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Every year an estimated 234 million major surgical procedures are undertaken worldwide. In 2009–10, 4.8 million hospital admissions involved surgical input in England alone, and around 4 in 5 adults are likely to have an operation in their lifetime. Despite these enormous numbers, lack of objective evidence for the indications and benefits (or otherwise) of surgical procedures is often lacking. Lack of robust research into surgical disease and treatments has been criticized. Less than 5% of national funding for health research involves surgery. This seems surprising as inappropriate surgical treatments can be hazardous for the patient and costly to the health care system. The demand for evidence-based clinical practice is increasing, driven by public and professional expectations. The scarcity of high-quality studies across many different fields of surgery has led to ambiguity in the management of many common surgical conditions with widely varying clinical outcomes in different geographical areas. Surgical treatments are costly and need to be justified not only on clinical benefit, but on their cost effectiveness compared to other treatments. Several approaches have been adopted to evaluate evidence of benefit for surgical treatments. This article outlines these and their application in a clinical setting. The components of evidence-based medicine and the GRADE method of evaluating quality of evidence are explored. The importance of taking into consideration cost effectiveness and patient attitudes to treatment are also discussed.

Foot complications are a common cause of hospital admission of patients with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the final presenting complication. Recognition of the patient at risk may prevent the development of foot complications initially, but if they occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries.

Peripheral arterial disease (PAD) is an atherosclerotic-driven condition that remains underdiagnosed and undertreated. In diabetic patients, PAD begins early, progresses rapidly, and is frequently asymptomatic, making it difficult to diagnose. Strict management of the metabolic instigators and use of screening techniques for PAD in diabetes can facilitate early diagnosis and reduce progression. Exercise is an equally effective treatment option in improving walking distance. Early revascularization must be offered early in suitable patients. Surgical bypass and endovascular revascularization are complementary and the choice of intervention should be applied appropriately by a multidisciplinary vascular team on a selective, patient-specific basis.

The objective of this study was to determine the effects of prescription omega-3 (n-3) fatty acid ethyl esters (Omacor®) on blood pressure, plasma lipids, and inflammatory marker concentrations in patients awaiting carotid endarterectomy. Patients awaiting carotid endarterectomy (n = 121) were randomised to Omacor® or olive oil as placebo (2 g/day) until surgery (median 21 days). Blood pressure, plasma lipids, and plasma inflammatory markers were determined. There were significant decreases in systolic and diastolic blood pressure and in plasma triglyceride, total cholesterol, low density lipoprotein-cholesterol, soluble vascular cellular adhesion molecule 1, and matrix metalloproteinase 2 concentrations, in both groups. The extent of triglyceride lowering was greater with Omacor® (25%) compared with placebo (9%). Soluble E-selectin concentration was significantly decreased in the Omacor® group but increased in the placebo group. At the end of the supplementation period there were no differences in blood pressure or in plasma lipid and inflammatory marker concentrations between the two groups. It is concluded that Omacor® given at 2 g/day for an average of 21 days to patients with advanced carotid atherosclerosis lowers triglycerides and soluble E-selectin concentrations, but has limited broad impact on the plasma lipid profile or on inflammatory markers. This may be because the duration of intervention was too short or the dose of n-3 fatty acids was too low.

Foot complications are a common cause of hospital admission of patients with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the final presenting complication. Recognition of the patient at risk may prevent the development of foot complications initially, but if they occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries.

Every year an estimated 234 million major surgical procedures are undertaken worldwide. In 2009–10, 4.8 million hospital admissions involved surgical input in England alone and around four in five adults are likely to have an operation in their lifetime. Despite these enormous numbers, objective evidence for the indications and benefits (or otherwise) of surgical procedures is often lacking. Lack of robust research into surgical disease and treatments has been criticized, and less than 2% of national funding for health research involves surgical projects. This seems surprising, as inappropriate surgical treatments can be hazardous for the patient and costly to the healthcare system. The demand for evidence-based clinical practice is increasing, driven by public and professional expectations. The scarcity of high-quality studies across many different fields of surgery has led to ambiguity in the management of many common surgical conditions, with widely varying clinical outcomes in different geographical areas. Surgical treatments are costly and need to be justified, not only on clinical benefit, but on their cost effectiveness compared to other treatments. This article outlines the various approaches that have been adopted to evaluate evidence of benefit for surgical treatments, and their application in a clinical setting. The components of evidence-based medicine and the GRADE method of evaluating quality of evidence are explored. The importance of taking into consideration cost-effectiveness and patient attitudes to treatment is also discussed.

Pancreaticoduodenectomy is the standard treatment for localised neoplasms of the pancreatic head. The operation can be performed safely in specialist units but good outcome is compromised if postoperative blood flow to the liver and biliary tree is inadequate. Coeliac artery occlusion with blood supply to the liver arising from the superior mesenteric artery via the gastroduodenal artery is difficult to recognise, especially intraoperatively. Recognition of absent hepatic artery pulsation after occlusion of the gastroduodenal artery opens a dilemma: should the resection be abandoned or should vascular reconstruction be undertaken, adding risk to an already complex procedure? We describe two cases with a resectable pancreatic endocrine tumour in which coeliac artery occlusion caused by median arcuate ligament compression was identified from cross-sectional imaging and reconstructions. We highlight two different strategies to correct the vascular insufficiency and allow safe pancreatic resection.

Kittipan Rerkasem1, Patrick J Gallagher2, Robert F Grimble3, Philip C Calder3, Clifford P Shearman41Department of Surgery, Faculty of Medicine, Chiang Mai University, Thailand; 2Department of Pathology, Southampton General Hospital, Southampton, UK; 3Institute of Human Nutrition, University of Southampton, Southampton, UK; 4Department of Vascular Surgery, Southampton General Hospital, Southampton, UKPurpose: Hypercholesterolemia is a critical problem in patients with carotid atherosclerosis. The adequacy of attention to lipid risk factors in patients with carotid stenosis awaiting carotid endarterectomy (CEA) has rarely been studied. We also assessed patient awareness of hypercholesterolemia and carotid plaque morphology.Methods: A prospective study was conducted of 141 consecutive patients admitted electively for CEA. Each patient’s medical history was taken. Plasma cholesterol concentrations were determined. Plaque histology was scored according to American Heart Association criteria and their modification.Results: Of patients who were aware of their hypercholesterolemia and who were receiving treatment, 28.6% had total cholesterol levels ≥5 mmol/L. Among those patients who had been told that they had no problem with hypercholesterolemia, 32.5% had plasma cholesterol concentrations ≥5 mmol/L. Among those patients who had never had their plasma cholesterol measured, 48.4% had total cholesterol levels ≥5 mmol/L. Patients in this last group tended to have more severe types of plaque pathology than those in other groups (12.9% plaque rupture).Conclusions: Hypercholesterolemia does not seem to be well managed in patients awaiting CEA.Keywords: cholesterol, carotid endarterectomy, hypercholesterolemia, atherosclerotic plaque

De Haro et al. report that C-reactive protein (CRP) is a predictor of abdominal aortic aneurysm (AAA) sac and neck expansion after endovascular AAA repair (EVAR) in the absence of endoleaks [1]. The authors mention that “even though earlier observations regarding the role of CRP in aneurysmal disease were inconsistent [2], more recent studies have revealed CRP as an independent risk marker for expansion in asymptomatic, uncomplicated, “degenerative” AAAs [3].” The first article [2] is a 2008 systematic review that failed to determine a consistent role for CRP in aneurysmal disease, while the “more recent studies” [3] is a 2012 report by the authors themselves. What the authors did not mention is that a 2014 systematic review [4] that also included the 2012 study by the authors [3] failed to provide convincing evidence that a specific biomarker can predict AAA progression. CRP is a non-specific marker of inflammation and its values fluctuate substantially in response to any inflammatory stimulus [5]. Furthermore, several agents may lower plasma CRP levels, like statins, ezetimibe, metformin, fenofibrate and infliximab [5]. Longterm elevated plasma CRP levels may also be a sign of EVAR graft infection [6]. It is difficult to correct for all these variables. Finally, the authors mention that expansion of the AAA sac and neck after the 6-month stabilization period from EVAR occurred in 63% and

In this issue of Angiology, Gray et al assessed the prevalence of carotid artery stenosis (CAS) and peripheral arterial disease (PAD) in patients with abdominal aortic aneurysms (AAAs); 30.4% of patients with AAA had concomitant CAS and 45.3% had PAD (resting ankle–brachial pressure index [ABPI] 50%) used to define ‘‘significant’’ carotid atherosclerosis. It was argued that severe carotid atherosclerosis is indeed a predictor of concomitant arterial disease in other vascular beds, whereas this does not apply to moderate forms of the disease. Specific factors may lead to the development of vascular disease in 1 vascular territory rather than in another. Crosssectional data from the National Health and Nutrition Examinations Surveys 1999 to 2004 were pooled (total 7550 patients). Active smoking was more common among patients with PAD (30.0% vs 23.9%, respectively; P 1⁄4 .02), whereas hyperlipidemia was more prevalent among patients with coronary heart disease (CHD; 68.4% vs 54.0%, respectively; P < .001). The CHD was more prevalent than PAD in whites (84.6% vs 76.6%, respectively; P 1⁄4 .001), whereas the opposite was true for blacks (6.7% vs 15.9%, respectively; P < .001). An increased risk of CHD was observed only with very low (

Background and Purpose— Previous studies have shown that atherosclerotic lesions express a number of matrix metalloproteinases (MMPs). Here we investigated whether transcript levels of MMP-1, -3, -7, -9, and -12 in carotid atherosclerotic plaques were correlated with histological features and clinical manifestations. Methods— Atherosclerotic plaques (n=50) removed from patients undergoing carotid endarterectomy were classified histologically using a system proposed by Virmani et al, and MMP-1, -3, -7, -9, and -12 transcript levels in these tissues were quantified by real-time reverse-transcriptase polymerase chain reaction. Results— Compared to plaques with a thick fibrous cap, those with a thin cap had a 7.8-fold higher MMP-1 transcript level ( P =0.006). MMP-3, -7, and -12 were 1.5-fold, 1.8-fold, and 2.1-fold, respectively, higher in thin cap plaques, but the differences did not reach statistical significance. MMP-12 transcript levels were significantly increased in ruptured plaques compared with lesions without cap disruption ( P =0.001). MMP-9 transcript levels were similar among the different types of lesion. MMP-1 and -12 transcript levels were significantly higher in plaques from patients with amaurosis fugax, than in those from asymptomatic patients ( P =0.029 and P =0.008 for MMP-1 and MMP-12, respectively), than in those from patients with stroke ( P =0.027 and P =0.001, respectively), and than in those from patients with transient ischemic attack ( P =0.046 and P =0.008, respectively). Conclusions— These data support a role of MMP-1 and -12 in determining atherosclerotic plaque stability.

Up to 15 % of people with diabetes will suffer foot complications, mostly commonly ulceration, at some time in their life. Diabetic foot ulcers have a major impact on their quality of life and significantly increase their risk of major amputation. The cost of treating this common complication is a significant amount of the health budget in developed countries and with the increasing prevalence of diabetes is likely to increase. Considerable evidence suggests that identification of those at risk, early treatment of complications and structured services will reduce first time ulceration and reduce amputation rates as well as being highly cost-effective.

The foot of a person with diabetes is at risk for a number of reasons. Neuropathy is common, particularly if diabetes is long-standing and glycaemic control has been poor. Not only does the neuropathy reduce sensation and result in deformity, making the foot susceptible to injury, but the autonomic component may cause arteriovenous shunting and other micro-circulatory changes, which result in reduced nutritional skin perfusion, despite a foot that may look pink and feel warm. Initially the patient may be unaware of the developing wound. Peripheral arterial disease affecting the main arteries of the lower limb is four times more common in people with diabetes. This may have previously been recognized, causing symptoms such as intermittent claudication, but is often asymptomatic, only becoming apparent when a minor wound on the foot fails to heal.

PAD is very common in people with diabetes and is one of the strongest predictors of developing nonhealing foot ulcers and suffering amputation. There is strong evidence to show that early detection of PAD and revascularization will reduce amputations. Despite this, many patients have no vascular assessment even when they present with a foot ulcer or before amputation. Even when identified, patients are referred late, which worsens their outcome. Currently there is no evidence to support surgical revascularization over endovascular treatments, but in reality the techniques are complementary and the choice of revascularization procedure should be determined by an experienced multidisciplinary vascular team. Surgical revascularization can achieve good results but careful patient selection, operative planning, and the use of autologous vein are necessary. What is clearly apparent is that at present not enough patients are being offered revascularization to prevent amputation.

A Bayesian surrogate modeling technique is proposed that may be able to predict an optimal bypass graft configuration for patients suffering with stenosis in the internal carotid artery (ICA). At the outset, this statistical technique is considered as a means for identifying key geometric parameters influencing haemodynamics in the human carotid bifurcation. This methodology uses a design of experiments (DoE) technique to generate candidate geometries for flow analysis. A pulsatile one dimensional Navier-Stokes solver incorporating fluid-wall interactions for a Newtonian fluid which predicts pressure and flow in the carotid bifurcation (comprising a stenosed segment in the internal carotid artery) is used for the numerical simulations. Two metrics, pressure variation factor (PVF) and maximum pressure (p(*)(m)) are employed to directly compare the global and local effects, respectively, of variations in the geometry. The values of PVF and p(*)(m) are then used to construct two Bayesian surrogate models. These models are statistically analyzed to visualize how each geometric parameter influences PVF and p(*)(m). Percentage of stenosis is found to influence these pressure based metrics more than any other geometric parameter. Later, we identify bypass grafts with optimal geometric and material properties which have low values of PVF on five test cases with 70%, 75%, 80%, 85%, and 90% stenosis in the ICA, respectively.5%, 80%, 85%, and 90% stenosis in the ICA, respectively.

Intermittent claudication is an early manifestation of atherosclerosis in the leg. The prognosis for the claudicating limb is reasonably good, but patients have excess cardiovascular morbidity and mortality rates compared with a control population. Increasing evidence suggests that the calf pain experienced when walking followed by rest generates a low-grade inflammatory response. The cumulative effects of these individual events may have an adverse effect on the progression of atherosclerosis.A review of the literature was performed to identify studies measuring the exercise-induced inflammatory response in claudicants and to try to identify the role of cumulative inflammatory changes in the progression of atherosclerosis. The effect of exercise training on these markers is briefly explored. Walking until the onset of calf pain (ischaemia) followed by rest (reperfusion) results in the generation of oxygen-derived free radicals, neutrophil activation and a generalized increase in vascular permeability. Baseline levels of chronic inflammatory markers such as acute-phase proteins are elevated in claudicants compared with controls, suggesting that the transient acute inflammatory response has longer-term consequences. Therapeutic exercise training appears to lead to an attenuation of these inflammatory markers.Intermittent claudication can be considered as part of an inflammatory disease process. However, the concerns that exercise training might potentiate the vascular inflammatory response appear to be unjustified, although further work is needed to clarify this. Exercise training should therefore be considered as an important treatment option for claudication.