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Objective the ability of colour duplex to accurately locate incompetent venous sites has been widely published; its value in pre-operative marking in simple primary varicose vein surgery is evaluated in this study. Design of study prospective randomised controlled trial. Setting regional vascular service, hospital patients. Subjects consecutive patients (149) undergoing primary varicose vein surgery where the only difference was one group of patients received duplex marking prior to surgery. Six weeks and 12 months post-operatively all patients had a colour duplex scan to determine the accuracy of surgery and the presence of residual/recurrent varicose veins and completed the Aberdeen, SF-36, and EuroQol quality of life questionnaires. Interventions varicose vein surgery. Main outcome measures Duplex evidence of venous incompetence, quality of life measures using the SF-36 and Aberdeen Varicose Veins Questionnaire. Results pre-operative marking of primary varicose veins by skilled duplex ultrasonography does not improve the accuracy or recurrence rate following surgery. Quality of life improved significantly following surgery in both groups, however there was no difference in this improvement between the groups. Conclusion the trial has not demonstrated any additional benefit of pre-operative colour duplex marking over that of clinical and hand held Doppler marking in terms of satisfactory varicose vein surgery performance at 6 weeks or 12 months in patients with primary varicose veins of the long saphenous system. It role in the short saphenous system is less clear. Copyright 2002 Harcourt Publishers Limited

Objectives to compare the outcome of exercise therapy or angioplasty for the treatment of patients with intermittent claudication. Design a summation analysis. Methods a search using MEDLINE and PUBMED between 1966 and April 1999 followed by a review of the manuscripts yielded 54 studies involving angioplasty and 27 studies involving exercise therapy for intermittent claudication. Studies were only included (12 angioplasty and nine exercise series) when results were available for patients with intermittent claudication alone, and when outcome was assessed in terms of symptoms at a minimum of 6 months. Results the total number of claudicants undergoing exercise therapy was 294 patients, with a mean symptomatic success rate of 38.4% and a mean improvement in maximum walking distance of 189.7% at 6 months. The total number of claudicants undergoing angioplasty was 2071, with a mean overall symptomatic success rate of 76.6%. The mean overall complication rate was 9% and mean major complication rate was 2.7% for the angioplasty studies. Conclusion although the result demonstrates an advantage of angioplasty over exercise therapy at 6 months, there is a small risk of major complications. However, comparison of studies was impaired due to disparity in patient numbers, limited follow-up time and lack of uniformity in outcome assessment. In order to achieve a valid comparison of these therapies in a future randomised study, a validated disease-specific instrument for the assessment of symptomatic outcome for claudicants is required. Copyright 2000 Harcourt Publishers Ltd

Introduction: inflammation and proteolysis are important processes in the development of abdominal aortic aneurysms (AAAs). Prostaglandin E2 (PGE2) (a product of cyclo-oxygenase 2), other inflammatory mediators and proteolytic enzymes are produced in high quantities in the aneurysm wall. We developed an explant culture system for AAA tissue to assess the effects of potential drug therapies. Methods: full thickness biopsies of human AAA were established in culture in the presence or absence of indomethacin (a cyclo-oxygenase-2 inhibitor). The conditioned medium was collected at 48 h intervals and analysed for products of collagen breakdown, matrix metalloproteinases, PGE2 and inflammatory cytokines. Explant viability was assessed by histology, glucose consumption, lactate dehydrogenase release and demonstration of protein synthesis in the tissue. Results: nuclear morphology was maintained for 4 or more days and this, together with biochemical assays, indicated that AAA explants were viable in short-term culture. Indomethacin (10 μM) markedly reduced AAA explant production of prostaglandin E2 from 320 ng/ml to 3.3 ng/ml (p=0.028, n=6). Indomethacin also reduced the release of interleukin-1β (IL-1β) (from 166 pg/ml to 9.8 pg/ml,p =0.04, n=5) and interleukin-6 (IL-6) (from 119 ng/ml to 57 ng/ml, p=0.028, n=6), but had no effect on monocyte chemotactic protein 1 or matrix metalloproteinase-9 secretion. Conclusions: short-term explants of AAA are a novel method to assess the effects of drugs on aneurysm tissue. Indomethacin reduces the production of PGE2, IL-1β and IL-6, suggesting that cyclo-oxygenase-2 inhibitors may control the inflammation in the aneurysm wall and potentially limit AAA growth. Copyright 1999 W.B. Saunders Company Ltd

SummaryFive different methods of measuring the clotting time of fresh whole blood have been compared. The Biobridge was the best instrument, and was able to measure both anticoagulation and hypercoagulation accurately and reproducibly.

A prospective study of 230 arch and carotid arteriograms in 229 patients with symptomatic cerebrovascular disease revealed that neurological morbidity was not significantly affected by patient age, nature of neurological symptoms, duration of procedure, volume of contrast medium or degree of arterial stenosis. The total neurological morbidity of 132 examinations carried out with non-ionic contrast medium (iohexol) was slightly lower than that of 98 examinations carried out with ionic contrast medium (meglumine and sodium iothalamate) but the difference was not statistically significant. However, the morbidity of 185 examinations performed by an experienced vascular radiologist was significantly lower (p< 0.025) than the morbidity of 45 examinations performed by a series of radiologists in training and the mean time required for the procedure was 18 min longer in the latter group (p< 0.001). These findings suggest that the neurological morbidity of arch and carotid arteriography in patients with cerebrovascular disease depends largely upon catheter technique and will not be significantly reduced by the use of non-ionic contrast medium.

1. We have determined the frequency of DNA polymorphisms of the human apolipoprotein AI-CIII-AIV gene cluster, detected with XmnI, PstI, and PvuII, in a group of patients with peripheral arterial disease. 2. Of the patients, 81 had no evidence of disease in the coronary and carotid arteries, 73 had coronary artery disease but no evidence of carotid artery disease, 25 patients had carotid artery disease but no evidence of coronary artery disease, and 38 had both coronary and carotid artery disease. 3. Levels of triacylglycerol, cholesterol, apolipoprotein B and apolipoprotein AI were not significantly different between the four patient groups. 4. The frequencies of the alleles for the apolipoprotein AI-CIII-AIV polymorphisms, detected with XmnI, PstI and PvuII, did not differ significantly in the patient groups when compared with a sample of clinically well normolipidaemic individuals also from a London population. 5. All five patients with the XmnI genotype we designate X2X2 had high levels of cholesterol, apolipoprotein B and apolipoprotein AI. 6. Patients with the rare VB2 allele of the apolipoprotein CIII-AIV restriction fragment length polymorphism had lower levels of cholesterol, acylglycerol and significantly lower levels of serum apolipoprotein. 7. Our observations suggest that variation in the apolipoprotein AI-CIII-AIV gene cluster may not be contributing significantly to the development of peripheral arterial disease, but variation associated with some of the restriction fragment length polymorphisms may be involved in determining levels of cholesterol- and apolipoprotein-B-containing lipoproteins.

Abdominal aortic aneurysm (AAA) can now be corrected by perfemoral introduction of a prosthetic tube graft with fixation using expandable metal stents. This technique requires a satisfactory iliac system, through which the graft can reach its destination, and suitable lengths of non-aneurysmal aorta below the renal arteries and above the aortic bifurcation for stent attachment. The feasibility for placement of endovascular grafts was assessed in 44 consecutive patients admitted for transabdominal AAA repair. The proximal and distal aneurysmal necks and the iliac arteries were assessed before operation by colour flow Doppler ultrasonography (duplex scanning), computed tomography and intravenous digital subtraction angiography, using intraoperative measurements as the ‘gold standard’. At operation 32 of 44 patients had a suitable proximal neck and five of 44 a suitable distal neck for endovascular grafting. Duplex scanning was the most accurate modality for preoperative assessment of the aneurysm necks. According to this technique 32 of 44 patients had a satisfactory iliac system for introduction of an endovascular graft. Overall only four of 44 patients were considered suitable for endovascular correction of AAA using a tube graft-stent combination.