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BACKGROUND Aortofemoral bypass(AFB), iliofemoral bypass(IFB), and aortoiliac endarterectomy(AIE) are the three most common techniques for anatomical open surgical revascularisation for patients with aorto-iliac occlusive disease(AIOD), but the optimal method of reconstruction is unknown. AIMS To review and compare mortality, morbidity and short- and long-term patency rates for AFB, IFB and AIE in patients with AIOD reported in the English language literature METHODS A MEDLINE(1970-2007) and Cochrane Library search for articles relating to AFB, IFB, AIE and AIOD was undertaken. Studies were included if: a) patency rates based on life-tables were available, and b) patient/study characteristics were reported. RESULTS 29 studies(5738 patients) for AFB, 11 studies(778 patients) for IFB and 11 studies(1490 patients) for AIE were included. Operative mortality was 4.1% for AFB, 2.7% for IFB and 2.7% for AIE (p

Objective: To determine the relationship between postoperative renal replacement therapy (RRT) and patient survival after open surgical repair (OR) of ruptured abdominal aortic aneurysm (rAAA). Methods: A retrospective review of consecutive patients who underwent OR for rAAA repair between January 2002 and July 2008 was performed. Early (30days) outcomes were assessed. Results: A total of 94 patients (69 men; median [range] age 73.8 [56-89] years) underwent OR of rAAA (infrarenal = 78, juxtarenal = 15, and suprarenal = 1). In-hospital mortality rate was 40% and mean (range) length of intensive care unit (ICU) stay was 9.3 (0-56) days. A total of 23 (24%) patients required postoperative RRT. In-hospital mortality rate was significantly higher (RRT: 87% (20 of 23) vs no RRT: 18 of 71 (25%), P < .0001) and ICU stay significantly longer (RRT: mean (range) days; 14.8 (1-44) vs no RRT: 7.5 (0-56), P = .04) in the RRT patients. On multivariate analysis, RRT (P = .0053) and/or inotropic support (P = .0033) were independent risk factors for death within 30 days of the index procedure. Conclusions: Renal replacement therapy following OR of rAAA is an independent risk factor for mortality.

Objective To compare a 'bypass-surgery-first' with a 'balloon-angioplasty-first' revascularisation strategy in patients with severe limb ischaemia (SLI) due to infrainguinal disease requiring immediate/early revascularisation. Design A stratified randomised controlled trial. A Delphi consensus study of vascular surgeons' and interventional radiologists' views on SLI treatment was performed before the trial. Setting Twenty-seven UK hospitals. Participants Patients presenting with SLI as the result of infrainguinal atherosclerosis and who, in the opinion of the responsible consultant vascular surgeon and interventional radiologist, required and were suitable for both surgery and angioplasty. Interventions Patients were randomised to either 'bypass-surgery-first' or 'balloon-angioplasty-first' revascularisation strategies. Main outcome measures The primary end point was amputation-free survival (AFS); secondary end points were overall survival (OS), health-related quality of life (HRQoL) and cost-effective use of hospital resources. Results AFS at 1 and 3 years was not significantly different for surgery and angioplasty. Interim analysis showed that surgery was associated with significantly lower immediate failure, higher 30-day morbidity and lower 12-month reintervention rates than angioplasty; 30-day mortality was similar. Beyond 2 years from randomisation, hazard ratios (HRs) were significantly reduced for both AFS (adjusted HR 0.37; 95% CI 0.17 to 0.77; p = 0.008) and OS (HR 0.34; 95% CI 0.17 to 0.71; p = 0.004) for surgery relative to angioplasty. By 2008 all but four patients had been followed for 3 years, some for over 7 years: 250 (56%) were dead, 168 (38%) were alive without amputation and 30 (7%) were alive with amputation. Considering the follow-up period as a whole, AFS and OS did not differ between treatments but for patients surviving beyond 2 years from randomisation, bypass was associated with reduced HRs for AFS (HR 0.85; 95% CI 0.50 to 1.07; p = 0.108) and OS (HR 0.61; 95% CI 0.50 to 0.75; p = 0.009), equating to an increase in restricted mean OS of 7.3 months (p = 0.02) and AFS of 5.9 months (p = 0.06) during the subsequent follow-up period. Vein bypasses and angioplasties performed better than prosthetic bypasses. HRQoL was non-significantly better in the surgery group; amputation was associated with a significant reduction in HRQoL. Over the first year, hospital costs for bypass were significantly higher (difference 5420 pounds; 95% CI 1547 pounds to 9294 pounds) than for angioplasty. However, by 3 and at 7 years the differences in cost between the two strategies were no longer significant. Patients randomised to surgery lived, on average, 29 days longer at an additional average cost of 2310 pounds. A 36-month perspective showed not significantly different mean quality-adjusted life times for angioplasty and surgery. The Delphi study revealed substantial disagreement between and among surgeons and radiologists on the appropriateness of bypass surgery or balloon angioplasty. Conclusions The findings of our study suggest that in patients with SLI due to infrainguinal disease the decision whether to perform bypass surgery or balloon angioplasty first appears to depend upon anticipated life expectancy. Patients expected to live less than 2 years should usually be offered balloon angioplasty first as it is associated with less morbidity and cost, and such patients are unlikely to enjoy the longer-term benefits of surgery. By contrast, those patients expected to live beyond 2 years should usually be offered bypass surgery first, especially where a vein is available as a conduit. Many patients who could not undergo a vein bypass would probably have been better served by a first attempt at balloon angioplasty than prosthetic bypass. The failure rate of angioplasty in SLI is high (c. 25%) and patients who underwent bypass after failed angioplasty fared significantly worse than those who underwent surgery as their first procedure. The interests of a significant proportion of BASIL patients may have been best served by primary amputation followed by high-quality rehabilitation. Further research is required to confirm or refute the BASIL findings and recommendations; validate the BASIL survival prediction model in a separate cohort of patients with SLI; examine the clinical and cost-effectiveness of new endovascular techniques and devices; and compare revascularisation with primary amputation and with best medical and nursing care in those SLI patients with the poorest survival prospects. Trial registration Current Controlled Trials ISRCTN45398889.

ObjectiveTo test the hypothesis that ultrasound-guided foam sclerotherapy (UGFS) is a safe and durable treatment for superficial venous reflux (SVR) associated with CEAP clinical grade 2-6 disease.MethodsThis was an interrogation of a prospectively gathered computerized database.ResultsBetween March 23, 2004 and December 31, 2009, 977 patients (1252 legs) underwent UGFS for unilateral (702 legs) or bilateral (550 legs) SVR in association with CEAP clinical grade 2-3 (n = 868), 4 (n = 232), or 5/6 (n = 152) disease. The following reflux in 1417 venous segments was treated: primary great saphenous vein (GSV) (n = 745); recurrent GSV (n = 286), primary small saphenous vein (SSV) (n = 189), recurrent SSV (n = 50); primary anterior accessory saphenous vein (AASV) (n = 93); recurrent AASV (n = 46); vein of the popliteal fossa (VOPF) (n = 5), and Giacomini vein (GV) (n = 3). Three hundred forty-eight legs (27.8%) had undergone previous surgery. Three patients suffered post-UGFS deep vein thrombosis (DVT) and one a pulmonary embolus (PE), all within the first month (0.4% venous thrombo-embolic complication rate). Five patients (0.5%) had transient visual disturbance at the time of, or shortly after, treatment. No other neurologic or serious complications were reported. During a mean (range) follow-up of 28 (

Lack of Level I evidence from randomized controlled trials (RCT) means that the relative merits of surgical and endovascular revascularization strategies for severe limb ischemia (SLI) due to infrainguinal disease remain unclear. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial remains the only multicenter RCT to have compared the clinical and cost-effectiveness of bypass surgery (BSX)-first and balloon angioplasty (BAP)−first revascularization strategies for infrainguinal SLI. An intention to treat analysis shows that out to 2 years both strategies were associated with similar amputation-free (AFS) and overall survival (OS) rates, as well as improvements in health-related quality of life. In the short-term, BSX was significantly more morbid and expensive. However, for those patients who survived for 2 years after randomization, initial randomization to a BSX-first strategy was associated with a significant increase in subsequent OS of about 7 months and a nonsignificant increase in subsequent AFS of about 6 months. Vein BSX performed significantly better than prosthetic BSX in terms of AFS but not OS. For most patients BAP also appears preferable to prosthetic BSX. Patients who underwent BSX after a failed BAP-first strategy did not fare as well as those who received BSX as their first procedure. Patients who are expected to live less than 2 years should usually be offered BAP first, especially when the alternative is prosthetic BSX. Those expected to survive beyond this time horizon (approximately 75% of the BASIL cohort) should usually be offered BSX first, especially where vein is available. Further RCTs to confirm or refute these findings and recommendations are required.

Objectives Ultrasound guided foam sclerotherapy (UGFS) is a minimally invasive treatment for varicose veins (VV) whose clinical and cost-effectiveness remains incompletely defined. The aim of the current study was to examine patients' expectations before and satisfaction after UGFS for VV in terms of relief of lower limb symptoms, improvement in appearance, and beneficial effect on life-style. Methods A consecutive series of 351 patients (464 limbs) undergoing UGFS for VV completed questionnaires one week prior to and six months after treatment. Results Pre and post-treatment response rates were 80%; 60% returned both questionnaires. Virtually all patients were expecting improvement in lower limb symptoms; these were exceeded in a third. Most patients expected cosmetic improvement and these were largely met. Two-thirds of patients expected significant life-style (clothes, work, social) benefits and outcomes were slightly less than expected. A quarter expected improvement in their interpersonal relationships. This benefit was greater than expected occurring in one-third of patients. Overall, a quarter of patients had their expectations exceeded and 10% (appearance and relationships) to 25% (clothing, work and social and leisure activities) were left with unmet expectations. Discussion When specifically asked most patients admit to having a wide range of expectations in relation to their VV treatment, many of them probably unanticipated by the clinician. However, present data indicate that UGFS is usually able to meet, and often exceeds, these physical and psychosocial needs and expectations. UGFS is, therefore, a highly effective treatment for VV from the patients' perspective.

Background: The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed in patients With severe lower limb ischemia (rest pain, tissue loss) who survive for 2 years after intervention that initial randomization to bypass surgery, compared with balloon angioplasty, was associated with an improvement in subsequent amputation-free survival and overall survival of about 6 and 7 months, respectively. The aim of this report is to describe the angiographic severity and extent of infrainguinal arterial disease in the BASIL trial cohort so that the trial outcomes can be appropriately generalized to other patient cohorts with similar anatomic (angiographic) patterns of disease.Methods: Preintervention angiograms were scored using the Bollinger method and the TransAtlantic Inter-Society Consensus (TASC) II classification system by three consultant interventional radiologists and two consultant vascular surgeons unaware of the treatment received or patient outcomes.Results: As was to be expected from the randomization process, patients in the two trial arms were Well matched in terms of angiographic severity and extent of disease as documented by Bollinger and TASC II. In patients with the least overall disease, it tended to be concentrated in the superficial femoral and popliteal arteries; which were the commonest sites of disease overall. The below knee arteries became increasingly involved as the overall severity of disease increased, but the disease in the above knee arteries did not tend to worsen. The posterior tibial artery was the most diseased crural artery, whereas the peroneal appeared relatively spared. There was less interobserver disagreement with the Bollinger method than with the TASC II classification system, which also appears inherently less sensitive to clinically important differences in infrapopliteal disease among patients with severe leg ischemia.Conclusions: Anatomic (angiographic) disease description in patients with severe leg ischemia requires a reproducible scoring system that is sensitive to differences in crural artery disease. The Bollinger system appears well suited for this purpose, but the TASC II classification system less so. We hope this detailed analysis will facilitate appropriate generalization of the BASIL trial data to other groups of patients affected by similar anatomic (angiographic) Patterns of disease. (J Vasc Surg 2010;51:32S-42S.)

Simon D Hobbs1, Martin W Claridge1, Antonius BM Wilmink1, Donald J Adam1, Mark E Thomas2, Andrew W Bradbury11University Department of Vascular Surgery and 2Department of Nephrology, Heart of England NHS Trust (Teaching), Birmingham, UKBackground: The Heart Outcomes Prevention Study (HOPE) demonstrated that ramipril resulted in a blood-pressure-independent 25% reduction in cardiovascular events in patients with peripheral arterial disease (PAD). Despite this, general practitioners and vascular surgeons remain reluctant to prescribe ACE inhibitors in this group of patients because of concerns about renal artery stenosis (RAS). We aimed to define the effect of ramipril on renal function in patients with intermittent claudication (IC).Methods and Results: Of 132 unselected patients with IC entering the study 78 (59%) were excluded due to: current ACE inhibitor use (38%), renal impairment (serum creatinine above normal range) (15%), known severe RAS (1%) or unwillingness to participate (5%). The remaining 54 patients were titrated to 10 mg ramipril and renal function was monitored at 1, 5, and 12 weeks. Treatment was discontinued during titration in 5 patients due to symptoms (3) or lack of compliance (2). In the remainder, median [IQR] serum creatinine increased (94 [85.8–103.3] to 98 [88.0–106.5] µmol/L, p ≤ 0.001) and median [IQR] GFR decreased (71.5 [64.6–82.3] to 68.7 [59.8–74.7] mL/min per 1.73 m2, p ≤ 0.001) between baseline and 5 weeks. These changes were not considered clinically significant. By 12 weeks these values had returned almost to baseline (Cr 95.5 [88.0–103.25] µmol/L, GFR 71.8 [65.3–77.4] mL/min). No patient had a serum creatinine rise >30%.Conclusion: Most of patients with IC and a normal serum creatinine can be safely commenced on ramipril provided they are screened, titrated and monitored as described above. Studies in patients with borderline renal impairment (serum creatinine up to 30% above baseline) are on-going.Keywords: peripheral arterial disease, ramipril, renal function, intermittent claudication

Objective To determine the long-term outcome of surgical repair of popliteal artery aneurysms (PAA). Methods A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1988 and 2006 was performed. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan-Meier methods. Results 48 patients underwent repair of 63 PAAs (ligation and bypass = 45, interposition grafting = 18). The 5-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 75%, 95%, 98% and 81%, respectively. The 10-year primary graft patency rates were significantly lower for emergency cases (59%) compared with elective cases (66%) (p = 0.0023). Thirteen patients (16 PAAs) required a total of 20 late re-interventions. Duplex ultrasound was available in 33 of 45 PAAs treated by ligation and bypass. Five (15%) PAAs demonstrated perfusion of the aneurysm sac at median(range) follow up of 75 (1–246) months after primary repair and two of these required emergency re-operation. Conclusions These data demonstrate that surgical PAA repair is associated with excellent long-term durability and provide an important benchmark with which to compare results of endovascular PAA repair. Patients treated using the ligation and bypass technique should be enrolled in an aneurysm sac surveillance program.

Background MRSA is a significant contributor to prolonged hospital stay, poor clinical outcome and increased healthcare costs amongst surgical patients. A PCR test has been developed for rapid detection of MRSA in nasal swabs. The aims of this study are (1) to estimate the effectiveness of screening using this rapid PCR tests vs culture in reducing MRSA cross-infection rates; (2) to compare the cost of each testing strategy, including subsequent health care costs; and (3) to model different policies for the early identification and control of MRSA infection in surgical patients. Methods/Design The study is a prospective two-period cross-over study set in 7 surgical wards covering different surgical specialities. A total of 10,000 patients > 18 years will be tested over 16 months. The only difference between the two study periods is the method used for the detection of MRSA in each ward (rapid v conventional culture), with all other infection control practices remaining consistent between the arms. The study has been designed to complement routine practice in the NHS. Outcomes are MRSA cross-infection rates (primary outcome) and need for antibiotic therapy and MRSA-related morbidity. Parallel economic and modelling studies are being conducted to aid in the interpretation of the results and to evaluate the cost-effectiveness of the rapid PCR screening strategy. Discussion This paper highlights the design, methods and operational aspects of a study evaluating rapid MRSA screening in the surgical ward setting.

The aim of the study was to investigate the reproducibility of estimation of Young’s modulus E and pressure strain elastic modulus Ep, derived from a tissue Doppler imaging (TDI) wall motion technique. Healthy subjects had their arteries insonated at the same sitting by two different observers and at two different sittings by the same observer. From 32 subjects in the reproducibility study, within-scan coefficient of variation (CV) was 4.5%. Intraobserver between-scan CV for E was 12.7% and for Ep 11.0%. Interobserver CVs were 8.3% and 9.3%, respectively. TDI is a reproducible, valid and highly sensitive direct assessment of arterial wall parameters. It is at least as reproducible as other ultrasound based methods for assessing arterial stiffness and also provides increased information about the arterial distension waveform. (E-mail: martin@claridge.org.uk )

We report a 90-year old man who presented with severe lower extremity ischaemia due to spontaneous dissection of a non-aneurysmal infrarenal abdominal aorta. The aortic lesion was treated using an aorto-uni-iliac stent-graft with contralateral common iliac artery occlusion and femoro-femoral cross-over bypass. The patient underwent digital amputation and debridement of the foot four weeks post-operatively. At 12 months follow-up, he remains symptom-free with an excluded dissection, patent reconstruction and healed foot.

Background The number of carotid endarterectomies (CEAs) performed in the UK, and thus the need to train surgeons in this operation, has increased markedly in recent years and may continue to do so. The aim of the present study was to assess the quality, clinical outcome and case-mix of supervised training in CEA in this unit. Methods The study was an analysis of a prospectively gathered database of all CEAs performed in this unit since 1975. Results Between 1 January 1975 and 31 December 1991, 247 CEAs were performed of which only 12 were done by supervised trainees. By contrast, between 1 January 1992 and 1 July 1996, 219 CEAs were performed, 92 (42 per cent) by supervised trainees (P < 0·0001). In cases performed since 1 January 1992, there was no significant difference between trainee and consultant operations with regard to age and sex of patient, smoking history, ischaemic heart disease, hypertension, diabetes, presence of preoperative infarction on computed tomography, indications for operation, degree of ipsilateral carotid stenosis, status of the contralateral carotid artery, use of a shunt or patch angioplasty. Since 1 January 1992, the total perioperative neurological event rate for supervised trainees was seven of 92 (7·6 per cent) of which one was fatal (cerebral infarction). The total neurological event rate for operations done by a consultant was nine of 127 (7·1 per cent), of which one was permanent and disabling and two were fatal (one cerebral infarction and one haemorrhage). Conclusion Since 1991 there has been a tenfold increase in the proportion of CEAs being performed by supervised trainees. This has been accomplished without deterioration in clinical outcome. With adequate supervision, training in CEA can be safe, even when trainees are exposed to a true cross-section of low-, medium- and high-risk cases.

Background The operative mortality rate for elective repair of asymptomatic abdominal aortic aneurysm (AAA) is falling but the fate of patients with ruptured AAA may have changed little over the past decade. Methods This study was an analysis of a prospectively gathered computerized database. Results In the 12 years to 31 December 1994, 1144 patients underwent (attempted) repair of AAA. In 514 patients (44·9 per cent) who had an operation for ruptured AAA there was no significant change in the mean age, male: female ratio (418:96), or operative mortality rate (35·0 per cent) over the interval of the study. Forty-seven patients died before reaching the operating theatre, giving an ‘intention to operate’ mortality rate of 405 per cent. A further 68 patients (10·8 per cent of all patients who presented with a ruptured AAA) were not offered operation because of poor medical condition (n = 34) or extreme age (n = 34); three patients refused operation. A greater proportion of patients had surgery between 1989 and 1994 (276 of 323, 85·4 per cent) than between 1983 and 1988 (238 of 309, 77·0 per cent) (P

BASIL trial participants* Summary Background The treatment of rest pain, ulceration, and gangrene of the leg (severe limb ischaemia) remains controversial. We instigated the BASIL trial to compare the outcome of bypass surgery and balloon angioplasty in such patients. Methods We randomly assigned 452 patients, who presented to 27 UK hospitals with severe limb ischaemia due to infra-inguinal disease, to receive a surgery-first (n=228) or an angioplasty-first (n=224) strategy. The primary endpoint was amputation (of trial leg) free survival. Analysis was by intention to treat. The BASIL trial is registered with the National Research Register (NRR) and as an International Standard Randomised Controlled Trial, number ISRCTN45398889. Findings The trial ran for 5·5 years, and follow-up finished when patients reached an endpoint (amputation of trial leg above the ankle or death). Seven individuals were lost to follow-up after randomisation (three assigned angioplasty, two surgery); of these, three were lost (one angioplasty, two surgery) during the first year of follow-up. 195 (86%) of 228 patients assigned to bypass surgery and 216 (96%) of 224 to balloon angioplasty underwent an attempt at their allocated intervention at a median (IQR) of 6 (3–16) and 6 (2–20) days after randomisation, respectively. At the end of follow-up, 248 (55%) patients were alive without amputation (of trial leg), 38 (8%) alive with amputation, 36 (8%) dead after amputation, and 130 (29%) dead without amputation. After 6 months, the two strategies did not differ significantly in amputation-free survival (48 vs 60 patients; unadjusted hazard ratio 1·07, 95% CI 0·72–1·6; adjusted hazard ratio 0·73, 0·49–1·07). We saw no difference in health-related quality of life between the two strategies, but for the first year the hospital costs associated with a surgery-first strategy were about one third higher than those with an angioplasty-first strategy. Interpretation In patients presenting with severe limb ischaemia due to infra-inguinal disease and who are suitable for surgery and angioplasty, a bypass-surgery-first and a balloon-angioplasty-first strategy are associated with broadly similar outcomes in terms of amputation-free survival, and in the short-term, surgery is more expensive than angioplasty.

Background. Despite the increasing sophistication of vascular surgical practice, more than three decades after its introduction to clinical practice, the ankle to brachial pressure index (ABPI) remains the cornerstone of non-invasive assessment of the patient with symptomatic peripheral arterial disease (PAD). Aim. To summarise what is known about ABPI and critically appraise its validity, reliability, reproducibility and extended utility. Methods. A MEDLINE (1966-2004) and Cochrane library search for articles relating to measurement of ABPI was undertaken; see text for further details. Results. There is considerable disagreement as to how ABPI should be measured. Furthermore, various factors, including the type of equipment used, and the experience of the operator, can result in significant inter- and intra-observer error. As such, care must be taken when interpreting data in the literature. ABPI is valuable in the assessment of patients with atypical symptoms, venous leg ulcers and after vascular and endovascular interventions. However, absolute pressures are probably more valuable in patients with critical limb ischaemia. ABPI is also useful in subjects with asymptomatic PAD where it correlates well with, and may be used in screening studies to quantify, cardiovascular risk. Conclusions. While its apparent simplicity can beguile the unwary, ABPI will continue to have a key role in the assessment of symptomatic PAD. ABPI is also likely to have extended utility in health screening and institution of best medical therapy in asymptomatic subjects.

Objective: To identify health-related quality-of-life (HRQoL) issues in patients with venous leg ulcers, with the aim of generating items for a treatment outcome measure. Method: Thirty-eight patients with venous leg ulcers were interviewed by a psychologist using a semi-structured guide; they also completed a HRQoL questionnaire (modified Skindex). Data from the questionnaire were examined to explore the impact of venous leg ulcers on patients’ lives. Interview transcripts were analysed using qualitative methods to identify additional venous leg ulcer-specific HRQoL items. Results: Skindex scores indicated that older patients had worse HRQoL (pConclusion: Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers. Declaration of interest: This study was funded by Pfizer, Sandwich, UK.

In 54 patients with unilateral leg ulceration of purely venous aetiology the only difference in venous reflux between affected and non-affected legs was with respect to the popliteal and crural veins. Deep and superficial venous reflux is common in legs without the skin changes typical of chronic venous insufficiency. The significance of venous reflux in an ulcerated leg cannot therefore be determined without reference to the contralateral, clinically normal, limb. Surgery should be directed at correcting reflux present in the ulcerated limb but not in the unaffected limb. In a minority of patients this entails superficial venous surgery alone, but in the majority such an approach would, ideally, entail correction of deep venous incompetence.

Perioperative hemorrhage is one of the principal causes of death in patients with ruptured abdominal aortic aneurysm (AAA). This study examines perioperative coagulation and fibrinolysis in patients undergoing ruptured AAA repair complicated by coagulopathy. Eight patients (8 men of median age 74, range 69-87, years) who developed clinical and laboratory evidence of coagulopathy during attempted repair of ruptured infrarenal AAA were prospectively studied. Platelet count, fibrinogen, clotting times, prothrombin fragment (PF) 1+2, and tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI) activities were measured preoperatively, immediately before, and 5 min and 24 hr after aortic declamping. Six patients died, three intraoperatively, one within 24 hr, and two in the late postoperative period. All patients had thrombocytopenia and prolonged clotting times intraoperatively with evidence of increased thrombin generation (as demonstrated by elevated PF 1+2). Five patients had increased systemic fibrinolysis (as demonstrated by elevated t-PA activity) preoperatively and/or before aortic declamping and all of these patients died. Three patients had perioperative inhibition of systemic fibrinolysis (as demonstrated by elevated PAI activity) and two survived. These data demonstrate that coagulopathy in ruptured AAA repair may be associated with a hyperfibrinolytic state. Further research is required to determine if (a) a causal relationship exists between hyperfibrinolysis and coagulopathy and (b) whether antifibrinolytic agents can improve outcome if targeted at this group of patients.

Introduction Although up to a half of patients undergoing abdominal aortic aneurysm (AAA) repair suffer myocardial injury, as indicated by a rise in cardiac troponin I (cTnI), this is infrequently accompanied by a rise in creatine kinase (CK)-MB fraction or electrocardiogram (ECG) changes. This study compares for the first time peri-operative cTnI, CK-MB and ECG changes in patients undergoing surgery for critical lower limb ischaemia (CLI). Methods Twenty-nine patients (20 men, median age 75 [range, 57–95] years) were studied prospectively. cTnI, CK/CK-MB ratio and ECG were performed pre-operatively and on post-operative days 1, 2 and 3. Results Eleven (38%) patients had an elevated cTnI >0.5 ng/ml. Five (17%) patients had an elevated CK-MB fraction >4% and all of these patients had an elevated cTnI. Eleven (38%) patients had ischaemic changes on ECG including seven of 11 (64%) patients with elevated cTnI and all five patients with elevated CK-MB fraction. There was no relationship between pre-operative cardiac status, antiplatelet use or type of anaesthesia and post-operative cTnI rise. Patients with a cTnI rise were younger ( p =0.01), and were more likely to have presented with gangrene ( p =0.04) and have a longer operation time ( p =0.01) than patients who did not demonstrate a cTnI rise. Four patients developed clinically apparent cardiac complications: cardio-pulmonary arrest ( n =1), cardiogenic shock ( n =1), acute CCF ( n =1) and rapid atrial fibrillation ( n =1). Survival at 6 months was 26 of 29 (90%) patients. Conclusion These data demonstrate that over a third of patients operated for CLI sustain peri-operative myocardial injury, many of which are not clinically apparent. Pre-operative medical optimisation may improve prognosis in this group of patients.

BackgroundIt has been suggested that hyperhomocysteinemia (HHcy) is an independent risk factor for peripheral arterial occlusive disease (PAOD). However, the relationship between dietary folate and vitamin B6, cofactors in the metabolism of homocysteine (Hcy), and PAOD is unclear.AimsTo study the relationship between dietary folate and B6 and PAOD.MethodsCase–control population based study of 392 men older than 50 years living in Huntingdon, United Kingdom. PAOD, defined as an ankle-brachial pressure index (ABPI) < 0.9, was present in 86 (22%) of subjects. Folate, vitamin B6, and vitamin B12 intakes were calculated by means of the EPIC (European Prospective Investigation into Cancer) food frequency questionnaire.ResultsDaily folate intake was significantly lower in case subjects (mean, 288; 95% confidence interval [CI], 266-309 μg) than in control subjects (324; 95% CI, 313-335 μg). Daily vitamin B6 intake was also lower in case subjects (2.05; 95% CI, 1.92-2.19 mg versus 2.26; 95% CI, 2.19-2.33 mg). Daily folate and vitamin B6 intakes were independent predictors of PAOD after adjusting for age, blood pressure, cholesterol levels, diabetes, and smoking status in a logistic regression model. This model suggests that increasing daily folate intake by 1 standard deviation decreased the risk of PAOD by 46%. A similar increase in daily vitamin B6 intake decreased the risk of PAOD by 29%.ConclusionIn men older than 50 years, dietary folate and B6 intakes are independent predictors of PAOD. Longitudinal studies are required to determine whether dietary modification can reduce the incidence of PAOD in the population.

Endothelial cell activation as an early response to hypovolaemic shock may be important in the pathogenesis of coagulopathy and multiple organ failure after aortic aneurysm rupture. The aim of this study was to determine whether any evidence could be found of changes in endothelial cell ultrastructure in patients undergoing operation for ruptured aneurysm and to establish a model for future studies of endothelial cells in these patients. At the start of operation, fat samples from the anterior abdominal wall were taken from five patients with ruptured abdominal aortic aneurysms and in an identical fashion from five control patients undergoing elective surgery. Endothelial cells lining capillaries were examined by transmission electron microscopy. Photomicrographs were taken of all capillaries present and these were assessed blindly by three independent observers. When compared with controls it was found that the luminal surface of the endothelial cells in patients with aneurysm rupture was more convoluted, with more frequent processes projecting into the lumen of the capillary. Budding of the luminal surface of the endothelial cell was seen in 11 of 45 capillaries in the rupture group and in none of 44 capillaries in the control group (P < 0.005). Budding was seen in at least one capillary of all five patients presenting with rupture but in none of the control group (P < 0.05). In conclusion, at the ultrastructural level there are changes within endothelial cells in capillaries at an early stage after ruptured abdominal aortic aneurysm.

The varicograms of 128 legs were reviewed by a panel of two vascular surgeons and a radiologist with a specialist vascular interest. Varicography effectively elucidates the anatomical basis of recurrence. Recurrent varicose veins were associated with (i) technically unsatisfactory surgery at the saphenofemoral junction (66 per cent) and (ii) failure to remove the long saphenous vein in the thigh (60 per cent). A new classification is offered as a basis for comparison of series, audit and surgical training.

Background: although chronic venous ulceration (CVU) is often viewed primarily as a disease of the elderly, recent epidemiological data suggest that a significant proportion of patients first develop CVU before middle age. Such patients may represent a distinct group in terms of aetiology, natural history, prognosis and therapeutic options. Aim: to compare patients who developed CVU before (Group 1) and after (Group 2) their 50th birthday. Methods: one hundred and eighteen consecutive patients with “pure” CVU underwent history and examination, measurement of ankle-brachial pressure index (ABPI) and duplex ultrasound examination of the affected limb. Pure venous ulcers were defined as those of >4 weeks duration in the presence of venous reflux (>0.5) and in association with an ankle: brachial pressure index of >0.8. Results: patients in Group 1 (n = 54, 46%) were more likely to be male (32/54 [59%] vs 14/64 [23%], p < 0.001 χ2), to have a higher median (interquartile [IQR]) body mass index (32 [27-39] vs 27 [23-34], p = 0.003, Mann-Whitney U [MWU]), to have a history of deep venous thrombosis (23/54 [43%] vs 16/64 [25%], p = 0.04 χ2) and of ipsilateral long bone fracture (13/54 [24%] vs 5/64 [8%], p = 0.01, χ2), to have previously undergone venous surgery (27/54 [50%] vs 19/64 [30%] a median (IQR) of 11.5 (6.5-19) and 10 (2-20) years earlier respectively, and to have worse disease in terms of the duration of present ulcer (12 (6-36) vs 8.5 [3-18] months, p = 0.035 MWU), the total duration of ulcer disease (216 [72-360] vs 48 [12-120] months, p < 0.001 MWU), and the number of episodes of ulceration (3 [2-7] vs 1 [1-3], p = 0.002 MWU). There was no significant difference between the two groups in the pattern and severity of venous reflux with 46/54 (85%) of Group 1 and 54/64 (84%) of Group 2 patients having surgically correctable superficial venous reflux. Conclusion: patients who develop CVU before their 50th birthday appear to represent a distinct group in terms of aetiology, natural history and prognosis. The importance of thrombo-embolic prophylaxis in the prevention, and the detection and correction of superficial venous reflux in the treatment, of such ulcers is re-emphasised.Eur J Vasc Endovasc Surg 26, 176-178 (2003)

Best medical treatment for peripheral arterial disease, including managing hypertension and diabetes, reduces morbidity and mortality and can obviate the need for invasive intervention

Objective: A more accurate means of prediction of abdominal aortic aneurysm (AAA) rupture would improve the clinical and cost effectiveness of prophylactic repair. The purpose of this study was to determine whether AAA wall distensibility can be used to predict time to rupture independently of other recognized risk factors. Methods: A prospective, six-center study of 210 patients with AAA in whom blood pressure (BP), maximum AAA diameter (Dmax), and AAA distensibility (pressure strain elastic modulus [Ep] and stiffness []) were measured at 6 months with an ultrasound scan–based echo-tracking technique. A stepwise, time-dependent, Cox proportional hazards model was used to determine the effect on time to rupture of age, gender, BP, Dmax, BP, Ep, , and change in Dmax, Ep, and adjusted for time between follow-up visits. Results: Median (interquartile range) AAA diameter was 48 mm (41 to 54 mm), median age was 72 years (68 to 77 years), and median follow-up period was 19 months (9 to 30 months). In the Cox model, female gender (hazards ratio [HR], 2.78; 95% CI, 1.23 to 6.28; P .014), larger Dmax (HR, 1.36 for 10% increase in Dmax; 95% CI, 1.12 to 1.66; P .002), higher diastolic BP (HR, 1.13 for 10% increase in BP; 95% CI, 1.13 to 1.92; P .004), and a decrease in Ep (increase in distensibility) over time (HR, 1.38 for 10% decrease in Ep over 6 months; 95% CI, 1.08 to 1.78; P .010) significantly reduced the time to rupture (had a shorter time to rupture). Conclusion: Women have a shorter time to AAA rupture. The measurement of AAA distensibility, diastolic BP, and diameter may provide a more accurate assessment of rupture risk than diameter alone. (J Vasc Surg 2003;37:112-7.) The decision to operate on an asymptomatic abdominal aortic aneurysm (AAA) involves weighing the risks of rupture against those of surgical repair. 1,2 Most surgeons believe that rupture risk is most closely related to maximum diameter. Data from the United Kingdom small AAA trial suggest that elective repair should not normally be considered until maximum diameter exceeds 5.5 cm. 3 However, a significant proportion of ruptured AAAs is less than 5.5 cm. At the same time, it is clear that many patients with larger AAAs die with, rather than of, their aneurysm. A more accurate means of assessing the risk of AAA rupture on an individual patient basis would improve the clinical and cost effectiveness of prophylactic repair. Previous work from our group has suggested that AAA wall distensibility can be reliably measured with an ultrasound scan‐ based echotracking technique 4 and is related to changes in aortic wall structure 5 and to both AAA growth and rupture. 6 The aim of this study was to investigate whether a change in AAA wall distensibility over time is related to rupture risk independently of other recognized risk factors.

Objective: To examine the association between superficial and deep vein incompetence demonstrated by duplex ultrasonography and the results of foot volumetry. Design: Duplex ultrasonography was used to detect superficial and deep venous incompetence. Foot volumetry was used to determine expulsion fraction (expelled volume/total foot volume, EF, %) and half-refilling time (HRT, seconds). Setting: Hospital outpatients attending the Royal Infirmary of Edinburgh. Patients: Forty-three patients with venous ulcer disease. Results: EF, obtained with tourniquet occlusion of superficial veins, in patients without deep vein incompetence was not significantly different from EF in patients with either femoral vein incompetence (FVI), popliteal vein incompetence (PVI) or both. HRT in patients without deep vein incompetence was significantly higher than HRT in patients with FVI ( p < 0.02), PVI ( p < 0.01) and both FVI and PVI ( p < 0.03, Wilcoxon signed rank test). EF and HRT values obtained without tourniquet occlusion were unrelated to the presence or absence of deep vein incompetence. There was no relationship between the results of foot volumetry and superficial vein incompetence. Conclusions: The results of foot volumetry are related to deep, but not superficial, venous incompetence as demonstrated by duplex ultrasonography.

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal reflux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and 52 (73 per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reflux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reflux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have difficulty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.

Introduction ‘‘kissing stent’’ insertion. All procedures were performed electively in patients with proximal common Angioplasty, with or without stenting, is increasingly iliac lesions, in whom it would not have been possible to place a stent without it protruding into the aorta. used to treat patients with symptomatic aorto-iliac occlusive disease. In patients with intermittent clauClinical indications included bilateral claudication (6 patients), unilateral claudication (3 patients), claudidication or critical limb ischaemia due to unilateral or bilateral common iliac artery (CIA) origin stenosis cation and contralateral rest pain and tissue loss (1 patient), unilateral rest pain and tissue loss (1 patient). and/or occlusion the ‘‘kissing balloon’’ technique has been advocated. In the largest reported series of 79 Thus, 16 limbs were affected by claudication and 4 by critical limb ischaemia. Four stents were placed in a patients, Insall described the technique as effective and durable. However, in this and another series there contralateral asymptomatic common iliac artery (Table 1), 1 was normal and the remainder had stenoses of was a significant incidence of dissection, thrombosis and residual stenosis. It has been suggested that 46%, 50% and 82%. The median (range) symptomatic of common iliac stenosis was 60% (50–95%) and the simultaneous bilateral placement of common iliac artery stents to refashion the aortic bifurcation, the sothree occlusions were 4, 35 and 44 mm in length. A variety of stents Palmaz (Cordis, Johnson & Johnson), called ‘‘kissing stents’’ technique, might reduce the incidence of these complications. To date, the two Symphony (Boston Scientific), Memotherm (Baird) and published series have reported favorable initial results Bridge stent (Medtronic) were used. Only one limb although follow-up has been short. The aim of this had more than one stent inserted. Post-procedurally study was to examine our experience with the ‘‘kissing 10 patients were maintained on aspirin and 2 on stents’’ technique in terms of procedure related morwarfarin. bidity and medium term haemodynamic and clinical Downstream angiographic lesions were present in 7 patency. Kissing stents have been defined as bilateral limbs as follows: external iliac (n=1), common femoral common iliac stents which extend into the aorta such (n=1), superficial femoral (n=1), profunda femoris that the two adjacent stent walls come into apposition (n=1), popliteal/crural (n=5). One patient had an for at least one cm in the native aorta. external iliac artery angioplasty. Major morbidity in 2 patients comprised: unilateral distal embolisation treated by means of aspiration and thrombolysis and a surgically repaired common femReport oral pseudo-aneurysm. One further patient had a delayed hospital discharge due to the development of Between 1993 and 1998, 5 males and 7 females, median bilateral iliac dissections which were treated with hep(range) age of 62 (43–73) years, underwent planned arin. All patients reported an immediate Rutherford ∗ Please address all correspondence to: A. W. Bradbury, Professor +2 or +3 improvement in their symptoms (Table 1). of Vascular Surgery, University Department of Surgery, Lincoln Patients were followed up in a dedicated House (Research Institute), Birmingham Heartlands Hospital, Bordersley Green East, Birmingham B9 5SS, U.K. clinic, clinical and haemodynamic outcomes were

Background who have objective evidence of MI. The ECG is difficult to interpret in the post-operative setting and often Peri-operative myocardial infarction (MI) occurs in does not display the classical ST segment elevation of acute myocardial infarction. Lastly, even if there is a 5–10% of patients undergoing major vascular surgery, is fatal in 50% of these cases and in total will account significant rise in creatine kinase leaked from dying myocardial cells (CK-MB) this may be masked by for more than 50% of all post-operative deaths. An even larger proportion of operated patients will suffer large quantities of creatine kinase (CK) released from skeletal muscle as the result of direct surgical trauma cardiac complications, which may be fatal or non-fatal, that are not demonstrably related to peri-operative or ischaemia/reperfusion injury. This makes the CK/ CK-MB ratio difficult to interpret. MI. These complications may have metabolic causes, but are perhaps more likely to be due to myocardial infarction that cannot be detected by the standard diagnostic tests for peri-operative MI. This injury Micro-infarction and the acute coronary may be referred to as minor myocardial injury or syndromes micro-infarction. Defining the aetiology, incidence, and treatment of Recently it has become possible to detect micro-inperi-operative cardiac complications has been farction by measuring cardiac structural proteins, such hampered by the limitations inherent in World Health as cardiac troponin, that are released following myoOrganisation (WHO) criteria for diagnosis of acute MI. cardial cell death. It has become apparent that even The WHO criteria require that two of the following though the occurrence of micro-infarction may not lead three features are present: a history of characteristic to an acute deterioration of left ventricular function, it prolonged ischaemic chest pain; evolutionary changes is associated with a very adverse longer term progon the electrocardiogram (ECG) and elevation of serial nosis. Most studies conducted with regard to this cardiac enzymes. However, in post-operative patients, have focused on the acute coronary syndromes. This is symptoms may be masked by the use of opiate anala group of conditions characterised by the spontaneous gesia, and atypical or even absent in up 75% of patients development of myocardial ischaemia due to the erosion, fissuring or rupture of coronary atherosclerotic ∗ Please address all correspondence to: A. W. Bradbury, University plaque resulting in intra-vascular thrombosis. At one Department of Vascular Surgery, Lincoln Building (Research Inextreme, this thrombosis will result in acute MI charstitute), Birmingham Heartlands & Solihull NHS Trust, Bordesley Green East, Birmingham B9 5SS, U.K. acterised by chest pain, ST-segment elevation on the

Varicose veins occur commonly in the general population but the aetiology is not well established. Varicosities are associated frequently with reflux of blood in the leg veins due to valvular incompetence. Our aim was to determine in the general population which lifestyle factors were related to reflux and thus implicated in the aetiology of varicose veins.In the Edinburgh Vein Study, 1566 men and women aged 18-64 years were sampled randomly from the general population in the city of Edinburgh, Scotland, and had duplex scans to measure reflux in eight venous segments in each leg. A self-administered questionnaire enquired about occupation, mobility at work, smoking, obstetric history, dietary fibre intake and bowel habit. A bowel record form was completed subsequently.In women, venous reflux was associated with decreased sitting at work (odds ratio [OR] = 0.76, 95% CI : 0.61-0.94), previous pregnancy (OR = 1.20, 95% CI : 0.93-1.54), and a lower prior use of oral contraceptives (OR = 0.84, 95% CI : 0.66-1.06). Mean body mass index was greater in women with superficial reflux compared to those with no reflux: 26.2 kg/m(2) (95% CI : 25.5-27.0) versus 25.2 kg/m(2) (95% CI : 24.8-25.6). On age adjustment, sitting at work remained related to reflux (OR = 0.78, 95% CI : 0.63-0.98) and prior use of oral contraceptives to superficial reflux (OR = 0.71, 95% CI : 0.50-1.01). In age-adjusted analyses in men, height was related to reflux, (OR = 1.13, 95% CI : 1.02-1.26) and straining at stool was related to superficial reflux (OR = 1.94, 95% CI : 1.12-3.35). No associations were found in either sex between reflux and social class, lifetime cigarette consumption, dietary fibre intake and intestinal transit time.This population study did not identify strong and consistent lifestyle risk factors for venous reflux although previous pregnancy, lower use of oral contraceptives, obesity and mobility at work in women and height and straining at stool in men may be implicated.

Background Recent changes in surgical training in the UK mean that operative experience must be gained more efficiently. However, it is important to demonstrate that improved training opportunities are not associated with inferior patient outcomes. The aim was to examine changes in training in infrainguinal bypass surgery and to compare the outcomes of operations performed by consultants and trainees. Methods A prospectively gathered, computerized database of 1077 consecutive infrainguinal bypasses performed on 1003 patients for chronic severe leg ischaemia between 1 January 1983 and 31 December 1998 was analysed. Results Consultants performed 733 (68 per cent) infrainguinal bypasses to the following distal sites: 347 (47 per cent) above-knee popliteal artery, 257 (35 per cent) below-knee popliteal artery, 121 (17 per cent) to a crural artery and eight (1 per cent) other. Trainees performed 344 operations: 170 (49 per cent) were to the above-knee popliteal artery, 122 (35 per cent) to the below-knee popliteal artery, 48 (14 per cent) crural and four (1 per cent) other. The operative mortality rate was 27 (4 per cent) of 733 for consultants and 11 (3 per cent) of 344 for trainees (P > 0·05, χ2 test). There were no significant differences in patency or limb salvage at 36 months after operation between consultants and trainees, regardless of the site of distal anastomosis and the type of conduit used. Conclusion With appropriate case selection and supervision, training in infrainguinal bypass grafting does not compromise early or long-term patient outcomes. Presented to the Vascular Surgical Society, Leicester, 24 November 1999, and published in abstract form as Br J Surg 2000; 87: 490

Objectives : the 1998 ECST final report suggests that the decision to operate on patients with greater than 70% symptomatic stenosis should be based on a statistical model incorporating age, sex and degree of stenosis.The aim of this study was to identify patients operated on the basis of the 1991 reports who would not now be offered surgery according to the 1998 ECST recommendations and to determine the surgical morbidity and mortality arising from these ««inappropriate»» CEAs. Methods interrogation of a prospectively gathered database of all CEAs performed for symptomatic stenosis between 1st January 1994 and 1st May 1998. CEAs were classified as ««beneficial»», ««uncertain»» or ««hazardous»» according to the 1998 ECST recommendations. Results : there were 154 males and 72 females (median age (range) was 67 (39–85) and 65 (38–81), respectively). In males 101 (66%) of CEAs were ««beneficial»», 51 (33%) were ««uncertain»» and only two (1%) were ««hazardous»». In women, the corresponding proportions were 13 (18%), 45 (63%) and 14 (19%), respectively. The combined peri-operative major stroke (Rankin 3–5) and death rate was 1.8% (4 patients). Of these, three, one and zero patients were in the ««beneficial»», ««uncertain»» and ««hazardous»» groups. Conclusions : strict adherence to the 1998 ECST recommendations would reduce by 50% the number of CEAs currently performed in this vascular unit and, in general, would restrict CEA to a higher risk group. The validity of the ECST model requires further evaluation.

Purpose: The role of medial calf perforating veins in the pathogenesis of the skin changes of chronic venous insufficiency (CVI) remains controversial. This study examined the relationship between abnormal medial calf perforating vein structure and function and the clinical severity of CVI. Methods: Duplex ultrasound was used as a means of determining the number, flow characteristics, and diameter of medial calf perforating veins, and the presence of deep and superficial main stem reflux or occlusion in 50 limbs with no clinical or duplex evidence of venous disease (clinical, etiological, anatomical, and pathological grade [CEAP] 0), 95 limbs with varicose veins only (CEAP 2/3), 58 limbs affected by lipodermatosclerosis but not ulcer (CEAP 4), and 108 limbs affected by healed or open venous ulcer (CEAP 5/6). Results: The proportion of limbs in which any perforating veins and incompetent perforating veins (IPVs) were demonstrated increased significantly with deteriorating clinical status (CEAP 0, 88% and 6%; CEAP 2/3, 95% and 52%; CEAP 4, 98% and 83%; and CEAP 5/6, 98% and 90%, respectively). The total number of perforators, the total number of IPVs, and the median diameters of perforators increased with deteriorating grade (CEAP 0 median diameter, 2 mm [interquartile range, 1 to 3 mm]; CEAP 2/3 median diameter, 3 mm [interquartile range, 2 to 4 mm]; CEAP 4 median diameter, 4 mm [interquartile range, 3 to 5 mm]; and CEAP 5/6 median diameter, 4 mm [interquartile range, 3 to 5 mm]). Conclusion: The deteriorating CEAP grade of CVI is associated with an increase in the number and diameter of medial calf perforating veins, particularly those permitting bidirectional flow. (J Vasc Surg 2000;32:138-43.)

Objective: internal carotid artery (ICA) plication prevents kinking and secures the distal intimal step following carotid endarterectomy (CEA). The aims of this prospective study were to quantify the proportion of patients in whom plication might be beneficial and determine whether plication is associated with an increased incidence of early restenosis and a reduction in postoperative thromboembolic complications. Methods: analysis of a prospectively gathered computerised database. Results: between 1 November 1992 and 31 December 1997, 228 consecutive CEAs were performed in 213 patients, of which 84 (37%) in 79 patients were plicated. Sixty endarterectomy sites have been examined by duplex ultrasonography at a median of 5 (range 1–44) months postoperatively. No abnormality was detected in 52 (87%), six (10%) had restenosis of

Purpose : Hemorrhage and thrombosis predisposing to myocardial infarction, multiple organ failure, and thromboembolism account for the majority of the morbidity and mortality associated with repair of ruptured and nonruptured abdominal aortic aneurysms (AAAs). The aim of this study was to examine coagulation and fibrinolysis in patients operated on for ruptured and nonruptured infrarenal AAAs. Methods : Ten patients operated on for ruptured and 9 patients operated on for nonruptured AAAs were studied. Tissue plasminogen activator (t-PA) antigen, thrombin-antithrombin (TAT), and D-dimer were measured before induction of anesthesia. Plasminogen activator inhibitor (PAI) activity, t-PA activity, and prothrombin fragment (PF) 1+2 were measured before induction of anesthesia, immediately before aortic clamp release, and 5 minutes and 24 hours after aortic clamp release. Results : Preoperatively, ruptured AAA was associated with significantly elevated t-PA antigen (median 15.7 ng/mL, range 9.0 to 22.1 ng/mL versus nonrupture: median 6.6 ng/mL, range 4.7 to 16.4 ng/mL; P < .01, Mann-Whitney test), increased PAI activity (median 36.5 arbitrary units/mL, range 20.6 to 38.8 arbitrary units/mL versus nonrupture: median 8.2 arbitrary units/mL, range 3.2 to 21.7 arbitrary units/mL; P < .001), reduced t-PA activity (median 0.12 IU/mL, range 0.06 to 0.4 IU/mL versus nonrupture: median 0.49 IU/mL, range 0.14 to 3.2 IU/mL; P < .01), elevated TAT (median 135.5 μg/L, range 61.2 to 209.4 μg/L versus nonrupture: median 21.6 μg/L, range 6.6 to 180.4 μg/L; P < .02) and elevated PF 1+2 (median 9.0 nmol/L, range 5.4 to 11.6 nmol/L versus nonrupture: median 2.2 nmol/L, range 0.7 to 7.1 nmol/L, P < .001). There was no significant difference in preoperative D-dimer levels (median 3460 ng/mL, range 1236 to 7860 ng/mL versus nonrupture: median 1642 ng/mL, range 728 to 5334 ng/mL; P = .07). The differences in PAI activity, t-PA activity, and PF 1+2 persisted throughout the course of surgery, but there was no significant difference between the groups at 24 hours. Conclusion: These novel data demonstrate that ruptured AAA repair is associated with inhibition of systemic fibrinolysis and intense thrombin generation. Similar changes are seen in nonruptured AAA but are of a lesser magnitude. This procoagulant state may contribute to the microvascular and macrovascular thrombosis that leads to myocardial infarction, multiple organ failure, and thromboembolism. (J Vasc Surg 1999;30:641-50.)

Aim: Aortic compliance as measured by the pressure–strain elastic modulus (Ep) and stiffness (β), may allow a more precise estimate of rupture risk. The aim of this study was to determine the relationships between compliance, maximal aneurysm diameter and growth rate. Methods: Sixty abdominal aortic aneurysm patients of median age 73 years, were studied. Growth rate was derived from repeat ultrasound scans obtained over a median period of 21 months (range 6–48). At the end of follow-up, patients underwent measurement of maximum aortic diameter, Ep and β using the Diamove echo-tracking system. Results: Growth rate correlated positively (r=0.6, P

Venous disease of the legs is common and comprises a wide spectrum of clinical severity from asymptomatic incompetence through hyphen-web, reticular and trunk varices to the skin changes of chronic venous insufficiency (CVI) and chronic venous ulceration (CVU) [1]. In the UK, more than 50 000 varicose vein (VV) operations are performed each year [2] and the direct annual health care costs of treating leg ulceration are estimated at £400–600 million [3]. In most developed countries venous disease accounts for 1-2% of total direct health care spending [4–6]. The indirect financial costs of venous disease are unknown but are almost certainly several-fold higher. It is perhaps surprising, therefore, how little information is available in the literature concerning the relationships between: (1) the presence of “venous” symptoms and objective evidence of venous disease on clinical examination (signs); (2) clinical status (symptoms and signs) and the results of venous investigations aimed at defining, functionally and anatomically, the pattern and severity of the venous disease; and (3) surgical intervention and improvements in clinical status and the results of such investigations.

Duplexltrasound is safe, inexpensive, and accurate enough to guide management in most cases

Background This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996). Methods A prospectively gathered database was analysed. Results Infrarenal AAA repair was performed in 1515 patients: 492 (32·5 per cent) had elective repair of an asymptomatic AAA; 194 (12·8 per cent) had elective repair of a symptomatic AAA; 156 (10·3 per cent) had emergency repair of a symptomatic non-ruptured AAA; and 673 (44·4 per cent) had surgery for a ruptured AAA. The 30-day and/or same admission mortality rates were 6·1, 5·8, 14·1 and 37 per cent respectively. Operative mortality increased in all four groups over the study interval, although this only attained statistical significance in patients having elective repair of a symptomatic, non-ruptured AAA. There was a significant increase in the age of patients undergoing elective repair of an asymptomatic AAA, but not in the other three groups. There was also a significant increase in the proportion of straight ‘tube’ grafts inserted in all four groups. Conclusions It remains the minority of patients who have elective operation before the onset of symptoms and/or rupture. Despite anaesthetic and surgical specialization, the results of AAA repair have not improved over the past two decades. Operative mortality may be increasing, possibly because of the increasing age and associated comorbidity of the patients presenting to this unit.

Background The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously. Methods A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic. Results At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0·001, χ2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0·001, χ2 test). Conclusion Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.

Prevention is better than cure