and blinded finite element analysis were performed to ascertain location and value of PWS. Ten CT data sets were analyzed by four different operators to ascertain interoperator reliability and by one operator twice to ascertain intraoperator reliability. An intraclass correlation coefficient was obtained. The Mann-Whitney U test and independent samples t test compared groups for statistical significance., Results: The intraclass correlation coefficient was 0.71 for interoperator reliability and 0.84 for intraoperator reliability. There was no statistically significant difference in the mean (SD) maximal AAA diameter between elective (6.47 [1.30] cm) and acute (7.08 [1.39] cm) patients (P = .073). The difference in PWS between elective (0.67 [0.30] MPa) and acute (1.11 [0.51] MPa) patients (P = .008) was statistically significant, however., Conclusion: Interoperator and intraoperator reliability in the derivation of PWS is acceptable. PWS, but not maximal diameter, was significantly higher in acute AAAs than in elective AAAs.

In this study we examined the ability of tissue factor (TF) alone, or in conjunction with factor VIIa, factor Xa and TFPI in activating a number of key signalling pathways associated with cellular growth, stress and differentiation responses in human endothelial cells. We used luciferase reporter systems to demonstrate the activation of p42/44 MAPK by the TF-FVIIa complex, mediated via the PAR1 receptor. TF alone was capable of interacting with the cell surface and was sufficient to activate the JNK-SAPK pathway and subsequently AP-1, but the level of activation was enhanced by the activity of FXa on PAR1 and 2. Furthermore, the phosphorylated form of the transmembrane-cytoplasmic domain of TF was directly responsible for activation of these pathways. CREB activation occurred in response to TF-FVIIa in a non-protease dependent manner but was lowered on addition of FXa. Finally, NFkappaB activation occurred in response to FVIIa or FXa, with the latter exhibiting higher levels of activation. In conclusion, we have shown that TF is capable of activating differing signalling pathways, via more than one mechanism. The differential influence of TF is modified depending on the presence of other coagulation factors and ultimately acts as a deciding factor in the determination of cellular fate.

Objectives: The main aims of treatment in patients with intermittent claudication (IC) are to improve the clinical indicators of lower limb ischaemia and patients' quality of life (QoL). The aims of this study were assess the clinical and cost effectiveness of a supervised exercise programme (SEP) in patients with IC., Design: Non-randomised, controlled trial., Setting: University teaching hospital., Patients and Methods: Two groups of patients with IC were studied. Seventy patients were sequentially recruited before and after the establishment of a Supervised Exercise Programme at our unit. Thirty-seven patients (median age 69 years, 26 men) received conservative medical therapy (CMT) and 33 patients (median age 67 years, 22 men) received CMT plus a 3 month SEP of graduated physical exercise for sixty minutes, three times each week. Patients were assessed prior to and at 6 months following treatment. At each assessment patient reported walking distances (PRWD), treadmill claudication and maximal distances (ICD and MWD), ankle brachial pressure indices (ABPI) pre & post exercise and patient reported QoL using the SF36 questionnaire were assessed., Results: Prior to intervention the two groups were well matched. Following treatment, CMT patients demonstrated no significant change in PRWD or ICD but did record a small but significant improvement in MWD. CMT was also associated with a negative effect size in the SF36 index and in 7 of the 8 SF36 QoL domains, effect size >-0.5 for the domains of Physical Function and Emotional Role. SEP patients demonstrated significant improvement in PRWD, ICD and MWD. SEP was associated with a positive effect size in the SF36 index and in 2 SF36 QoL domains but a negative effect size in a further 2 domains. However, all QoL effect sizes following SEP were < +/-0.5. Intergroup differences in effect sizes were >0.5 for the SF36 domains of Physical Function, Physical Role, Emotion Role and SF36 index. SEP resulted in a 0.027 quality adjusted life year (QALY) gain over CMT in the first year post-treatment thus the cost/QALY gained of SEP is pound1780 at 1 year., Conclusions: Compared to CMT, SEP increases walking distances, improves QoL and is a highly cost-effective treatment for IC.

Endovenous laser therapy (EVLT) is a minimally invasive treatment for varicose veins. This study compares early quality-of-life (QoL) outcomes following EVLT and surgery. Two nonrandomized groups were studied: an EVLT group with 70 patients, median age 49 (interquartile range [IQR] 35-58) years, and a surgery group with 62 patients, median age 49 (IQR 35-61) years. Patients were assessed prior to and at 1, 6, and 12 weeks following the procedure using the Short Form 36 (SF-36), the Aberdeen Varicose Veins Questionnaire (AVVQ), and the Venous Clinical Severity Score (VCSS). Follow-up at 1, 6, and 12 weeks was 100%, 77%, and 70% following EVLT and 100%, 85%, and 47% following surgery. SF-36 scores were significantly better in the EVLT group at 1 week (Physical Functioning, Role Physical, Bodily Pain, Vitality, and Social Functioning domains) and at 6 weeks (Physical Functioning and Role Physical). At 12 weeks, no significant differences were evident between the groups. AVVQ scores were significantly better in the EVLT group at 6 and 12 weeks. VCSS scores were significantly improved in both groups at 12 weeks. EVLT and surgery provide similar QoL improvements in patients with varicose veins. EVLT, however, removes the QoL limitations experienced by patients in the early postoperative period.

Introduction: There is growing evidence that heat shock proteins (HSPs), a family of stress-inducible proteins may be involved in the pathogenesis of atherosclerotic vascular diseases. Here, we systematically review the evidence behind this notion., Methods: A detailed literature search and extensive bibliographic review of literature relating to HSPs and atherosclerotic vascular disease., Results: Atherosclerotic vascular disease is classified into four main areas of presentation: carotid, coronary, aortic and peripheral vascular disease, for consideration in this review. In each of these vascular diseases, the evidence linking HSPs and atherosclerosis is outlined in a systematic manner. Current evidence suggests that components of the immune system may be involved in the pathogenesis of atherosclerosis, with HSPs acting as auto-antigens in the immune response. HSPs are detected in atherosclerotic lesions and antibodies to HSPs are increased in patients with vascular disease; the rise often correlating with the severity of atherosclerosis. The levels of anti-HSP antibodies have been shown to be independent predictors of risk and have prognostic value., Conclusion: There is a strong link between heat shock protein expression and the principal manifestations of atherosclerotic vascular diseases. A better understanding of this involvement could lead to the development of new and improved treatment strategies.

Background: The decision to repair an asymptomatic abdominal aortic aneurysm (AAA) is currently based on diameter (> or =5.5 cm) alone. However, aneurysms less than 5.5 cm do rupture while some reach greater than 5.5 cm without rupturing. Hence the need to predict the risk of rupture on an individual patient basis is important. This study aims to calculate and compare wall stress in ruptured and non-ruptured AAA., Methods: The 3D geometries of AAA were derived from CT scans of 27 patients (12 ruptured and 15 non-ruptured). AAA geometry, systolic blood pressure and literature derived material properties, were utilised to calculate wall stress for individual AAA using finite element analysis., Results: Peak wall stress was significantly higher in the ruptured AAA (mean 1.02 MPa) than the non-ruptured AAA (mean 0.62 MPa). In patients with an identifiable site of rupture on CT scan, the area of peak wall stress correlated with rupture site., Conclusions: Peak wall stress can be calculated from routinely performed CT scans and may be a better predictor of risk of rupture than AAA diameter on an individual patient basis.

Background: There is considerable variability in the reported value of clinical examination in the diagnosis of abdominal aortic aneurysms (AAA). This study aims to assess accuracy of abdominal examination by a doctor, a nurse and the patient in the diagnosis of AAA and whether this accuracy is related to the size of the aneurysm and/or the BMI of the patient., Methods: 164 patients, 138 men and 26 women, median age 71 years, consented to participate in this prospective, single blind, controlled study. Thirty-nine patients attending for carotid duplex were used as controls. Abdominal examination was performed by a doctor and a nurse. Patients then performed self-examination., Results: Examination by a doctor, a nurse and the patient were similar in accuracy in diagnosing/excluding AAA which was directly related to AAA size and patient BMI. The Negative Predicted Value of abdominal examination exceeds 0.9 with AAA diameters > or =4 cm and the Positive Predictive Value exceeds 0.8 with AAA diameters > or =5 cm., Conclusions: Abdominal examination by a doctor, a nurse and the patient is of value in the exclusion and diagnosis of significant AAA. It should be promoted and may represent a useful adjunct to population screening with ultrasound.

Objective: ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications. The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers., Method: eighteen diabetic patients with ischaemic, non-healing lower-extremity ulcers were recruited in a double-blind study. Patients were randomly assigned either to receive 100% oxygen (treatment group) or air (control group), at 2.4 atmospheres of absolute pressure for 90 min daily (total of 30 treatments)., Results: healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group. The median decrease of the wound areas in the treatment group was 100% and in the control group was 52% (p=0.027). Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen, there was a potential saving in the total cost of treatment for each patient during the study., Conclusion: hyperbaric oxygen enhanced the healing of ischaemic, non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible.

Objectives: the aim of this study was to illustrate how a Bayesian hierarchical modelling approach can aid the reliable comparison of outcome rates between surgeons., Design: retrospective analysis of prospective and retrospective data., Materials: binary outcome data (death/stroke within 30 days), together with information on 15 possible risk factors specific for CEA were available on 836 CEAs performed by four vascular surgeons from 1992-99. The median patient age was 68 (range 38-86) years and 60% were men., Methods: the model was developed using the WinBUGS software. After adjusting for patient-level risk factors, a cross-validatory approach was adopted to identify "divergent" performance. A ranking exercise was also carried out., Results: the overall observed 30-day stroke/death rate was 3.9% (33/836). The model found diabetes, stroke and heart disease to be significant risk factors. There was no significant difference between the predicted and observed outcome rates for any surgeon (Bayesian p -value>0.05). Each surgeon had a median rank of 3 with associated 95% CI 1.0-5.0, despite the variability of observed stroke/death rate from 2.9-4.4%. After risk adjustment, there was very little residual between-surgeon variability in outcome rate., Conclusions: Bayesian hierarchical models can help to accurately quantify the uncertainty associated with surgeons' performance and rank.

Objectives: the aim was to test the predictive accuracy of POSSUM and P-POSSUM on patients undergoing CEA., Design: retrospective and prospective study., Materials: 499 CEAs performed by four vascular surgeons from a single unit from 1992-99. The median age was 68 (range 38-86) and 60% were men., Methods: physiological parameters, operative parameters and the 30-day mortality were collected. Predicted mortality for each patient was calculated using POSSUM and P-POSSUM equations. Patients were stratified into risk groups and observed and predicted deaths were compared. Accuracy of the prediction was assessed using chi-squared analysis., Results: the observed 30-day mortality was 1.8% (9/499). The predicted deaths using POSSUM and P-POSSUM analysis were 49 and 25 respectively compared to nine observed deaths. There was significant evidence of lack of fit of both models in predicting mortality (chi-squared analysis, p<0.05)., Conclusions: POSSUM and P-POSSUM overpredict mortality and are unsuitable for comparative audit of CEA. Models developed specific for CEA might accurately predict mortality., (Copyright 2002 Harcourt Publishers Limited.)

Objective: The objective of our study was to investigate whether such an incision results in a reduction in blood flow, and therefore haemoglobin oxygen saturation, across the wound., Design: Microvascular oxygenation was measured with lightguide spectrophotometry in 21 patients undergoing femoropopliteal or femorodistal bypass procedures. A series of measurements were made in the groin, medial and lateral to the surface marking of the femoral artery. The mean oxygen saturation on each side was calculated, and the contra-lateral groin was used as a control. The measurements were repeated at 2 and 7 days postop., Results: Oxygen saturation in the skin of the operated groins was increased significantly from baseline at 2 days postop (f = 25.80, p < 0.001) and had begun to return to normal by day 7. The rise was more marked on the lateral side of the wound than on the medial (f = 12.32, p < 0.001). There was no such difference in the control groins. All wounds healed at 10 days., Conclusions: These results show a significant difference in skin oxygenation between the lateral and medial sides of the groin following longitudinal incision. This may contribute to the relatively high incidence of postoperative infection in these wounds.

Objectives: To determine the patency and acceptability of the Memotherm endovascular stent in the treatment of iliac arterial occlusions., Materials and Methods: Twenty-two patients (12 males and 10 females) underwent stenting of iliac occlusions of the aortoiliac bifurcation, the common iliac artery and the external iliac artery. All patients were reassessed at 3, 6 and 12 month intervals and then yearly to evaluate their symptoms and Doppler pressure measurements. Comparison was made with results from other studies treating iliac occlusions by angioplasty alone or combined with stenting., Results: Out of 22 patients, 21 had an immediate and sustained improvement over the whole of the follow-up period. The Ankle-brachial Index (ABI) increased from a mean value of 0.49 to 0.81 3-months postprocedure and improved to 0.85 at 12 months (paired t-test p < 0.001). At 6 and 12 months the stent patency remained at 95.5%, which compares favourably with other studies. There were four minor and one major complication associated with the stenting procedure., Conclusions: The Memothern self-expanding stent is a useful, safe and effective device suitable for the majority of iliac occlusions. Further long-term evaluation is warranted to confirm its advantages over open surgery.

Objectives and Design: A prospective study of 709 patients undergoing carotid surgery in the U.K. and Ireland was performed to evaluate the performance of vascular surgeons., Materials and Methods: Fifty-nine surgeons (range 2-39 cases each) were sampled and all patients undergoing surgery over a 6-month period (1 March 1994-31 August 1994) were included in the study. Indications for surgery were TIA (35.9%), AF (23.3%), CVA (21.4%) and "others" (19.6%)., Results: Mean ipsilateral stenosis was 82% (30%-99%). Thirty-one percent of patients had preoperative neurological consults. Shunts were used in 67.6%, tacking sutures in 40.1%, drains in 71.9% and patches in 54.4% of cases. At 30 days there were nine (1.3%) deaths (four cardiac, three neurological). There were 15 ipsilateral postoperative CVAs (2.1%); 19% of patients had one or more complication, usually minor. Statistical analysis showed no independent risk factor for CVA other than seniority of the surgeon., Conclusions: A combined stroke/death rate of 3% for the series was obtained at 30 days for all cases. This large, validated study suggests that members of the Vascular Society of G.B. and Ireland currently have a very low morbidity/mortality rate for performing carotid surgery. Continued audit is required to ensure that this quality of service does not deteriorate.

Objective: To assess the long-term patency of a modified biological conduit, the glutaraldehyde-tanned bovine carotid artery, in above-knee infrainguinal arterial reconstruction., Patients and Methods: Prospective follow-up of a cohort of 58 above-knee femoropopliteal grafts in 55 patients. Graft patency was assessed at yearly intervals with doppler ankle pressure measurements., Results: The median follow-up period has been 67 months. Nine grafts occluded within 30 days of surgery and a further 19 graft closures have been observed in the follow-up period. The overall cumulative primary graft patency at 1, 3 and 5 years was 70%, 61% and 56%, respectively. If the 30-day graft failures are excluded, the primary graft patency rises to 83%, 74% and 68% at 1, 3 and 5 years, respectively. Six limbs have been amputated, four above the knee and two below the knee. There were no graft aneurysms and no graft infections., Conclusion: Results indicate that the modified bovine carotid artery graft with an above-knee anastomosis does not seem to be inferior to PTFE, but is inferior to reversed vein. Modified biological conduits offer a reasonable alternative to synthetic grafts for infrainguinal arterial reconstruction and appear to maintain acceptable long-term mechanical stability.

Purpose: To quantitate the workload, resource requirement and outcome involved in the management of patients with chronic limb-threatening ischaemia when adopting an aggressive reconstructive policy., Methods: Prospective clinical audit of all patients with severe lower limb ischaemia presenting to a single specialist Vascular Surgeon in a 3 year period., Results: A total of 228 patients were treated with 275 severely ischaemic limbs. Two hundred and thirty-five limbs (85.5%) had procedures to improve blood supply, 19 (6.9%) underwent primary amputation and 21 (7.7%) were treated conservatively. The principal outcome measures were limb-salvage, death and graft patency. The cumulative limb-salvage, including those undergoing primary amputation, at 30 days, 1, 2, 3 and 4 years was 94.2%, 82.7%, 73.1%, 68.3% and 65.3% respectively. The cumulative patient survival was 91.7%, 69.2%, 58.1%, 47.9% and 40.6% for the same intervals. For reconstructive vascular surgery, excluding amputation and rehabilitation, a total of 383 hospital admissions were required covering 7343 hospital days, 64.5% of patients were managed in a single admission. The median duration of stay was 16 days for the first admission. Operations included 361 separate procedures to improve blood supply and 70 major limb amputations., Conclusions: The management of chronic limb-threatening ischaemia presents major resource implications. An acceptable limb-salvage rate can be achieved although there is a high initial mortality. In view of the poor overall survival any benefits for these patients should be viewed as relatively short-term objectives.

Objectives: To study the relationship between carotid plaque morphology and the degree of stenosis on Duplex ultrasonography and symptoms., Design: Prospective open clinical study., Methods: 2,590 patients with 5,180 carotid arteries were scanned, 4,560 were initially analysed in terms of symptoms but 54 were excluded, leaving a total of 4,258., Results: Localising symptoms were present with respect to 1,342 vessels (29.4%). Two-thirds of symptomatic patients had normal carotid arteries. Tight stenosis (80-99%) was more likely to be associated with symptoms than low-grade (20-79%) stenosis (chi 2 = 28.0, p < 0.0001). Plaque type was identified in 1,558 bifurcations (36.6%). Heterogeneous type I & II plaques accounted for one third of plaques. There was a relationship between plaque morphology and degree of stenosis. At < 20% stenosis only 4.4% of plaques were heterogeneous whereas at 80-99% stenosis 84.5% of plaques were heterogeneous. Amaurosis fugax was the only symptom that had any association with a particular plaque morphology. Seventy-two percent of plaques associated with this symptom were heterogeneous in nature., Conclusions: Carotid plaque morphology and degree of internal carotid stenosis are mutually dependent factors and both reflect the severity of atherosclerotic disease. Plaque morphology does not add to the sensitivity of stenosis in predicting the presence of symptoms.

Digital systolic pressure measurements were made on 140 big toes using a photoplethysmographic technique before and after extrinsic heating of the foot. Most patients with apparent, critically ischemic feet demonstrated vasomotor activity, suggesting that much of the microcirculation of the foot was in fact intact. Significantly, nine of 21 feet which would have fallen into a critically ischemic category were recategorized after heating into a less severe group. These data confirm the value of toe pressure measurements in the assessment of severe ischemia but show that adequate foot vasodilation is essential to allow accurate conclusions to be drawn and to allow meaningful interpretation of results.

Percentage of carotid stenosis and plaque morphology as determined by duplex scanning were correlated with symptoms and CT evidence of infarction in 108 patients. Severity of carotid stenosis less than 49% or greater than 50% narrowing was not associated with an increased risk of ipsilateral symptoms or CT infarction. However, a heterogeneous plaque appearance, suggesting intraplaque hemorrhage, did correlate with ipsilateral cerebral symptoms. Heterogeneous plaque appearance may be a more reliable indication for carotid endarterectomy than a hemodynamically significant stenosis.

Segmental systolic pressures were measured in a group of patients with clinically irreversible ischemia. There was a good relationship between the level of pressure in a limb and the eventual outcome, but a particular level of pressure was found to be a poor indicator of a specific level of viability. These results support previous concern about the limitations of systolic pressure measurements in determining the level of limb viability. We suggest that local intrinsic regulation of the microcirculation plays a major role in the ultimate survival of tissues in an ischemic limb.

Twenty-one chemical sympathectomies were assessed in this study by taking infra-red thermograms of the feet before and after the procedure. Patients with relatively high perfusion pressures were shown to have the best response, while those with a low perfusion pressure had little or no increase in mean temperature in the foot.

Twenty patients with ischemic rest pain were treated with intravenous pentoxifylline, 1,200 mg daily, for up to three weeks. Ten patients obtained sufficient relief to avoid surgical intervention. Seven of these had complete or near complete relief of rest pain, but the other three required continuing analgesia. Transcutaneous oxygen measurements showed a significant increase after the course of treatment. There were marked gastrointestinal side effects in six patients, necessitating early withdrawal from the study. Three of these six patients had shown a favorable response to medication prior to withdrawal. These preliminary results suggest that pentoxifylline may provide a sufficient increase in tissue oxygen availability to avoid, or at least postpone, surgical intervention. A double blind controlled study is required to further assess the efficacy of this drug as an intravenous treatment.