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Background: A systematic review and network meta-analysis was undertaken to consider the evidence for the efficacy and tolerability of placebo, cilostazol, naftidrofuryl oxalate and pentoxifylline in patients with intermittent claudication due to peripheral arterial disease (PAD). Methods: MEDLINE, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Conference Proceedings, BIOSIS, National Research Register and MetaRegister databases were searched. Eligible studies were randomized controlled trials (RCTs) and published systematic reviews of patients with intermittent claudication due to PAD and whose symptoms persisted despite a period of conservative management. Study selection was conducted by one reviewer with involvement from a clinician. Data were extracted by one reviewer with no blinding to authors or journal, and checked by a second reviewer. Outcome measures were maximum walking distance (MWD) and pain-free walking distance (PFWD). Results: The review identified 1876 citations; 26 RCTs met the inclusion criteria for the systematic review. Eleven trials provided data relevant for the meta-analysis. Naftidrofuryl oxalate was ranked first for both MWD and PFWD (probability of 0·947 and 0·987, respectively, of being the best treatment) followed by cilostazol and pentoxifylline. For naftidrofuryl oxalate, cilostazol and pentoxifylline, MWD increased by 60 (95 per cent credible interval 20 to 114) per cent, 25 (11 to 40) per cent and 11 (−1 to 24) per cent respectively relative to placebo, and PFWD increased by 49, 13 and 9 per cent. Conclusion: Naftidrofuryl oxalate and cilostazol are both effective treatments for claudication; naftidrofuryl oxalate is likely to be the most effective, with minimal serious adverse events. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: The aim was to establish national data for lower-limb revascularization and major amputation procedures performed in England. Methods: Data for lower-limb revascularization procedures and major amputations were collected from the Hospital Episode Statistics (finished consultant episodes) which is published yearly by the Department of Health. Transluminal procedures were analysed from 1998 onwards. Age adjustment was performed according to figures for the resident population of England in the interval studied. Results: In all age groups, revascularization rates initially increased to a peak in the mid-1990s. This was followed by a steady decline in procedures to the present day. However, amputations gradually increased in the 45-64-years age group and showed only a slight decline in the 65-74-years age group. Among patients aged over 75 years there was a marked decline from the mid-1990s to present-day. Data for diabetics showed similar trends. Conclusion: The national rate of amputation initially rose despite an increasing number of vascular interventions. It is significant, however, that among patients aged over 75 years this has been followed by a decrease in both revascularization procedures and amputation rates to present levels, the lowest for 14 years. [ABSTRACT FROM AUTHOR]

Background: Surgical-site infections (SSIs) are common after major abdominal and groin bypass surgery. Tissue oxygen tension has been shown to predict these infections accurately. This study assessed whether a non-invasive measurement of tissue oxygenation, tissue oxygen saturation as measured by spectrophotometry, was as accurate. Methods: Fifty-nine patients having major abdominal or groin bypass surgery had tissue oxygen saturation measured by near-infrared spectrophotometry at the incision site and in the arm before operation, and at 12, 24 and 48 h after surgery. Masked outcome assessments for SSI were made at 7 and 30 days after operation. Results: In this retrospective analysis, 17 patients (29 per cent) developed an SSI. At 12 h after operation there was a significant difference in tissue oxygen saturation at the surgical site between patients who developed an SSI and those who did not (mean(s.d.) 43·4(18·1) versus 55·8(22·0) per cent; P = 0·032). These oxygen saturation readings were found to be more specific and sensitive in predicting SSIs than the National Nosocomial Infection Surveillance system. Discussion: There is a difference in postoperative surgical-site oxygen saturation between patients who subsequently develop SSIs and those who do not. Prediction of SSIs provides opportunities for intervention and prevention. Copyright © 2006 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Antiplatelet agents may prevent vascular events and death in patients with peripheral vascular disease (PVD). Methods: A systematic review of 39 randomized controlled trials of antiplatelet therapy in patients with PVD was performed. Results: For patients with PVD the number suffering a non-fatal myocardial infarction, non-fatal stroke or vascular death in the antiplatelet group was 6·5 per cent compared with 8·1 per cent in the placebo group (odds ratio 0·78 (95 per cent confidence interval (c.i.) 0·63–0·96); P = 0·02), favouring antiplatelet treatment. For infrainguinal bypass surgery (ten trials) and balloon angioplasty (two) the differences were still in favour of antiplatelet therapy, but they did not reach statistical significance. In five trials of aspirin against another antiplatelet agent, 8·4 per cent in the aspirin group suffered a vascular event compared with 6·6 per cent in the second antiplatelet group (odds ratio 0·76 (95 per cent c.i. 0·64–0·91); P < 0·01), favouring ticlopidine/clopidogrel/aspirin + dipyridamole against aspirin alone. Conclusion: Antiplatelet therapy reduces serious vascular events and vascular death in patients with PVD. For infrainguinal arterial surgery or balloon angioplasty the benefit remains unproven, but the number of trials to date is small. There is also evidence to support the use of antiplatelet drugs other than aspirin for the prevention of vascular events in those with PVD. [ABSTRACT FROM AUTHOR]

Discusses the abstract of a study examining the effects of immunomodulatory agents on the proliferation of rat aortic vascular smooth muscle cells (vSMC). Comparison of vSMC proliferation in control versus study group; Proliferation rate.

Focuses on the natural history of atherosclerotic renal artery stenosis (ARAS). Effect of ARAS on renal function and control of blood pressure; Impact of the revascularization of patients on mortality rate due to the disease; Measurement of serum creatinine, kidney length and diastolic blood pressure.

Summary Background: Warfarin induced skin necrosis is a rare complication with a prevalence of 0·01–0·1 per cent. It was first described in 1943. Methods: A literature review was undertaken using Medline; all relevant papers on this rare compli-cation of warfarin therapy were used. Results: There are several adverse skin manifestations associated with the use of oral anticoagulants, ranging from ecchymoses and purpura, haemorrhagic necrosis, maculopapular vesicular urticarial eruptions to purple toes. This article concentrates mainly on warfarin induced skin necrosis. The syndrome typically occurs during the first few days of warfarin therapy, often in association with the administration of a large initial loading dose of the drug. Although the precise nature of the disease is still unknown, advances in knowledge about protein C, protein S and antithrombin III anticoagulant pathways have led to a better understanding of the mechanisms involved in pathogenesis. Differential diagnosis between warfarin induced skin necrosis and necrotizing fasciitis, venous gangrene and other causes of skin necrosis may be difficult; the disease may also be confused with other dermatological entities. Conclusion: Warfarin induced skin necrosis, while rare, is an important complication. All surgeons should be aware of its existence. [ABSTRACT FROM AUTHOR]

During a 6 year period 60 patients with atherosclerotic renovascular disease were followed by a single renal unit. Angiotensin converting enzyme inhibitors were being taken by 22% of patients at the time of diagnosis of the atherosclerotic renovascular disease. Intervention to revascularize renal tissue by surgery or angioplasty was performed in 32 patients. Revascularization was not undertaken because of unilateral disease, patient preference, poor operative risk or renal size. The mean age for the nonintervention group was 66.9 years and 63.4 years for the intervention group. Peripheral vascular, disease was common in both groups (96% nonintervention group versus 86% intervention group). There was a statistically significant difference in improvement in renal function in the intervention group (34.4% versus 10.7%) in spite of more patients being dialysis dependent in the intervention group (28.1% versus 14.3%). There was no statistically significant difference in survival between the two groups although the trend was for better survival in the group with intervention. Patients presenting with impaired renal function and atherosclerotic renovascular disease can have useful improvement in renal function with revascularization without any detriment to survival. [ABSTRACT FROM PUBLISHER]

Aims: It has been suggested that the presence of Chlamydia pneumoniae in atherosderotic tissue may be related to plaque instability and the triggering of clinical events. The aim of this study was to identify any association between the presence of C. pneumoniae in carotid plaques and 1) ipsilateral symptomatology; 2) degree of stenosis; and 3) necrotic core volume. Methods: Seventy-three carotid plaques causing 70–99% stenosis by duplex were removed en-bloc during carotid endarterectomy. Of those, 45 were related to symptoms (11 to amaurosis fugax-AF, 20 to transient ischaemic attacks-TIAs and 14 to stroke) and 28 were asymptomatic. Nested polymerase chain reaction (PCR) was used to detect the presence of chlamydial DNA and computerised planimetry to quantify the necrotic core volume. The latter was expressed as a percentage of plaque volume. Results: PCR revealed the presence of chlamydial DNA in 26/73 (35%) carotid plaques. The prevalence in symptomatic plaques was 14/26 (54%) and in asymptomatic ones was 12/28 (46% (χ[sup 2] = 1.5, d.f. = 1, P = 0.2). Within the symptomatic group there was a higher prevalence of chlamydial DNA 1) in plaques associated with stroke (8/14, 57%) and TIAs (5/20, 36%) than in those associated with AF (1/11, 7%) (χ[sup 2] = 7.3, d.f. = 2, P = 0.03) and 2) in those causing higher degrees of stenosis (90% versus 85%, P = 0.05)*. Within the asymptomatic group there was a higher prevalence in plaques having a larger necrotic core (21% versus 12%, P = 0.05), Student’s t-test. Conclusions: Our study shows that 35% of carotid plaques contained C. pneumoniae. Although there was no significant difference in the presence of chlamydial DNA between symptomatic and asymptomatic plaques, within the symptomatic group the presence of C. pneumoniae was significantly higher in severely stenotic plaques and in those associated with cerebral ischaemia (TIAs and stroke) and notably reduced in those associated with retinal ... [ABSTRACT FROM AUTHOR]

Extended treatment [ABSTRACT FROM AUTHOR]

An abstract of the article "Anatomic Factors in Patient Selection for Carotid Artery Stenting (CAS): A New Scoring System," by R. Williams et al is presented.

Examines the therapeutic use of aspirin. Variability in antiplatelet effects of aspirin; Resistance of certain individuals to aspirin; Pharmacokinetics and pharmacodynamics of the medicine.

A response from the authors of the article "Systematic review and economic evaluation of cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease" in a 2011 issue is presented.

Aims: Patients with peripheral bypass grafts have highly active platelets and are routinely given aspirin to reduce the risk of thrombotic vascular occlusion. This trial was conducted to determine if the addition of clopidogrel to aspirin enhances antiplatelet therapy in such patients. Methods: A randomized placebo controlled study was performed on 20 patients with functioning infrainguinal bypass grafts. In addition to their regular aspirin therapy, patients were randomized to receive either clopidogrel (Group 1) or placebo (Group 2) for one week. Platelet activation was measured ex vivo by platelet aggregometry and flow cytometry. Results: In Group 1 there was a significant reduction in spontaneous (SPA), adenosine diphosphate (ADP) and arachidonic acid (AA) induced platelet aggregation following treatment; SPA 3 min -21·0% (P = 0·001), ADP 3 min -4·7% (P = 0·007), and with AA 6 min by -27·4% (P < 0·001). No significant change in platelet aggregation was observed in Group 2 during the study. With flow cytometry a statistically significant reduction was observed in Group 1 in both activation dependent pselectin expression (P = 0·017) and GPIIb/IIIa activation (P = 0·031). No significant change was observed in the flow cytometry measures in Group 2 during the study. Conclusions: This study has demonstrated that the addition of clopidogrel to aspirin reduces platelet activation and aggregation, supporting a longer-term trial with clinical endpoints. [ABSTRACT FROM AUTHOR]

Aim: Homocysteine (HCY) is an independent risk factor for occlusive vascular disease, the relationship of hyperhomocysteinaemia with aneurysms has not been established. The aim of this study was to assess the incidence of elevated HCY in patients with aortic aneurysms compared to controls, and patients with occlusive arterial disease. Methods: We measured HCY levels in 200 patients, 43 age- and sex-matched patients without vascular disease, 97 with aortic aneurysms (64 thoracoabdominal and 33 infrarenal) investigated for surgical intervention, and 60 patients with limb ischaemia (35 claudicants and 25 with critical limb ischaemia). Fasting blood samples were taken; serum separated and stored at -70 °C, HCY levels were measured using fluorescence polarization immunoassay (Abbott IMx® assay). Results are presented as mean ± SEM with 95 per cent confidence intervals, and the Mann–Whitney U -test was used for statistical analysis. Results: Nine per cent of controls were hyperhomocysteineaemic (>15 µm L-1 ); the mean HCY level was 9.35 ± 0.64 (95 per cent CI: 8.06–10.65) µm L-1 . Thirty-two per cent of the patients with aneurysms had elevated homocysteine, 13.20 ± 0.62 (95 per cent CI: 11.97–14.43) µm L-1 , and 26 per cent of patients with limb ischaemia were hyperhomocysteinaemic 13.24 ± 0.68 (95 per cent CI: 11.88–14.61) µm L-1 . HCY levels in both aneurysmal and occlusive disease were significantly higher than controls (P < 0.0001), and there was no difference between the occlusive and aneurysmal group. Conclusion: Homocysteine is prevalent in both aneurysmal and occlusive vascular disease. The treatment of hyperhomocysteinaemia is cheap, simple and inexpensive, and may represent a mechanism to modify the disease process. [ABSTRACT FROM AUTHOR]

SummaryBackground: There is considerable debate over the management of infected infrainguinal grafts. This report describes recent experience in this field and documents the change in clinical practice needed to deal with methicillin-resistant Staphylococcus aureus (MRSA). Methods: All infected infrainguinal grafts between January 1991 and July 1997 were reviewed. In the light of the findings, clinical practice was modified considerably. A further 1 year was audited prospectively up to August 1998. Results: Twenty-six patients were treated for 27 infrainguinal graft infections (25 prosthetic, two vein). Twenty were treated by complete graft excision as the initial therapy; graft preservation was attempted in six patients. Before 1995, the infecting organisms were predominantly Pseudomonas aeruginosa or methicillin-sensitive staphylococci. Subsequently all 14 patients treated up to 1997 had infection with MRSA. The overall amputation rate was 17 of 26; ten amputations were in patients with MRSA. Four patients died, all with MRSA sepsis. As a result of this experience a policy of complete isolation was adopted for all patients infected with MRSA. In the 12 months since this policy was introduced, 77 infrainguinal grafts (61 vein, 16 prosthetic) have been inserted. Two grafts (3 per cent) have become infected, necessitating graft excision and amputation. Conclusion: MRSA infection of an infrainguinal graft is a serious complication with high associated amputation and mortality rates. Isolation and barrier nursing appeared to contain the problem. Presented in part to the annual meeting of the Vascular Surgical Society of Great Britain and Ireland, London, UK, November 1997 and published in abstract form as Br J Surg 1998; 85: 564. [ABSTRACT FROM AUTHOR]