112 results on '"Donald J. Adam"'
Search Results
2. Complex Endovascular Repair of Paravisceral Infective Native Aortic Aneurysms
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Maciej Juszczak, Harvinder Mann, Michael Riste, Andrew Woodhouse, Karl Sörelius, Martin Claridge, and Donald J. Adam
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Radiology, Nuclear Medicine and imaging ,Surgery ,Cardiology and Cardiovascular Medicine - Abstract
Objective: To report the early and mid-term outcome of complex endovascular repair (EVAR) for paravisceral infective native aortic aneurysms (INAA). Methods: Interrogation of a prospectively maintained database identified consecutive patients who underwent non-elective complex EVAR for paravisceral INAAs in a single institution between December 2013 and June 2020. All patients were considered to have definite INAAs based on diagnostic criteria. Patients who had prior aortic repair were excluded. Results: A total of 26 patients (19 men; mean age 67 years [SD = 11.4]; median diameter 60 mm [IQR: 55–73]) with acute symptomatic (n = 24) or contained ruptured (n = 2) aneurysms underwent surgeon-modified fenestrated EVAR (SM-FEVAR; n = 24) or chimney-periscope EVAR (CHIMPS; n = 2). Median observed follow-up was 36.2 months (18.3–53.5). Nine patients had positive venous blood cultures and a further seven had recent or concomitant infection. All patients received pre- and post-operative antibiotic therapy and rifampicin-soaked endografts. A total of 95 vessels were targeted for preservation and 86 were stent-grafted. One vessel occluded intra-operatively and a further 3 occluded within 30 days. The 30-day/in-hospital mortality was 11.5% (n = 3), and the estimated 1- and 3-year survival (±SD) was 85% ± 7%. Infection-related complications (IRCs) occurred in two patients: both developed new INAA within 30 days of index repair and were treated by EVAR with no mortality. Estimated 3-year freedom from late re-intervention was 100%. One patient required infrarenal EVAR for a non-infective aneurysm at 43 months. Conclusion: Complex EVAR for paravisceral INAAs is associated with acceptable early and mid-term outcomes and is an acceptable alternative to open surgery. We propose that these patients are managed with long-term antimicrobials, impregnation of graft material with rifampicin, and rigorous post-operative surveillance. Clinical Impact A multi-disciplinary approach is required to deliver the best possible outcome for patients with this challenging aortic pathology.
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- 2022
3. Multicenter Study to Evaluate Endovascular Repair of Extent I-III Thoracoabdominal Aneurysms Without Prophylactic Cerebrospinal Fluid Drainage
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Giulianna B, Marcondes, Nolan C, Cirillo-Penn, Emanuel R, Tenorio, Donald J, Adam, Carlos, Timaran, Martin J, Austermann, Luca, Bertoglio, Tomasz, Jakimowicz, Michele, Piazza, Maciej T, Juszczak, Carla K, Scott, Bärbel, Berekoven, Roberto, Chiesa, Guilherme B B, Lima, Katarzyna, Jama, Francesco, Squizzato, Martin, Claridge, Bernardo C, Mendes, and Gustavo S, Oderich
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Surgery - Abstract
To assess outcomes of fenestrated-branched endovascular aortic repair (FB-EVAR) of Extent I-III thoracoabdominal aortic aneurysms (TAAAs) without prophylactic cerebrospinal fluid drainage (CSFD).Prophylactic CSFD has been routinely used during endovascular TAAA repair, but concerns about major drain-related complications gave led to revising this paradigm.We reviewed a multicenter cohort of 541 patients treated for Extent I-III TAAAs by FB-EVAR without prophylactic CSFD. Spinal cord injury (SCI) was graded as ambulatory (paraparesis) or non-ambulatory (paraplegia). Endpoints were any SCI, permanent paraplegia, response to rescue treatment, major drain-related complications, mortality, and patient survival.There were 22 Extent I, 240 Extent II and 279 Extent III TAAAs. Thirty-day mortality was 3%. SCI occurred in 45 patients (8%), paraparesis occurring in 23 (4%) and paraplegia in 22 patients (4%). SCI was more common in patients with Extent I-II compared to Extent III TAAAs (12% vs. 5%, P=0.01). Rescue treatment included permissive hypertension in all patients, with CSFD in 22 (4%). Symptom improvement was noted in 73%. Twelve patients (2%) had permanent paraplegia. Two patients (0.4%) had major drain-related complications. Independent predictors for SCI by multivariate logistic regression were sustained peri-operative hypotension (OR 4.4, 95% CI 1.7-11.1), patent collateral network (OR 0.3, 95% CI 0.1-0.6), and total length of aortic coverage (OR 1.05, CI 95% 1.01-1.10). Patient survival at 3-years was 72±3%.FB-EVAR of Extent I-III TAAAs without CSFD has low mortality and low rates of permanent paraplegia (2%). SCI occurred in 8% of patients, and rescue treatment improved symptoms in 73% of them.
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- 2022
4. Back Table Or In Situ? Select Your Window
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Donald J. Adam and Martin W.C. Claridge
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Surgery ,Cardiology and Cardiovascular Medicine - Published
- 2023
5. Effect of ramipril on renal function in patients with intermittent claudication
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Simon D Hobbs, Martin W Claridge, Antonius BM Wilmink, Donald J Adam, Mark E Thomas, and Andrew W Bradbury
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Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
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
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- 2008
6. Fenestrated-branched endovascular repair for distal thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk
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Ahmed Shalan, Emanuel R. Tenorio, Jorge G. Mascaro, Maciej T. Juszczak, Martin W. Claridge, Andrea Melloni, Luca Bertoglio, Roberto Chiesa, Gustavo S. Oderich, and Donald J. Adam
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Male ,Branch ,Time Factors ,Aortic Aneurysm, Thoracic ,Endovascular ,Spinal Cord Ischemia ,Endovascular Procedures ,Prosthesis Design ,Fenestrated ,Blood Vessel Prosthesis ,Blood Vessel Prosthesis Implantation ,Postoperative Complications ,Treatment Outcome ,Risk Factors ,Humans ,Stents ,Surgery ,Distal repair ,Frozen elephant trunk ,Cardiology and Cardiovascular Medicine ,Aged ,Retrospective Studies - Abstract
To report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET).Interrogation of prospectively maintained databases from four high-volume aortic centers identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. The primary end point was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, midterm survival, and freedom from reintervention. Data are presented as median (interquartile range).A total of 39 patients (21 men; median age, 73 years [67-75 years]) with degenerative (n = 22) and postdissection thoracoabdominal aortic aneurysms (n = 17) (median diameter, 71 mm [61-78 mm]) were identified. Distal FBEVAR was intended in 27 patients (median interval, 9.8 months [6.2-16.6 months]), anticipated in 7, and unexpected in 5. A total of 31 patients had a two- (n = 24) or three-stage (n = 7) distal FBEVAR. Renovisceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. Thirty-day mortality was 2.6% (n = 1; respiratory failure and spinal cord ischemia [SCI]). Six survivors also developed SCI, which was associated with complete (n = 4) or partial recovery (n = 2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7 months). Eleven patients required 16 late reinterventions. Estimated 3-year survival and freedom from reintervention were 84% ± 6% and 63% ± 10%, respectively.Distal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Midterm patient survival is favorable, but there remains a high requirement for late reintervention. FBEVAR represents an acceptable alternative to distal open thoracoabdominal aortic aneurysm repair.
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- 2022
7. Digital Transformation of Borehole Sonic Services in the Oil and Gas Industry
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Donald, J. Adam, additional, Wielemaker, Erik, additional, Velez, Edgar, additional, Liang, Lin, additional, Lei, Ting, additional, Blyth, Matthew, additional, and Prioul, Romain, additional
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- 2021
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8. The Impact of Anisotropic Mechanical Properties on Stimulation and Wellbore Stability in the Beetaloo Basin, Northern Territory, Australia
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Donald, J Adam, primary and Neville, Thomas J., additional
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- 2021
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9. Geomechanics Characterization of Nahr Umr and Laffan Shales Through Anisotropic Geomechanics and Shale Stability Analysis for Drilling Optimization
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Xi, Guifen, additional, Draoui, Elyes Habib, additional, Alblooshi, Jamal Rashed, additional, Al-Jaberi, Salem Mubarak, additional, Al-Badi, Bader Saif, additional, Muniz, Eudes Siqueira, additional, Guerra, Julian, additional, Donald, J. Adam, additional, Povstyanova, Magdalena, additional, Martin, J. Wesley, additional, Balliache, Norka Marcano, additional, and Deenadayalu, Chaitanya, additional
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- 2020
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10. Endovascular Repair of Acute Thoracoabdominal Aortic Aneurysms with Surgeon-modified Fenestrated Endografts
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Donald J. Adam, Maciej T. Juszczak, Martin W Claridge, and Massimo Vezzosi
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medicine.medical_specialty ,business.industry ,medicine ,Surgery ,Cardiology and Cardiovascular Medicine ,Thoracoabdominal Aortic Aneurysms ,business - Published
- 2019
11. Fusion Imaging Guided EVAR Reduces Radiation - The Results of a Prospective Radiation Evaluation During EVAR (REVAR)
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Hisashi Tonda, Andrew Mayes, Hervé Rousseau, Robert Rhee, Adrien Hertault, Stéphan Haulon, Donald J. Adam, and Aurélia Bianchini
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Image fusion ,business.industry ,Medicine ,Surgery ,Radiation ,Cardiology and Cardiovascular Medicine ,Nuclear medicine ,business - Published
- 2019
12. The proposed UK abdominal aortic aneurysm guidelines: A much needed wakeup call
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Bijan Modarai, Donald J. Adam, Mark Tyrrell, and Tara M. Mastracci
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medicine.medical_specialty ,Treatment outcome ,Clinical Decision-Making ,MEDLINE ,Aortic aneurysm ,Clinical decision making ,Risk Factors ,medicine ,Humans ,Evidence-Based Medicine ,business.industry ,General surgery ,Patient Selection ,Endovascular Procedures ,Evidence-based medicine ,medicine.disease ,Abdominal aortic aneurysm ,United Kingdom ,Outcome and Process Assessment, Health Care ,Treatment Outcome ,Practice Guidelines as Topic ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Abdominal surgery ,Aortic Aneurysm, Abdominal - Published
- 2018
13. TI elastic-property inversion on basis of walkaway VSP and full-waveform sonic
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Donald, J. Adam, primary, Jocker, Jeroen, additional, Leaney, Scott, additional, Dasgupta, Suvodip, additional, Van Kleef, Franciscus, additional, and Brindle, Frank, additional
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- 2018
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14. Effect of endovascular and open abdominal aortic aneurysm repair on thrombin generation and fibrinolysis
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Rajiv K. Vohra, Robert S.M. Davies, Mohamed Abdelhamid, Andrew W. Bradbury, and Donald J. Adam
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Antithrombin III ,Aortography ,Endovascular aneurysm repair ,Blood Vessel Prosthesis Implantation ,Aortic aneurysm ,Aneurysm ,Internal medicine ,Fibrinolysis ,medicine ,Humans ,cardiovascular diseases ,Aged ,Aged, 80 and over ,business.industry ,Endovascular Procedures ,Thrombin ,Case-control study ,Thrombosis ,Middle Aged ,medicine.disease ,Peptide Fragments ,Abdominal aortic aneurysm ,Surgery ,Plasminogen Inactivators ,Treatment Outcome ,Case-Control Studies ,Tissue Plasminogen Activator ,Cardiology ,Female ,Prothrombin ,Tomography, X-Ray Computed ,Cardiology and Cardiovascular Medicine ,business ,Plasminogen activator ,Biomarkers ,Aortic Aneurysm, Abdominal ,Peptide Hydrolases ,Abdominal surgery - Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is associated with a prothrombotic diathesis that may increase the risk of cardiovascular events. This diathesis is exacerbated in the short term by open aneurysm repair (OAR) and endovascular aneurysm repair (EVAR). However, the effect of EVAR and OAR on coagulation and fibrinolysis in the medium and long term is poorly understood. The purpose of this study was to investigate the medium-term effects of EVAR and OAR on thrombin generation, neutralization, and fibrinolysis. METHODS Prothrombin fragment (PF)1+2, thrombin antithrombin (TAT) complex, plasminogen activator inhibitor (PAI) activity, and tissue-plasminogen activator (t-PA) antigen were measured in eight age-matched controls (AMCs), 29 patients with AAA immediately before (preoperatively) and 12 months after EVAR (post-EVAR), and in 11 patients at a mean of 16 months after OAR (post-OAR). RESULTS Preoperatively, PF1+2 levels were significantly higher in patients with AAAs than in AMC. PF1+2 levels post-EVAR and post-OAR were significantly lower than preoperative values and similar to AMC. There was no significant difference in TAT, PAI, or t-PA between AMC, AAA preoperatively, and post-EVAR. Post-OAR, PAI activity was significantly higher than in preoperative patients. CONCLUSIONS AAA is associated with increased thrombin generation without upregulation of fibrinolysis. The prothrombotic, hypofibrinolytic diathesis observed in patients with AAA returns toward normal in the medium term after EVAR and OAR, although there is a trend toward decreased fibrinolysis post-OAR.
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- 2013
15. Coagulation, fibrinolysis, and platelet activation in patients undergoing open and endovascular repair of abdominal aortic aneurysm
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Andrew W. Bradbury, Robert S.M. Davies, Mohamed Abdelhamid, Rajiv K. Vohra, Michael L. Wall, and Donald J. Adam
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Endovascular aneurysm repair ,Risk Assessment ,Aortic aneurysm ,Blood Vessel Prosthesis Implantation ,Risk Factors ,Internal medicine ,Fibrinolysis ,medicine ,Animals ,Humans ,cardiovascular diseases ,Platelet activation ,Blood Coagulation ,Surgical repair ,business.industry ,Endovascular Procedures ,Thrombosis ,Perioperative ,medicine.disease ,Platelet Activation ,Abdominal aortic aneurysm ,Surgery ,Treatment Outcome ,Hemostasis ,Cardiology ,Female ,business ,Cardiology and Cardiovascular Medicine ,Biomarkers ,Aortic Aneurysm, Abdominal - Abstract
Background Endovascular aneurysm repair (EVAR) is associated with an improved perioperative mortality compared to open surgical repair. This benefit may reflect reduced incidence of microvascular and macrovascular thrombotic complications after EVAR. Purpose The purpose of this study was to review and compare the effects of abdominal aortic aneurysm (AAA), open surgical repair, and EVAR on coagulation, fibrinolysis, and platelet activation. Methods A MEDLINE (1966-2010) and Cochrane library search for articles relating to the effects of AAA, open surgical repair, and EVAR on hemostasis was performed utilizing and cross-linking terms such as clotting, fibrinolysis, AAA, EVAR, and open surgical repair. Studies with a small cohort of patients (less than 7) or in which values of assessed biomarkers were not included were rejected. Results AAA is associated with increased thrombin generation, activity, and fibrin turnover as evidenced by increased plasma levels of thrombin-antithrombin III-complex (TAT), activated protein C-protein C inhibitor (APC-PCI), fibrin-monomer-fibrinogen (FM-F), F1+2, fibrinogen, and D-dimer. The extent of hemostatic derangement correlates with the volume of intraluminal thrombus. This procoagulant state is exaggerated in the immediate perioperative period after both open surgical repair and EVAR, but is attenuated at medium-term follow-up although not normalized. Conclusion The resultant prothrombotic diathesis after open surgical repair and EVAR may account for the high level of perioperative thrombotic complications.
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- 2011
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16. Endovascular aneurysm repair reverses the increased titer and the inflammatory activity of interleukin-1α in the serum of patients with abdominal aortic aneurysm
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Andrew W. Bradbury, Gerard B. Nash, G. Ed Rainger, Donald J. Adam, Clara M. Yates, and Mohamed Abdelhamid
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medicine.medical_specialty ,Chemokine ,Time Factors ,Neutrophils ,medicine.medical_treatment ,Down-Regulation ,Stimulation ,Aortography ,Endovascular aneurysm repair ,Gastroenterology ,Aortic aneurysm ,Interleukin-1alpha ,Internal medicine ,Cell Adhesion ,Humans ,Medicine ,Cells, Cultured ,Aged ,Aged, 80 and over ,Immunoassay ,Analysis of Variance ,Microscopy, Video ,biology ,Tumor Necrosis Factor-alpha ,business.industry ,Endovascular Procedures ,Transendothelial and Transepithelial Migration ,Endothelial Cells ,medicine.disease ,Abdominal aortic aneurysm ,Treatment Outcome ,Cytokine ,England ,Case-Control Studies ,Immunology ,biology.protein ,Surgery ,Tumor necrosis factor alpha ,Inflammation Mediators ,Tomography, X-Ray Computed ,Cardiology and Cardiovascular Medicine ,business ,Biomarkers ,Aortic Aneurysm, Abdominal ,Abdominal surgery - Abstract
ObjectiveTo examine serum cytokine/chemokine profiles before and 6 months after endovascular repair (EVAR) of abdominal aortic aneurysm (AAA) and to determine whether they correlate with serum inflammatory activity using an in vitro model of leukocyte recruitment.MethodsSerum IL-1-α, IL-1β, IL-4, IL-6, IL-8, IL-10, IFN-γ, IP-10, MCP-1, TNF-α, and TNF-β were measured using a cytometry-based immunoassay. To test patient serum for direct inflammatory activity, human endothelial cells (EC) were stimulated with 30% patient serum for 24 hours. To test patient serum for the ability to prime EC for inflammatory responses, EC were incubated with 30% patient serum for 24 hours, followed by stimulation with low-dose (5 U/mL) TNF for 4 hours. Under both regimens of stimulation, the degree of EC activation was assessed by assaying neutrophil recruitment in a flow-based model.ResultsOnly IL-1α (67.9 ± 10.4 pg/mL vs 41.9 ± 7.4 pg/mL) and IL-8 (51.5 ± 5.1 vs 32.6 ± 4.7 pg/mL) changed significantly after surgery. Patient serum alone was unable to activate EC. However, serum from both time points could prime EC responses to low-dose TNF. Thus, after priming with preoperative serum, EC stimulated with TNF could recruit 76.7 ± 12.0 neutrophils/mm2 into the subendothelial cell space. Post-EVAR serum was significantly less effective (44.4 ± 10.2 neutrophils/mm2). This reduction in neutrophil recruitment correlated with reduced IL-1α in post-EVAR serum. The addition of a neutralizing antibody against IL-1α to pre-EVAR serum inhibited EC priming and neutrophil recruitment, strongly implying that this cytokine was the priming agent.ConclusionEVAR reduces serum IL-1α and its inflammatory activity in patient serum. IL-1α is, therefore, implicated in the molecular pathology of AAAs and may have potential as a clinically useful biomarker.Clinical RelevanceContinuing uncertainty exists over which patients will benefit from abdominal aortic aneurysm (AAA) repair in addition to medical therapy as well as which repair method, open or endovascular, is the most clinically and cost-effective. Greater understanding of AAA development and progression, and the subsequent identification of biomarkers for rupture risk, are likely to result in better selection of patients for intervention and provide better measures of successful repair. These novel data implicate interleukin (IL)-1α in the molecular pathology of AAA. Further, they suggest that IL-1α may be a predictive biomarker for AAA size as well as outcome after endovascular aneurysm repair.
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- 2011
17. Duplex Ultrasound Outcomes following Ultrasound-guided Foam Sclerotherapy of Symptomatic Recurrent Great Saphenous Varicose Veins
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Gareth Bate, K.A.L. Darvall, Andrew W. Bradbury, S.H. Silverman, and Donald J. Adam
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Adult ,Male ,medicine.medical_specialty ,Time Factors ,Chronic venous insufficiency ,medicine.medical_treatment ,Sodium Tetradecyl Sulfate ,Recurrence ,Sclerotherapy ,Varicose veins ,medicine ,Sodium tetradecyl sulphate ,Humans ,Duplex ultrasound ,Saphenous Vein ,Ultrasonography, Interventional ,Aged ,Medicine(all) ,Aged, 80 and over ,Ultrasonography, Doppler, Duplex ,business.industry ,Ultrasound ,Reflux ,Middle Aged ,medicine.disease ,Sclerosing Solutions ,Ultrasound guided ,Surgery ,Treatment Outcome ,England ,Duplex (building) ,Retreatment ,Female ,Radiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
ObjectivesTo describe duplex ultrasound (DUS) outcomes 12 months following ultrasound-guided foam sclerotherapy (UGFS) of recurrent great saphenous varicose veins (GSVV).MethodsA consecutive series of UK National Health Service patients underwent serial DUS examinations following UGFS with 3% sodium tetradecyl sulphate for symptomatic recurrent GSVV.Results91 treated legs (CEAP C2/3 58, C4 21, C5 8, C6 4) belonging to 73 patients (24 male) of median age 58 (range 32–86) years were enrolled between November 2004 and May 2007. The median volume of foam used was 8 (range 4–14) ml. Above-knee (AK) and below-knee (BK) GSV reflux was present in 88 (97%) and 80 (88%) legs respectively prior to treatment. AK and BK-GSV reflux was completely eradicated by a single session of UGFS in 86 (98%) and 74 (93%) legs respectively; and by two sessions of UGFS in 88 (100%) and 77 (97%) legs respectively. In those legs where GSV reflux had been eradicated, recanalisation occurred in 7/78 (9%) AK and 8/68 (12%) BK-GSV segments after 12 months follow-up. Retreatment, where undertaken, with a single UGFS session effectively eradicated all GSV reflux in all cases of recanalisation.DiscussionA single session of UGFS can eradicate reflux in the AK and BK-GSV in over 93% of patients with symptomatic recurrent GSVV. Re-recurrence at 12 months is superior to that reported after redo GSV surgery, similar to that observed following other minimally-invasive techniques and, when it occurs, is effectively and simply treated by a single further session of UGFS.
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- 2011
18. Healing and Recurrence Rates Following Ultrasound-guided Foam Sclerotherapy of Superficial Venous Reflux in Patients with Chronic Venous Ulceration
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K.H. Pang, Andrew W. Bradbury, Donald J. Adam, Gareth Bate, and K.A.L. Darvall
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Kaplan-Meier Estimate ,Chronic venous ulcers ,Varicose Ulcer ,Recurrence ,Interquartile range ,Sclerotherapy ,medicine ,Recurrence rates ,Humans ,In patient ,Prospective Studies ,Ultrasonography, Interventional ,Aged ,Medicine(all) ,Wound Healing ,business.industry ,Middle Aged ,Sclerosing Solutions ,Ultrasound guided ,Surgery ,Healing rates ,Treatment Outcome ,Venous ulceration ,Databases as Topic ,England ,Venous Insufficiency ,Chronic Disease ,Venous reflux ,Female ,Cardiology and Cardiovascular Medicine ,business ,Ultrasound-guided foam sclerotherapy - Abstract
Objectives To determine healing and recurrence rates following ultrasound-guided foam sclerotherapy (UGFS) of superficial venous reflux (SVR) in patients with healed (clinical, etiologic, anatomic and pathophysiologic (CEAP) classification, C5) and open (C6) chronic venous ulceration (CVU). Methods Between 1 March 2005 and 31 December 2009, 130 consecutive patients (132 limbs, 49 CEAP C5, 83 C6) of median age 70 (interquartile range (IQR) 56–76) years underwent UGFS as part of their treatment for CVU. Results The median (IQR) follow-up time was 16 (12–32) months. One C6 patient moved abroad 1 week after UGFS and was lost to follow-up. Healing was observed in 67/82 (82%) remaining C6 patients at a median (IQR) of 1 (1–2) month following their first UGFS treatment. In 49 limbs originally treated for C5 disease, and in 67 limbs treated for C6 that healed following UGFS, there were five recurrent ulcers during the follow-up period, giving a 4.9% Kaplan–Meier estimate of recurrence at 2 years. In legs treated for C6 and C5 disease, the median (IQR) ulcer-free periods were 22 (IQR 9–32) and 14 (IQR 8–36) months, respectively. Discussion Healing rates following UGFS for CVU are comparable to those reported after surgery but recurrence may be lower. UGFS is a safe, clinically effective and, thus, highly attractive minimally invasive alternative to surgery in patients with C5 and C6 disease.
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- 2010
19. Radiation Dose Reduction During EVAR: Results from a Prospective Multicentre Study (The REVAR Study)
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Hervé Rousseau, Stéphan Haulon, George A. Antoniou, Aurélia Bianchini, Adrien Hertault, Donald J. Adam, Hisashi Tonda, and Robert Rhee
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Male ,Time Factors ,Computed Tomography Angiography ,medicine.medical_treatment ,Operative Time ,Contrast Media ,030204 cardiovascular system & hematology ,Demographic data ,Radiation Dosage ,Radiography, Interventional ,Endovascular aneurysm repair ,Aortography ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Blood Vessel Prosthesis Implantation ,0302 clinical medicine ,Radiation Protection ,Japan ,Predictive Value of Tests ,Radiation Monitoring ,Risk Factors ,medicine ,Humans ,Prospective Studies ,Aged ,Aged, 80 and over ,Dose delivery ,business.industry ,Radiation dose ,Endovascular Procedures ,Radiation Exposure ,Computed tomographic angiography ,Radiation exposure ,Europe ,Treatment Outcome ,Dose area product ,Practice Guidelines as Topic ,Female ,New York City ,Surgery ,Guideline Adherence ,Patient Safety ,business ,Nuclear medicine ,Cardiology and Cardiovascular Medicine ,Body mass index ,Aortic Aneurysm, Abdominal - Abstract
OBJECTIVE To evaluate radiation exposure in standard endovascular aneurysm repair (EVAR) using intra-operative guidance with pre-operative computed tomographic angiography (CTA) fusion and strict ALARA guidelines in a modern hybrid room. MATERIAL AND METHODS Between February and November 2016, consecutive patients with AAA undergoing EVAR with a bifurcated device in a hybrid room under fusion imaging guidance were prospectively enrolled in six aortic centres from the United States (n = 1), Europe (n = 4), and Japan (n = 1). Demographic data including body mass index (BMI), indirect dose area product (DAP), cumulative air kerma (CAK), variables influencing dose delivery, and contrast media volume were collected. RESULTS 85 patients (90.4% males) were included. The median age was 75 (IQR 69-81), with a median BMI of 27.4 (IQR 24.7-30.6). Median DAP and CAK were 14.7 (IQR 10.0-27.7) Gy·cm and 107 (IQR 68.0-189.0) mGy, respectively. The median contrast volume was 47 mL (IQR 35-70) (equivalent to 14.1g of iodine [IQR 10.5-21.0]). Median DAP per centre was 28.1 (n = 16, IQR 12.6-47.1), 15.9 (n = 11, IQR 11.9-22.5), 14.2 (n = 12, IQR 10.9-25.7), 20.2 (n = 18, IQR 7.0-39.5), 10.3 (n = 27, IQR 8.2-14.7) and 26.5 (n = 1) Gy·cm. In multivariable analysis, collimation was the only factor that was significantly associated with DAP reduction, (coefficient = -0.014 per percentage of collimation, 95% CI -0.019 to -0.008, p
- Published
- 2018
20. Photoplethysmographic Venous Refilling Times Following Ultrasound Guided Foam Sclerotherapy for Symptomatic Superficial Venous Reflux: Relationship with Clinical Outcomes
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Andrew W. Bradbury, R.C. Sam, S.H. Silverman, Donald J. Adam, Gareth Bate, and K.A.L. Darvall
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Adult ,Male ,Quality of life ,medicine.medical_specialty ,Duplex ultrasonography ,medicine.medical_treatment ,Severity of Illness Index ,Young Adult ,Symptom relief ,Photoplethysmogram ,Sclerotherapy ,Varicose veins ,medicine ,Humans ,Photoplethysmography ,Ultrasonography, Interventional ,Aged ,Medicine(all) ,Ultrasonography, Doppler, Duplex ,business.industry ,Middle Aged ,Sclerosing Solutions ,Ultrasound guided ,Treatment Outcome ,Lower Extremity ,Venous Insufficiency ,Venous reflux ,Female ,Surgery ,Radiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
IntroductionDigital photoplethysmography (PPG) provides an inexpensive, reproducible, quantitative, non-invasive assessment of lower limb venous function.AimTo examine the relationship between venous refilling time (VRT) and severity of venous disease, and also between changes in VRT and symptomatic improvement after ultrasound guided foam sclerotherapy (UGFS) for symptomatic superficial venous reflux (SVR).MethodsPrior to and 6 months after UGFS, 246 patients (317 limbs) completed a symptom questionnaire, underwent duplex ultrasonography and clinical assessment, and VRT measurement by digital PPG. Health related quality of life (HRQL) questionnaires were also completed.ResultsMedian VRT improved from 11 to 31 s (P
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- 2010
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21. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Health-related quality of life outcomes, resource utilization, and cost-effectiveness analysis
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John F. Forbes, I. Gillespie, Andrew W. Bradbury, C. V. Ruckley, Donald J. Adam, F. Gerry R. Fowkes, Gillian M. Raab, and Jocelyn Bell
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Male ,medicine.medical_specialty ,Time Factors ,Randomization ,Cost-Benefit Analysis ,medicine.medical_treatment ,Constriction, Pathologic ,Revascularization ,Severity of Illness Index ,law.invention ,Blood Vessel Prosthesis Implantation ,Randomized controlled trial ,Quality of life ,Ischemia ,law ,Surveys and Questionnaires ,Severity of illness ,medicine ,Humans ,Saphenous Vein ,Prospective Studies ,Hospital Costs ,Aged ,Aged, 80 and over ,Peripheral Vascular Diseases ,business.industry ,Cost-effectiveness analysis ,Length of Stay ,Middle Aged ,United Kingdom ,Quality-adjusted life year ,Radiography ,Treatment Outcome ,Lower Extremity ,Bypass surgery ,Emergency medicine ,Quality of Life ,Physical therapy ,Health Resources ,Female ,Surgery ,Quality-Adjusted Life Years ,business ,Cardiology and Cardiovascular Medicine ,Vascular Surgical Procedures ,Angioplasty, Balloon - Abstract
Background:The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that survival in patients with severe lower limb ischemia (rest pain, tissue loss) who survived postintervention for >2 years after initial randomization to bypass surgery (BSX) vs balloon angioplasty (BAP) was associated with an improvement in subsequent amputation-free and overall survival of about 6 and 7 months, respectively. We now compare the effect on hospital costs and health-related quality of life (HRQOL) of the BSX-first and BAP-first revascularization strategies using a within-trial cost-effectiveness analysis.Methods: We measured HRQOL using the Vascular Quality of Life Questionnaire (VascuQol), the Short Form 36 (SF-36), and the EuroQol (EQ-5D) health outcome measure up to 3 years from randomization. Hospital use was measured and valued using United Kingdom National Health Service hospital costs over 3 years. Analysis was by intention-to-treat. Incremental cost-effectiveness ratios were estimated for cost per quality-adjusted life-year (QALY) gained. Uncertainty was assessed using nonparametric bootstrapping of incremental costs and incremental effects.Results: No significant differences in HRQOL emerged when the two treatment strategies were compared. During the first year from randomization, the mean cost of inpatient hospital treatment in patients allocated to BSX ($34,378) was estimated to be about $8469 (95% confidence interval, $2,417-$14,522) greater than that of patients allocated to BAP ($25,909). Owing to increased costs subsequently incurred by the BAP patients, this difference decreased at the end of follow-up to $5521 ($45,322 for BSX vs $39,801 for BAP) and was no longer significant. The incremental cost-effectiveness ratio of a BSX-first strategy was $184,492 per QALY gained. The probability that BSX was more cost-effective than BAP was relatively low given the similar distributions in HRQOL, survival, and hospital costs.Conclusions: Adopting a BSX-first strategy for patients with severe limb ischemia does result in a modest increase in hospital costs, with a small positive but insignificant gain in disease-specific and generic HRQOL. However, the real-world choice between BSX-first and BAP-first revascularization strategies for severe limb ischemia due to infrainguinal disease cannot depend on costs alone and will require a more comprehensive consideration of individual patient preferences conditioned by expectations of survival and other health outcomes. ( J Vase Surg 2010;51:43S-51S.)
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- 2010
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22. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: A survival prediction model to facilitate clinical decision making
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John F. Forbes, Donald J. Adam, Gillian M. Raab, I. Gillespie, Andrew W. Bradbury, Jocelyn Bell, C. V. Ruckley, and F. Gerry R. Fowkes
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Male ,Reoperation ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Constriction, Pathologic ,Revascularization ,Risk Assessment ,Severity of Illness Index ,Amputation, Surgical ,Decision Support Techniques ,law.invention ,Angina ,Blood Vessel Prosthesis Implantation ,Randomized controlled trial ,Ischemia ,Risk Factors ,law ,Internal medicine ,medicine ,Humans ,Saphenous Vein ,Prospective Studies ,Prospective cohort study ,Survival analysis ,Aged ,Proportional Hazards Models ,Aged, 80 and over ,Peripheral Vascular Diseases ,Proportional hazards model ,business.industry ,Middle Aged ,medicine.disease ,Survival Analysis ,United Kingdom ,Surgery ,Radiography ,Treatment Outcome ,Lower Extremity ,Bypass surgery ,Amputation ,Female ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Angioplasty, Balloon - Abstract
Background: An intention-to-treat analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI) due to infrainguinal disease who survived for 2 years after intervention, initial randomization to a bypass surgery (BSX)-first vs balloon angioplasty (BAP)-first revascularization strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. This study explored the value of baseline factors to estimate the likelihood of survival to 2 years for the trial cohort (Cox model) and for individual BASIL trial patients (Weibull model) as an aid to clinical decision making.Methods: Of 452 patients presenting to 27 United Kingdom hospitals, 228 were randomly assigned to a BSX-first and 224 to a BAP-first revascularization strategy. Patients were monitored for at least 3 years. Baseline factors affecting the survival of the entire cohort were examined with a multivariate Cox model. The chances of survival at 1 and 2 years for patients with given baseline characteristics were estimated with a Weibull parametric model.Results: At the end of follow-up, 172 patients (38%) were alive without major limb amputation of the trial leg, and 202 (45%) were alive. Baseline factors that were significant in the Cox model were BASIL randomization stratification group, below knee Bollinger angiogram score, body mass index, age, diabetes, creatinine level, and smoking status. Using these factors to define five equally sized groups, we identified patients with 2-year survival rates of 50% to 90%. The factors that contributed to the Weibull predictive model were age, presence of tissue loss, serum creatinine, number of ankle pressure measurements detectable, maximum ankle pressure measured, a history of myocardial infarction or angina, a history of stroke or transient ischemia attack, below knee Bollinger angiogram score, body mass index, and smoking status.Conclusions: Patients in the BASIL trial were at high risk of amputation and death regardless of revascularization strategy. However, baseline factors can be used to stratify those risks. Furthermore, within a parametric Weibull model, certain of these factors can be used to help predict outcomes for individuals. It may thus be possible to define the clinical and anatomic (angiographic) characteristics of SLI patients who are likely and not likely to live for >2 years after intervention. Used appropriately in the context of the BASIL trial outcomes, this may aid clinical decision making regarding a BSX- or BAP-first revascularization strategy in SLI patients like those randomized in BASIL. ( J Vase Surg 2010;51:52S-68S.)
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- 2010
23. Changes in health-related quality of life after ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins
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Andrew W. Bradbury, Donald J. Adam, Gareth Bate, K.A.L. Darvall, S.H. Silverman, and R.C. Sam
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Adult ,Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Compression stockings ,Varicose Veins ,Young Adult ,Quality of life ,Surveys and Questionnaires ,Sclerotherapy ,Varicose veins ,Humans ,Medicine ,Saphenous Vein ,Ultrasonography, Interventional ,Aged ,Aged, 80 and over ,Varix ,business.industry ,Vascular disease ,Sclerosing Solutions ,Middle Aged ,medicine.disease ,humanities ,Surgery ,Treatment Outcome ,Quality of Life ,Female ,medicine.symptom ,business ,Varices ,Cardiology and Cardiovascular Medicine ,Stockings, Compression - Abstract
Health-related quality of life (HRQOL) improves after superficial venous surgery for varicose veins, but the effect of ultrasound-guided foam sclerotherapy on HRQOL is unknown. The aim of this study was to determine changes in HRQOL after ultrasound-guided foam sclerotherapy for varicose veins.Consecutive patients undergoing ultrasound-guided foam sclerotherapy for varicose veins were sent the Short Form 12 (SF-12) questionnaire, a generic measure of HRQOL, and the Aberdeen Varicose Vein Symptom Score (AVSS) questionnaire, a disease-specific measure of HRQOL, 1 week before treatment and 1, 6, and 12 months after treatment.The study enrolled 296 patients (34% male; 395 treated legs) with a median age of 57 years (range, 22-89 years). Of these, 24% had had previous superficial venous surgery, and 66% were CEAP C(2-3) (uncomplicated varicose veins). Questionnaire completion rates were 82%, 73%, and 69% at 1, 6, and 12 months after treatment. The median Physical Component Summary score of the SF-12 (higher score indicates better HRQOL) improved from 47.6 pretreatment to 49.4 at 1 month (P.008, Wilcoxon signed rank test), to 51.9 at 6 months (P.0005), and to 52.9 at 12 months (P.0005). The median AVSS (lower score indicates better HRQOL) improved from 19.0 pretreatment to 16.5 at 1 month (P.0005), to 8.7 at 6 months (P.0005), and to 8.6 at 12 months (P.0005).Ultrasound-guided foam sclerotherapy for great and small saphenous varicose veins leads to significant improvements in generic and disease-specific HRQOL for at least 12 months after treatment.
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- 2010
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24. Endovascular Repair of Acute Thoraco-abdominal Aortic Aneurysms
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Chiara Mascoli, Jorge Mascaro, Andreas Koutsoumpelis, Aaron Ranasinghe, Mauro Iafrancesco, Donald J. Adam, Martin W Claridge, Massimo Vezzosi, and Paul Clift
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Male ,medicine.medical_specialty ,Cerebrospinal Fluid Drainage ,Aortic Rupture ,Kaplan-Meier Estimate ,030204 cardiovascular system & hematology ,Prosthesis Design ,03 medical and health sciences ,Aortic aneurysm ,0302 clinical medicine ,Aneurysm ,Postoperative Complications ,Ischemia ,Risk Factors ,medicine ,Off the shelf ,Humans ,In patient ,030212 general & internal medicine ,Prospective Studies ,Aged ,Aortic Aneurysm, Thoracic ,business.industry ,Endovascular Procedures ,medicine.disease ,Surgery ,Blood Vessel Prosthesis ,Blood pressure ,Treatment Outcome ,Spinal Cord ,30 day mortality ,Acute Disease ,Feasibility Studies ,Female ,Stents ,business ,Paraplegia ,Cardiology and Cardiovascular Medicine ,Aneurysm, Infected ,Follow-Up Studies - Abstract
Objectives The outcome of endovascular repair (EVAR) for acute thoraco-abdominal aortic aneurysm (TAAA) is reported and the applicability of the t-Branch off the shelf (OTS) device is determined. Methods Interrogation of a prospectively maintained database identified all patients who underwent EVAR for acute TAAA between September 2012 (when the first non-elective t-Branch case was performed) and November 2015. Early and medium-term outcomes were analysed. Survival and re-intervention-free survival were calculated by Kaplan–Meier analysis. Results A total of 39 patients (27 men; mean ± SD age, 72 ± 8 years) were treated for acute symptomatic (n = 29) or ruptured (n = 10) TAAA (20 anatomical extent I–III, 19 extent IV). Fourteen patients had mycotic aneurysms. The mean aneurysm diameter was 80 ± 20 mm. The mean ± SD follow-up was 21.4 ± 15.4 months. Surgeon modified fenestrated EVAR was used in 24 patients, chimney/periscope EVAR in two, and t-Branch in 13 (33%) patients. Aortic coverage was greater than 40 mm above the coeliac axis in all patients. A total of 127 target vessels (TVs) were preserved (mean 3.3 per patient) and two occluded within 30 days. The 30 day mortality was 26%. Four (10%) patients developed spinal cord ischaemia (SCI): two with paraplegia died within 30 days, and two with paraparesis recovered completely with blood pressure manipulation and cerebrospinal fluid drainage. Estimated overall survival (±SD) at 12 and 24 months was 71.8 ± 7.2% and 63.2 ± 7.9%, respectively. Estimated freedom from re-intervention at 12 and 24 months was 93 ± 4.8% and 85.3 ± 6.8%, respectively. Conclusions EVAR for acute TAAA is associated with acceptable early and mid-term results in patients who have no other treatment options. Only one third of these patients were suitable for the t-Branch device, indicating that further advances in device design are required to treat the majority of acute TAAA patients with commercially available OTS technology.
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- 2018
25. Ultrasound-Guided Foam Sclerotherapy for the Treatment of Chronic Venous Ulceration: A Preliminary Study
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Gareth Bate, Donald J. Adam, Andrew W. Bradbury, K.A.L. Darvall, and S.H. Silverman
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Adult ,Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Pilot Projects ,Severity of Illness Index ,Young Adult ,Interquartile range ,Recurrence ,Severity of illness ,Varicose veins ,Sclerotherapy ,medicine ,Humans ,Varicose Ulcer ,Prospective Studies ,Prospective cohort study ,Ultrasonography, Interventional ,Aged ,Aged, 80 and over ,Medicine(all) ,Ultrasonography, Doppler, Duplex ,Wound Healing ,business.industry ,Middle Aged ,Combined Modality Therapy ,digestive system diseases ,Surgery ,Clinical trial ,Venous ulceration ,Treatment Outcome ,Varicose ulcer ,Chronic Disease ,Female ,Radiology ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Stockings, Compression - Abstract
Objectives When compared to compression therapy alone, surgical correction of superficial venous reflux (SVR) reduces recurrence but does not appear to increase healing of chronic venous ulceration (CVU). The role of ultrasound-guided foam sclerotherapy (UGFS) of SVR as part of the treatment of CVU remains uncertain. The aim of this study is to describe CVU healing and recurrence rates after UGFS and to relate these outcomes to patterns of pre- and post-intervention venous reflux. Methods A prospective study of 27 consecutive patients (28 legs) of median age 69 (interquartile range 54–79) years undergoing UGFS for SVR in addition to compression for treatment of CVU of median duration 12 (IQR 6–23) months. Prior to and 1, 6, and 12 months after treatment patients underwent clinical and duplex assessment. Results 8 limbs (29%) had deep and superficial venous reflux, and 20 limbs had SVR alone. There was a history of DVT in 4 limbs, and 4 patients were on warfarin. No limbs had significant arterial disease and all received post-UGFS compression. Median volume of (3% STD) foam used was 8 (range 2–14) ml. 1, 3 and 6 months after UGFS, 22 (79%), 27 (96%) and 27 (96%) CVU had healed. At 12 months, 25 ulcers remained healed, 2 ulcers had recurred; one patient had died from carcinomatosis. Discussion Following UGFS as an adjunct to compression, 96% of CVU healed within 3 months and only 2 healed ulcers (7%) had recurred at 12 months. UGFS appears to be an attractive minimally-invasive alternative to surgery to treat SVR in patients with CVU, especially the elderly and frail.
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- 2009
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26. Recovery after ultrasound-guided foam sclerotherapy compared with conventional surgery for varicose veins
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Gareth Bate, K.A.L. Darvall, Donald J. Adam, and Andrew W. Bradbury
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Male ,Automobile Driving ,medicine.medical_specialty ,Contusions ,medicine.medical_treatment ,Conventional surgery ,Varicose Veins ,Recurrence ,Surveys and Questionnaires ,Laparotomy ,Sclerotherapy ,Varicose veins ,medicine ,Humans ,Saphenous Vein ,Ultrasonography, Interventional ,Aged ,Leg ,Pain, Postoperative ,Varix ,business.industry ,Vascular disease ,Middle Aged ,medicine.disease ,Sclerosing Solutions ,Ultrasound guided ,Surgery ,Treatment Outcome ,Female ,medicine.symptom ,business ,Varices - Abstract
BackgroundThe advantages of minimally invasive alternatives such as ultrasound-guided foam sclerotherapy (UGFS) over conventional surgery for the treatment of varicose veins include lower morbidity and faster recovery times. The aim was to compare morbidity, analgesia use, and time to return to driving and work following UGFS with those reported after conventional surgery for varicose veins.MethodsPatients who had UGFS or surgery for varicose veins were sent a questionnaire 4 weeks after treatment.ResultsA total of 332 (84·9 per cent) of 391 patients who had UGFS and 53 (56 per cent) of 94 who had surgery returned a questionnaire. The groups were similar in terms of age, sex, and the proportion who had treatment of bilateral or recurrent veins. Patients who had surgery were more likely to have significant bruising (44 versus 7·2 per cent; P < 0·001) and pain (17 versus 5·5 per cent; P = 0·001). After UGFS, 43·2 per cent of patients returned to work within 24 h compared with none who had surgery (P < 0·001). Patients who had UGFS were more likely to return to driving within 4 days (P = 0·014).ConclusionUGFS was associated with less pain and analgesia requirement, time off work and quicker return to driving.
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- 2009
27. Medium-term results of ultrasound-guided foam sclerotherapy for small saphenous varicose veins
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Donald J. Adam, S.H. Silverman, Gareth Bate, K.A.L. Darvall, and Andrew W. Bradbury
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Varicose Veins ,Recurrence ,Interquartile range ,Popliteal vein ,Sclerotherapy ,Varicose veins ,medicine ,Humans ,Saphenous Vein ,Ultrasonography, Interventional ,Aged ,Leg ,Ultrasonography, Doppler, Duplex ,Varix ,Vascular disease ,business.industry ,Middle Aged ,medicine.disease ,Sclerosing Solutions ,Thrombosis ,Surgery ,Treatment Outcome ,Venous Insufficiency ,Quality of Life ,Female ,Radiology ,medicine.symptom ,business ,Varices - Abstract
Background The results of surgery for small saphenous varicose vein (SSV) varicosities may be suboptimal in terms of recurrence and complications. The role of minimally invasive alternatives remains incompletely defined. The aim was to review the medium-term outcomes of ultrasound-guided foam sclerotherapy (UGFS) for SSV. Methods Eighty-six patients (92 legs) undergoing UGFS for SSV were assessed before, and 1, 6 and 12 months after treatment. Outcome measures were occlusion of, and abolition of reflux in, the SSV (technical success), absence of visible varicose veins (clinical success) and improvement in disease-specific health-related quality of life (HRQL) following treatment (Aberdeen Varicose Vein Symptom Severity Score (AVSS)). Results The technical and clinical success rates at 12 months were 91 and 93 per cent respectively; only three patients required a second treatment. After treatment of isolated SSV varicosities there was a significant improvement in AVSS, from a median of 19·0 (interquartile range 13·4–26·8) before treatment to 10·2 (4·0–18·3) and 9·7 (3·5–19·1) at 6 and 12 months respectively. The only complication was a popliteal vein thrombosis that required anticoagulation. Conclusion UGFS was an effective treatment for SSV, with abolition of reflux and visible varicose veins, and improvement in HRQL for at least 12 months.
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- 2009
28. Measurement of arterial stiffness in subjects with vascular disease: Are vessel wall changes more sensitive than increase in intima–media thickness?
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Peter R. Hoskins, Donald J. Adam, Gareth Bate, Andrew W. Bradbury, A.B.M. Wilmink, and Martin W Claridge
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Male ,Risk ,Tunica media ,medicine.medical_specialty ,Blood Pressure ,Distension ,Internal medicine ,medicine ,Humans ,Aged ,Aged, 80 and over ,Peripheral Vascular Diseases ,Vascular disease ,business.industry ,Signal Processing, Computer-Assisted ,Arteries ,Middle Aged ,Atherosclerosis ,medicine.disease ,Tunica intima ,Surgery ,Carotid Arteries ,medicine.anatomical_structure ,Blood pressure ,Intima-media thickness ,Cardiology ,Vascular resistance ,Arterial stiffness ,Female ,Vascular Resistance ,Tunica Intima ,Tunica Media ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background and aims It is widely accepted that subjects with vascular disease have increased arterial stiffness and intima–media thickness (IMT) when compared with healthy controls. The aim of this study was to investigate indices of arterial stiffness and IMT in the common carotid arteries (CCAs) of subjects with and without peripheral arterial disease (PAD), in order to look for evidence of change in wall quality and quantity to explain increased stiffness that has been found in the arteries of subjects with vascular disease. Methods and results The arterial distension waveform (ADW), IMT, diameter and brachial blood pressure were measured to calculate Young's Modulus ( E ) and elastic modulus ( Ep ) in the common carotid arteries of subjects with and without PAD. 38 subjects with confirmed PAD were compared with 43 normal controls matched for age, sex, smoking and hypertension. The mean diameter (8.35mm [95% CI 7.93–8.77] vs . 6.93mm [6.65–7.20] P vs . 0.88mm [0.82–0.93] P =0.020, increase 12.5%), Ep (315kPa [185–444] vs . 190kPa [164–216] P =0.034, increase 66%) and E (1383kPa [836–1930] vs . 744kPa [641–846] P =0.006, increase 86%) were all significantly higher in subjects with PAD. Conclusions This study suggests that increased stiffness observed in subjects with peripheral vascular disease is a result of change in both quantity and quality of the arterial wall. Changes in indices of arterial stiffness were much higher than changes in IMT and diameter. These preliminary observations may be an indication that indices of arterial stiffness are a sensitive early marker of atherosclerosis.
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- 2009
29. Higher prevalence of thrombophilia in patients with varicose veins and venous ulcers than controls
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S.H. Silverman, R.C. Sam, Christopher Fegan, Andrew W. Bradbury, K.A.L. Darvall, and Donald J. Adam
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Adult ,Male ,medicine.medical_specialty ,Deep vein ,Population ,Thrombophilia ,Gastroenterology ,Severity of Illness Index ,Antithrombins ,Protein S ,Varicose Ulcer ,Varicose Veins ,Risk Factors ,Internal medicine ,Varicose veins ,medicine ,Factor V Leiden ,Prevalence ,Humans ,education ,Subclinical infection ,Aged ,Aged, 80 and over ,education.field_of_study ,Ultrasonography, Doppler, Duplex ,business.industry ,Factor V ,Middle Aged ,medicine.disease ,Thrombosis ,Blood Coagulation Factors ,Surgery ,medicine.anatomical_structure ,Case-Control Studies ,Chronic Disease ,Antibodies, Antiphospholipid ,Female ,Prothrombin ,medicine.symptom ,business ,Cardiology and Cardiovascular Medicine ,Protein C ,Biomarkers ,medicine.drug - Abstract
Background Uncontrolled studies suggest that patients with chronic venous ulceration (CVU) have an increased prevalence of thrombophilia, similar to that observed in patients with deep vein thrombosis. This study compared the nature and prevalence of thrombophilia in patients with varicose veins (VV, CEAP clinical [C] grade C 2 to C 3 ) and patients with CVU (C 5 to C 6 ) with an age- and sex-matched population without clinical or duplex ultrasound evidence of venous disease. Methods Twenty-seven patients with VV, 27 patients with CVU, and 54 age- and sex-matched case controls with no clinical or duplex evidence of lower limb venous disease, underwent testing for factor V Leiden and prothrombin 20210A mutations, antithrombin deficiencies, and levels of antiphospholipid antibodies, homocysteine, protein C and S, and factor VIII, IX, and XI. Results The overall prevalences of single and multiple thrombophilias were significantly higher in cases than in controls. Specifically, in VV patients, the prevalences of no, single, and multiple thrombophilias were 33%, 52%, and 15%, respectively, compared with 63%, 26%, and 11% in VV controls. In CVU patients, the prevalences of no, single, and multiple thrombophilias was 26%, 30%, and 44%, respectively, compared with 66%, 22%, and 11% in CVU controls. Compared with controls, only factor XI levels were significantly higher in VV patients, and homocysteine and factor VIII, IX, and XI levels were all significantly higher in CVU patients. Conclusion Patients with VV, and particularly CVU, have significantly higher prevalences of single and multiple thrombophilias than age- and sex-matched controls without clinical or duplex evidence of lower limb venous disease. These data support the hypothesis that thrombophilia predisposes to the development of superficial and deep lower limb venous reflux, and so VV and CVU, through the increased occurrence of clinical and subclinical thrombosis.
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- 2009
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30. Surgical Versus Endovascular Reconstruction for Chronic Mesenteric Ischemia: A Contemporary UK Series
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Andrew W. Bradbury, Michael L. Wall, M.H. Simms, Robert S.M. Davies, Donald J. Adam, Rajiv K. Vohra, and S.H. Silverman
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Male ,medicine.medical_specialty ,Time Factors ,Constriction, Pathologic ,Kaplan-Meier Estimate ,Risk Assessment ,Ischemia ,Mesenteric Vascular Occlusion ,Occlusion ,medicine ,Humans ,Hospital Mortality ,Vascular Patency ,Aged ,Retrospective Studies ,Aged, 80 and over ,Retrospective review ,Graft patency ,business.industry ,General Medicine ,Perioperative ,Length of Stay ,Middle Aged ,Vascular surgery ,medicine.disease ,United Kingdom ,Surgery ,Stenosis ,Treatment Outcome ,Chronic mesenteric ischemia ,Replantation ,Chronic Disease ,Female ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Hospital stay ,Angioplasty, Balloon - Abstract
Objective: To assess the outcome of surgical (SR) and endovascular (ER) reconstruction for chronic mesenteric ischemia (CMI). Methods: Retrospective review of consecutive patients who underwent SR or ER for CMI in 3 UK vascular surgery units between 1996 and 2006. Early (30 days) outcomes (symptom recurrence, vessel/graft patency, reintervention, mortality) were assessed. Results: A total of 27 patients underwent 32 reconstructions (SR = 17, ER = 15). A total of 44 of 56 (79%) diseased arteries underwent SR (n = 26; bypass = 24, reimplantation = 2; occlusion = 16, stenosis = 10) or ER (n = 18; stenosis = 16, occlusion = 2). Perioperative mortality for SR and ER was 6% and 0%, respectively (P ≥ .99). Hospital stay was shorter following ER (mean, 4.3 vs. 14.2 days, P = .0003). Mean (range) follow-up for SR and ER was 34 (1-94) and 34 (0-135) months, respectively. At 2 years, SR demonstrated superior secondary patency (100% vs. 65%) and clinical patency (100% vs. 73%). Conclusions: Surgical mesenteric reconstruction is associated with significantly longer hospital stay, but superior long-term outcome compared to endovascular reconstruction.
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- 2009
31. The role of tissue factor in patients undergoing open repair of ruptured and nonruptured abdominal aortic aneurysms
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Andrew W. Bradbury, Donald J. Adam, Paul C. Haggart, Simon D. Hobbs, and Christopher Fegan
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Male ,medicine.medical_specialty ,Carboxypeptidase B2 ,Aortic Rupture ,Lipoproteins ,Tissue plasminogen activator ,Gastroenterology ,Thromboplastin ,Aortic aneurysm ,Tissue factor ,Tissue factor pathway inhibitor ,Interquartile range ,Internal medicine ,Plasminogen Activator Inhibitor 1 ,medicine ,Humans ,Prospective cohort study ,Aged ,Aged, 80 and over ,business.industry ,Perioperative ,Middle Aged ,medicine.disease ,Anesthesia ,Tissue Plasminogen Activator ,Female ,Surgery ,business ,Cardiology and Cardiovascular Medicine ,Plasminogen activator ,medicine.drug ,Aortic Aneurysm, Abdominal ,Factor Xa Inhibitors - Abstract
Background Ruptured abdominal aortic aneurysm (AAA) is associated with the development of a procoagulant and hypofibrinolytic state. Tissue factor (TF) and its naturally occurring inhibitor, tissue factor pathway inhibitor (TFPI), play a central role in the initiation and progression of such a hypercoagulable state, but their role in patients undergoing open AAA repair has not previously been examined. Methods A prospective study was conducted of 17 patients undergoing elective AAA repair and 10 patients undergoing emergency AAA repair. Blood was taken before induction, and 5 minutes, 24 hours, and 48 hours after aortic cross-clamp release and assayed for plasma TF, TFPI, tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI), and thrombin-activatable fibrinolysis inhibitor (TAFI) activities. Results TF activity was significantly higher at all time points in patients with ruptured AAA compared with nonruptured AAA. The median (interquartile range, IRQ) TF activity (AU/mL) was 9.9 vs 3.2 (IRQ, 5.9 to 12.6 vs 2.0 to 7.6; P = .005) at preinduction; 10.7 vs 1.5 (IRQ, 9.2 to 18.3 vs 0.1 to 6.6; P = .003) at 5 minutes after clamp release; 9.5 vs 3.3 (IRQ, 7.0 to 13.5 vs 1.0 to 7.9; P = .013) at 24 hours, and 9.6 vs 3.9 (IRQ, 7.6 to 12.6 vs 2.4 to 8.7; P = .006) at 48 hours. TFPI levels were not significantly different between ruptured AAA and nonruptured AAA before or during operation but became significantly elevated at 24 and 48 hours in patients who had undergone repair of ruptured AAA. Ruptured AAA repair was associated with a hypofibrinolytic state compared with nonruptured AAA. Conclusions The present study has demonstrated for the first time, to our knowledge, that ruptured AAA is associated with significantly higher perioperative levels of circulating TF compared with nonruptured AAA. Furthermore, in the immediate perioperative period, the high levels of TF are not associated with a corresponding rise in TFPI levels, indicating an unopposed prothrombotic state. Direct inhibition of TF by administration of anti-TF antibodies or recombinant TFPI remains to be evaluated in subjects presenting with hemorrhage due to ruptured AAA, but if given early enough, it may attenuate the early deleterious effects of unopposed TF expression and ultimately contribute to improved outcomes.
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- 2007
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32. Chronic Venous Disease in a Cohort of Healthy UK Asian Men
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K.A.L. Darvall, S.H. Silverman, R.C. Sam, Donald J. Adam, Andrew W. Bradbury, S.D. Hobbs, and A. Rehman
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Adult ,Male ,medicine.medical_specialty ,Physical examination ,Caucasian ,Age Distribution ,Asian People ,Risk Factors ,Chronic venous disease ,Varicose veins ,Epidemiology ,Prevalence ,Ethnicity ,Humans ,Medicine ,Prospective Studies ,Photoplethysmography ,Prospective cohort study ,Life Style ,Aged ,Ultrasonography ,Medicine(all) ,Asian ,medicine.diagnostic_test ,business.industry ,Reflux ,Middle Aged ,United Kingdom ,Surgery ,Cohort ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Venous disease ,Lower limbs venous ultrasonography ,Blood Flow Velocity - Abstract
Objectives This group has previously reported that UK Asians are significantly less likely to undergo surgery for lower limb venous disease than age and sex matched Caucasians. The aim of the present study was to estimate the prevalence of lower limb chronic venous disease (CVD) in the UK Asian male population. Design A prospective, epidemiological survey. Materials and methods 100 unselected Asian men attending a local Mosque were assessed for the evidence of lower limb CVD, involving the collection of data on history and clinical signs and objective assessments of venous pathophysiology using lower limb venous ultrasonography and venous photoplethysmography (PPG). Results On clinical examination, 80 limbs (in 50 subjects) had clinical evidence of CVD, the majority of cases consisting of varicose veins (CEAP C2). No limbs had either healed or active ulceration (C5/6), and only 2 limbs had thread veins (C1). Eight subjects had had previous venous surgery. The venous refill time (vRT) measured by PPG was lower in limbs with CVD. On venous ultrasound, reflux was present in 73/200 limbs, affecting primarily the GSV system, with only 7 limbs having deep venous reflux. Conclusions Present data strongly suggest that the low rates of superficial venous surgery in UK Asians is not because they are inherently less likely to develop CVD.
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- 2007
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33. The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: A randomized controlled trial
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S.D. Hobbs, Donald J. Adam, Tim Marshall, Chris Fegan, and Andrew W. Bradbury
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Male ,medicine.medical_specialty ,Randomization ,medicine.medical_treatment ,Antithrombin III ,Tetrazoles ,Enzyme-Linked Immunosorbent Assay ,Physical exercise ,Walking ,law.invention ,Fibrinolytic Agents ,Randomized controlled trial ,law ,Angioplasty ,Internal medicine ,Fibrinolysis ,medicine ,Humans ,Protein Precursors ,Aged ,business.industry ,Intermittent Claudication ,Middle Aged ,Peptide Fragments ,Intermittent claudication ,Cilostazol ,Exercise Therapy ,Surgery ,Treatment Outcome ,Cardiology ,Female ,Prothrombin ,medicine.symptom ,Claudication ,business ,Cardiology and Cardiovascular Medicine ,Biomarkers ,Follow-Up Studies ,Peptide Hydrolases ,medicine.drug - Abstract
Background The prothrombotic, hypofibrinolytic state that develops in patients with intermittent claudication (IC) upon walking due to ischemia-reperfusion injury (IRI) of the leg muscles may contribute to the high incidence of life- and limb-threatening thrombotic events observed in this patient group. Treatments, such as angioplasty, that obtund the IRI also ameliorate the procoagulant diathesis. The effect on this diathesis of supervised exercise and cilostazol, both of which provide symptomatic benefit in IC, but without significantly obtunding IRI, is unknown. Methods Thirty-four patients (27 men and 7 women; median age, 67 years; range, 63-72 years) were randomized to receive best medical therapy (BMT) plus supervised exercise (n = 9), BMT plus cilostazol (n = 9), BMT plus supervised exercise plus cilostazol (n = 7), or BMT alone (n = 9) in a 2 × 2 factorial design. Thrombin-antithrombin complex and prothrombin fragments 1 and 2, both markers of thrombin generation; plasminogen activator inhibitor antigen and tissue plasminogen activator antigen, both markers of fibrinolysis; ankle-brachial pressure index (ABPI); and initial and absolute claudication distance (ACD) were measured at baseline and then 3 and 6 months after randomization. Results At 6 months, when compared with receiving BMT only, supervised exercise and cilostazol resulted in improvements in ABPI of 18% and 13% and in ACD of 40% and 64%, respectively. The effects on ABPI and ACD of combining supervised exercise and cilostazol were additive. Supervised exercise, cilostazol, and supervised exercise combined with cilostazol had no significant effect on any of the four hemostatic markers. Conclusions Treatment of IC by supervised exercise or cilostazol results in significant improvements in ABPI and ACD but has no demonstrable effect on the prothrombotic diathesis. This suggests that supervised exercise and cilostazol, unlike angioplasty, are unlikely to have a long-term beneficial effect on the thrombotic risks faced by these patients.
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- 2007
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34. Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts
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Robert Fitridge, Donald J. Adam, David Ernest Hartley, Michael Berce, and John Lennon Anderson
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Male ,Reoperation ,medicine.medical_specialty ,medicine.medical_treatment ,Prosthesis Design ,Radiography, Interventional ,Aortic aneurysm ,Angioplasty ,Medicine ,Humans ,cardiovascular diseases ,Mesenteric arteries ,Aged ,medicine.diagnostic_test ,business.industry ,Stent ,Angiography, Digital Subtraction ,medicine.disease ,Abdominal aortic aneurysm ,Surgery ,Prosthesis Failure ,Ostium ,medicine.anatomical_structure ,surgical procedures, operative ,Treatment Outcome ,Angiography ,cardiovascular system ,Stents ,Radiology ,business ,Cardiology and Cardiovascular Medicine ,Perfusion ,Aortic Aneurysm, Abdominal - Abstract
Three patients with type I proximal endoleak after previous endovascular abdominal aortic aneurysm (AAA) repair were treated with fenestrated endovascular stent grafts. Six renal arteries, three superior mesenteric arteries, and one coeliac axis were targeted for incorporation by graft fenestration. The fenestration-renal ostium interface was secured with balloon-expandable stents and completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. All patients made an uncomplicated recovery. Fenestrated endovascular stent grafts can be used to salvage failed prior endovascular AAA repair in patients who are considered unsuitable for other endovascular or open surgical interventions.
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- 2006
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35. The Low Incidence of Surgery for Non-Cardiac Vascular Disease in UK Asians may be Explained by a Low Prevalence of Disease
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A.B.M. Wilmink, Donald J. Adam, Ahsin Manzoor Bhatti, Andrew W. Bradbury, S.D. Hobbs, A. Rehman, and R.C. Sam
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Male ,medicine.medical_specialty ,Caucasians ,medicine.medical_treatment ,Pilot Projects ,Disease ,White People ,Asian People ,Peripheral arterial disease ,Epidemiology ,Prevalence ,Ethnicity ,Humans ,Medicine ,Pakistan ,Prospective Studies ,Caucasian population ,Aged ,Peripheral Vascular Diseases ,Medicine(all) ,business.industry ,Vascular disease ,Incidence (epidemiology) ,Middle Aged ,medicine.disease ,United Kingdom ,Abdominal aortic aneurysm ,Surgery ,Asians ,body regions ,medicine.anatomical_structure ,Amputation ,Research Design ,cardiovascular system ,Ankle ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Aortic Aneurysm, Abdominal - Abstract
Aims Firstly, to compare rates of surgery for non-cardiac vascular disease in Caucasians and Asians and secondarily to assess the prevalence of peripheral arterial disease (PAD) and abdominal aortic aneurysm (AAA) in the male UK Asian population. Methods Analysis of a prospective database followed by an epidemiological survey of 100 unselected Pakistani males, in which demographic and anthropometric data were collected alongside aortic ultrasonography and measurement of ankle: brachial pressure index (ABPI). Results Although 14.1% of our catchment area is Asian, after correction for age, they only accounted for 64/2268 (2.8%) of procedures for PAD and AAA. Specifically, Asians were 10 times less likely to undergo AAA repair and 3 times less likely to undergo procedures for lower limb peripheral bypass, amputation and endovascular intervention. In the epidemiological study, 26 subjects had a significant history of ischaemic heart disease, 21 were diabetic, 32 had hypertension and 60 were current or ex-smokers. Median aortic diameter [IQR] was 17.6 mm [16.3–19.1 mm] and no subject had an AAA. In 200 limbs, median ABPI [IQR] was 1.12 [1.04–1.21]. Only 2 patients had an ABPI Conclusion Despite a high prevalence of cardiovascular risk factors and ischaemic heart disease, the prevalence of PAD and AAA is much lower than would have been expected in an age- and sex-matched Caucasian population. These data suggest that the reduced incidence of surgery for PAD and AAA in UK Asians is due to a low prevalence of disease.
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- 2006
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36. A Comparison Between the Short Term and Long Term Benefits of Screening for Abdominal Aortic Aneurysms from the Huntingdon Aneurysm Screening Programme
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Martin W Claridge, O. Will, C.R.G. Quick, A. Fries, T. Wilmink, Donald J. Adam, Andrew W. Bradbury, and C.S. Hubbard
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Male ,medicine.medical_specialty ,Time Factors ,Aortic Rupture ,Long term benefits ,Population based ,Screening programme ,Aneurysm ,Internal medicine ,medicine ,Humans ,Mass Screening ,Screening study ,Medicine(all) ,Clinical Trials as Topic ,business.industry ,Incidence ,Incidence (epidemiology) ,Mortality reduction ,Middle Aged ,medicine.disease ,Survival Analysis ,United Kingdom ,Abdominal aortic aneurysm ,Number needed to screen ,Surgery ,Screening ,Cardiology and Cardiovascular Medicine ,business ,Aortic Aneurysm, Abdominal ,Follow-Up Studies - Abstract
Background The UK Multicentre Aneurysm Screening Study (MASS) showed a 44% reduction in AAA-related mortality after 4 years and predicted an increased number of deaths prevented in the longer term. We aim to compare the 5 and 13 years benefit from aneurysm screening in the Huntingdon Aneurysm screening programme. Methods Incidence and mortality of ruptured AAA (RAAA) after 5 and 13 years of screening in a population based aneurysm screening program. Results Five years of screening resulted in a reduction in the incidence of RAAA of 49% (95% CI: 3–74%). Nine out of 11 ruptures in the invited group did not survive (mortality 82%; 95% CI: 48–98%) compared to 38 non-survivors from 51 ruptures in the control group (mortality 75%; 95% CI: 60–86%). Five years of screening resulted in an RAAA-related mortality reduction of 45% (95% CI: −15 to 74%). After 13 years of screening the incidence of RAAA was reduced by 73% (95% CI: 58–82%). Twenty-one out of 29 ruptures in the invited group did not survive (mortality 72%; 95% CI: 53–87%) compared to 64 non-survivors from 82 ruptures in the control group (mortality 78%; 95% CI: 68–86%). Thirteen years screening resulted in a reduction of mortality from RAAA of 75% (95% CI: 58–84%). The number needed to screen to prevent one death reduced from 1380 after 5 years to 505 after 13 years. The number of elective AAA operations needed to prevent one death reduced from 6 after 5 years to 4 after 13 years. Conclusion AAA screening becomes increasingly beneficial as screening continues over the longer term. Benefits continue to increase after screening has ceased.
- Published
- 2006
37. Late reintervention for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm repair in an Australian population
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S. Raptis, Donald J. Adam, and Robert Fitridge
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Adult ,Male ,Reoperation ,medicine.medical_specialty ,Aortography ,Time Factors ,Iliac Artery ,Risk Assessment ,Severity of Illness Index ,Aortic aneurysm ,Blood Vessel Prosthesis Implantation ,Postoperative Complications ,Blood vessel prosthesis ,medicine ,Humans ,Aorta, Abdominal ,Prospective Studies ,Registries ,Prospective cohort study ,Survival rate ,Aged ,Probability ,Aged, 80 and over ,medicine.diagnostic_test ,business.industry ,Vascular disease ,Mortality rate ,Australia ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Abdominal aortic aneurysm ,Surgery ,Blood Vessel Prosthesis ,Prosthesis Failure ,Survival Rate ,Female ,business ,Cardiology and Cardiovascular Medicine ,Aortic Aneurysm, Abdominal ,Follow-Up Studies - Abstract
Objective To examine late reintervention rates for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm (AAA) repair in an Australian population. Methods Interrogation of a prospective computerized database identified 1256 consecutive patients (1058 men, 198 women; median age, 70 years; range, 40 to 97 years) who survived open repair of nonruptured (n = 957, group I) and ruptured (n = 299, group II) infrarenal AAA in a single institution between January 1, 1982 and December 31, 2003. Median (range) follow-up was 41 (1 to 261) months for group I and 30 (1 to 243) months for group II. Results In group I, 33 patients (3.4%) underwent 38 late reinterventions: 20 patients (2.1%) for aortic graft-related events at a median (range) interval of 36 (1 to 94) months after the index AAA repair, with a 30-day mortality rate of 15%; and 13 patients (1.4%) for new aortoiliac disease at a median (range) interval of 33 (3 to 207) months, with 30-day mortality of 8%. In group II, 15 patients (5%) underwent 16 late reinterventions: 10 patients (3.3%) for aortic graft-related events at a median (range) interval of 5 (2 to 112) months, with a 30-day mortality of 10%; and five patients (1.7%) for new aortoiliac disease at a median (range) interval of 67 (39-105) months, with a 30-day mortality of 40%. There was no significant difference in the late reintervention rate between the groups: group I, 33 (3.4%) of 957 vs group II, 15 (5%) of 299 ( P = .23). For all patients, the estimated survival at 1, 3, 5 and 10-years was 90%, 79.4%, 66.4%, and 31.6%, respectively; estimated survival free from reintervention at 1, 3, 5 and 10-years was 98.7%, 97.1%, 95.1%, and 91.9%, respectively. Conclusions These data demonstrate, for the first time, that open AAA repair has excellent long-term durability in an Australian population and the results compare favorably with previous reports from North America and Europe. These data represent an important benchmark for comparison of the results of endovascular AAA repair in this patient population.
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- 2006
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38. The constitutive procoagulant and hypofibrinolytic state in patients with intermittent claudication due to infrainguinal disease significantly improves with percutaneous transluminal balloon angioplasty
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Andrew W. Bradbury, S.D. Hobbs, Donald J. Adam, Tim Marshall, and Chris Fegan
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Antithrombin III ,Ischemia ,Revascularization ,law.invention ,Randomized controlled trial ,Interquartile range ,law ,Angioplasty ,Internal medicine ,Plasminogen Activator Inhibitor 1 ,Fibrinolysis ,Humans ,Medicine ,Blood Coagulation ,Aged ,business.industry ,Intermittent Claudication ,Middle Aged ,medicine.disease ,Intermittent claudication ,Exercise Therapy ,Surgery ,Cardiology ,Female ,medicine.symptom ,business ,Claudication ,Cardiology and Cardiovascular Medicine ,Angioplasty, Balloon ,Peptide Hydrolases - Abstract
Background Patients with intermittent lower limb claudication (IC) exhibit a prothrombotic diathesis that is acutely exacerbated by exercise. This may occur because of ischemia/reperfusion injury within the leg muscles during walking and may contribute to the increased risk of thrombotic vascular events in this group of patients. This randomized study compared the effect of lower limb revascularization by percutaneous transluminal balloon angioplasty (PTA), supervised exercise, and best medical therapy (BMT) alone on this prothrombotic state. Methods Twenty-three patients (16 men and 7 women; median age, 67 years; range, 57-77 years) with IC due to infrainguinal disease were randomized to receive BMT alone (n = 7), BMT plus PTA (n = 9), or BMT plus supervised exercise (n = 7) as part of the Health Technology Assessment–funded EXercise vs Angioplasty in Claudication Trial (EXACT). Patients were assessed at baseline and at 3 and 6 months. Thrombin-antithrombin complex (TAT) was determined as a marker of thrombin generation, and plasminogen activator inhibitor (PAI) antigen was determined as a marker of fibrinolysis. Increased TAT indicates a procoagulant state, and increased PAI antigen indicates a hypofibrinolytic state. Results At 6 months, subjects randomized to BMT plus PTA demonstrated a significant improvement in ankle-brachial pressure index ( P = .013) and maximal walking distance ( P = .008), a significant decline in resting thrombin generation (median [interquartile range] TAT, 6.4 μg/L [2.7-13.5 μg/L] to 1.5 μg/L [0.3-2.9 μg/L]; P = .038), and an improvement in resting fibrinolysis (median [interquartile range] PAI-1, 10.0 ng/mL [1.0-20.5 ng/mL] to 1.0 ng/mL [1.0-14.8 ng/mL]; P = .043). There was no significant change in any of these parameters in patients randomized to BMT plus supervised exercise or to BMT alone. Conclusions The addition of lower limb revascularization by PTA to BMT in patients with IC due to infra-inguinal disease results in a medium-term improvement in the resting procoagulant and hypofibrinolytic state. This may translate into a reduction in morbidity and mortality from thrombotic vascular events in this group of patients.
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- 2006
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39. Abstract 19080: Risk Stratification in Arch Surgery: When High Risk is Too High? Implications for Open or Endovascular Repair From a 15-Years Survey on Over 350 Patients
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Donald J. Adam, Peter J Riley, Domenico Pagano, Ian McCafferty, Mauro Iafrancesco, Martin W Claridge, Jorge Mascaro, Vamsidhar B. Dronavalli, and Aaron M. Ranasinghe
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Aorta ,Logistic euroscore ,medicine.medical_specialty ,business.industry ,Quality assessment ,Tar ,Surgery ,Physiology (medical) ,medicine.artery ,Risk stratification ,Aortic arch replacement ,Medicine ,Arch ,Cardiology and Cardiovascular Medicine ,business - Abstract
Introduction: At present, there are not risk scoring tools to predict in-hospital mortality for total aortic arch replacement (TAR), Hypothesis: To assess if Logistic Euroscore (LogES) is a useful tool for risk assessment in aortic arch surgery and which other operative factors may help to better identify high-risk patients. Methods: All patients who underwent open arch procedure between 1998 and 2013 were identified from our prospectively collected database which include 93 preoperative variables. Results: Three-hundred-fifty-seven open arch procedures were identified. Two-hundred-forty-two patients underwent TAR, 199 with conventional technique and 43 with frozen elephant trunk (FET) technique. Patients with higher LogES had higher in-hospital mortality (see table 1). Patient with a LogEs 60 were classified as low-, high- or very high-risk, respectively. Complexity of surgery, defined as need for aortic root replacement (ARR) and/or mitral valve repair/replacement (MVR), increased significantly the risk of operation (27% vs. 4.2%, p:0.004) only in conventional TAR in high-risk patients. Low-risk patients were associated with low mortality regardless the extent of surgery whilst very high risk-patients had a high-risk of death even with simple operations. Mortality risk in FET was not increased by need for ARR/MVR. Rate of permanent neurological deficit remained low in all category of patients. Spinal cord injury (SCI) did not occur in any conventional TAR. Conclusions: Open surgery should remain the treatment of choice for patients with low/moderate LogES and high LogES without need for ARR/MVR. Patient with very-high LogES who do not need ARR/MVR should be consider for endovascular repair. Patient with high and very-high LogES and need for ARR/MVR cannot undergo endovascular treatment and remain a significant challenge. FET remains a procedure with an increase risk of death and SCI.
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- 2014
40. Repair of juxtarenal para-anastomotic aortic aneurysms after previous open repair with fenestrated and branched endovascular stent grafts
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John Lennon Anderson, Michael Berce, David Ernest Hartley, and Donald J. Adam
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Male ,Reoperation ,medicine.medical_specialty ,medicine.medical_treatment ,Anastomosis ,Prosthesis Design ,Aortic aneurysm ,Blood Vessel Prosthesis Implantation ,Aneurysm ,medicine ,Humans ,cardiovascular diseases ,Device Removal ,Aged ,medicine.diagnostic_test ,business.industry ,Angiography ,Stent ,medicine.disease ,Abdominal aortic aneurysm ,Surgery ,Prosthesis Failure ,Ostium ,surgical procedures, operative ,cardiovascular system ,Stents ,Radiology ,business ,Tomography, X-Ray Computed ,Cardiology and Cardiovascular Medicine ,Perfusion ,Aortic Aneurysm, Abdominal ,Follow-Up Studies - Abstract
Three patients with juxtarenal para-anastomotic aortic aneurysms after previous open abdominal aortic aneurysm repair were treated with custom-designed fenestrated and branched Zenith endovascular stent grafts. Six renal arteries and two superior mesenteric arteries were targeted for incorporation by graft fenestrations and branches. The fenestration/renal ostium interface was secured with balloon-expandable Genesis stents (n = 5) or Jostent stent grafts (n = 1). Completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. During follow-up, one patient developed asymptomatic renal artery occlusion and underwent further endovascular intervention for type I distal endoleak. Computed tomography at 12 months demonstrated complete aneurysm exclusion in all patients with antegrade perfusion in the remaining target vessels. Fenestrated and branched endovascular stent grafts may be an acceptable alternative to conventional open repair in this group of patients.
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- 2005
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41. The Association Between Raised Coagulation Factor Levels and Venous Thrombo-embolism
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Donald J. Adam, M. Wong, Christopher Fegan, S.H. Silverman, Andrew W. Bradbury, and R.C. Sam
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medicine.medical_specialty ,Population ,Thrombophilia ,Venous thrombo embolism ,Risk Factors ,hemic and lymphatic diseases ,Thromboembolism ,Internal medicine ,medicine ,Humans ,cardiovascular diseases ,education ,Medicine(all) ,education.field_of_study ,Coagulation ,business.industry ,Incidence (epidemiology) ,medicine.disease ,Blood Coagulation Factors ,Pulmonary embolism ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Complication ,Protein C ,medicine.drug - Abstract
The overall population incidence of venous thromboembolism (VTE) is approximately 0.1% per year and increases steeply with age. The commonest presentation is lower limb deep vein thrombosis (DVT), complicated in a proportion of patients by symptomatic acute pulmonary embolism (PE). The latter remains the commonest single cause of potentially preventable death in surgical and obstetric patients. The commonest long-term complication of DVT is the post-thrombotic syndrome (PTS), which develops in up to 20% of cases, resulting in significant morbidity and enormous health care and socio-economic costs. Virchow’s Triad describes the risk factors for VTE; namely, altered endothelium, blood flow and hypercoagulability (thrombophilia [TP]). TP may be acquired or inherited, and may affect the clotting and/or fibrinolytic cascades (Table 1, Fig. 1). The classical ‘deficiency’ TP, such as protein C and S and ATIII deficiency, can predispose to extensive and atypical episodes of VTE in early life; especially if more than one co-exists in the same patient along with other environmental factors. However, as the majority of patients affected by VTE do not apparently have a ‘deficiency’ TP, their contribution to the overall burden of VTE remains difficult to define. Nevertheless, a
- Published
- 2005
42. Intra-abdominal Packing for Uncontrollable Haemorrhage During Ruptured Abdominal Aortic Aneurysm Repair
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Robert Fitridge, S. Raptis, and Donald J. Adam
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Male ,Ruptured aortic aneurysm ,medicine.medical_specialty ,Prosthesis-Related Infections ,Aortic Rupture ,Fistula ,Hemorrhage ,Ruptured Aortic Aneurysm ,Sepsis ,Blood Vessel Prosthesis Implantation ,Aneurysm ,medicine ,Humans ,Tampons, Surgical ,Prospective Studies ,Intraoperative Complications ,Abscess ,Fasciitis ,Survival rate ,Aged ,Aged, 80 and over ,Medicine(all) ,Abdominal packing ,business.industry ,Middle Aged ,medicine.disease ,Hemostasis, Surgical ,Surgery ,Databases as Topic ,Abdominal trauma ,Female ,Radiology ,Cardiology and Cardiovascular Medicine ,business ,Aortic Aneurysm, Abdominal - Abstract
Objective Intra-abdominal packing is a valuable adjunct in patients with abdominal trauma and uncontrollable bleeding but few data exist regarding early and late outcome associated with this technique in patients with ruptured abdominal aortic aneurysm (AAA). Methods Interrogation of a prospective vascular surgical database identified 23 patients (22 men; median age 69, range 59–82, years) with ruptured AAA who required intra-abdominal packing for control of coagulopathic haemorrhage after insertion of an aortic graft between January 1982 and December 2003. Co-morbidity, operative and outcome data were retrieved. Results Haemostasis was achieved and packs were removed within 48 h in 20 patients. In those patients who had a graft inserted, the peri-operative mortality rate was 12 of 23 (52%) patients (vs. 172 of 455 (38%) patients who were not packed, NS). Three (13%) patients developed early intra-abdominal sepsis, which was universally fatal: graft-enteric fistula, intra-abdominal abscess with necrotizing fasciitis of the abdominal wound, and infected retroperitoneal haematoma. Two of 11 (18%) survivors developed late graft-related infective complications: major aortic graft infection at 6 months and symptomatic infected para-anastomotic aortic false aneurysm at 39 months. Early and late intra-abdominal infective complications were significantly more common in patients who were packed than in those who were not (packed: five of 23, 22% vs. non-packed: five of 455, 1%; p Conclusion These data demonstrate that intra-abdominal packing in coagulopathic patients with ruptured AAA can achieve an acceptable survival rate. However, this technique may be associated with an increased incidence of early and late intra-abdominal infective complications.
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- 2005
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43. Assessment of smoking status in patients with peripheral arterial disease
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A.B.M. Wilmink, Andrew W. Bradbury, Simon D. Hobbs, and Donald J. Adam
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Male ,medicine.medical_specialty ,Arterial disease ,Urinary system ,Sensitivity and Specificity ,chemistry.chemical_compound ,Internal medicine ,medicine ,Outpatient clinic ,Humans ,Cotinine ,Aged ,Peripheral Vascular Diseases ,Carbon Monoxide ,Vascular disease ,business.industry ,Smoking ,Middle Aged ,medicine.disease ,Intermittent claudication ,Peripheral ,Cross-Sectional Studies ,chemistry ,Breath Tests ,Anesthesia ,Linear Models ,Colorimetry ,Female ,Surgery ,medicine.symptom ,business ,Breath carbon monoxide ,Cardiology and Cardiovascular Medicine - Abstract
ObjectiveTo assess the utility of a novel rapid urinary cotinine assay to detect and quantify the level of smoking in patients with peripheral arterial disease.MethodsThis was a cross-sectional study in a vascular surgical outpatient department of a large teaching hospital. Participants were 100 consecutive subjects presenting to a hospital outpatient clinic with a diagnosis of intermittent claudication confirmed by a positive Edinburgh claudication questionnaire and an ankle-brachial pressure index of less than 0.9. Main outcome measures were patient-offered smoking history, exhaled breath carbon monoxide levels, urinary cotinine levels as measured by a novel rapid assay, and laboratory-measured creatinine-adjusted urinary cotinine levels.ResultsFifty-five subjects declared that they were current smokers, 40 declared that they were ex-smokers, and 5 declared that they were never-smokers. Of the 40 ex-smokers, 6 subjects (15%) had urinary cotinine levels greater than 500 ng/mL (regular smokers), and a further 2 (5%) had urinary cotinine levels between 100 and 500 ng/mL (light, irregular, or passive smokers). The rapid urinary cotinine assay had a sensitivity and specificity of 100% and 98%, respectively, in its ability to detect active smoking, and the degree of smoking correlated well with laboratory creatinine-corrected urinary cotinine levels (Spearman coefficient, 0.805; P < .001). By contrast, exhaled carbon monoxide had a sensitivity and specificity of 95% and 89%, respectively, and although it correlated well with urinary cotinine (Spearman coefficient, 0.782; P < .001), it was found on linear regression analysis to be unreliable in differentiating light smokers from nonsmokers.ConclusionsPatient-offered smoking history is unreliable because there is no correlation between the patient-reported number of cigarettes smoked per day and urinary cotinine levels. The novel rapid assay for urinary cotinine described here is superior to exhaled carbon monoxide measurement in detecting the level of smoking exposure among patients with intermittent claudication, and its results correlate well with laboratory-measured cotinine.
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- 2005
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44. Hemostatic markers before operation in patients with acutely symptomatic nonruptured and ruptured infrarenal abdominal aortic aneurysm
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Paul C. Haggart, Donald J. Adam, Andrew W. Bradbury, and Christopher A. Ludlam
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Aortic Rupture ,Gastroenterology ,Asymptomatic ,Sensitivity and Specificity ,chemistry.chemical_compound ,Predictive Value of Tests ,Internal medicine ,D-dimer ,Fibrinolysis ,medicine ,Humans ,Prospective Studies ,Aged ,Prothrombin time ,Hemostasis ,medicine.diagnostic_test ,business.industry ,Thrombin ,medicine.disease ,Abdominal aortic aneurysm ,Surgery ,Plasminogen Inactivators ,chemistry ,Plasminogen activator inhibitor-1 ,Female ,Blood Coagulation Tests ,medicine.symptom ,business ,Cardiology and Cardiovascular Medicine ,Plasminogen activator ,Partial thromboplastin time ,Aortic Aneurysm, Abdominal - Abstract
Background: In patients with acutely symptomatic but nonruptured abdominal aortic aneurysm (AAA), emergent repair is associated with an increased mortality rate as compared with semi-elective repair. Previous results have shown that ruptured but not asymptomatic AAA repair is associated with intense thrombin generation and inhibition of systemic fibrinolysis. The purpose of this study was to determine whether circulating markers of coagulation and fibrinolysis may be used to distinguish acutely symptomatic nonruptured and ruptured AAA. Methods: A prospective study was performed of 44 patients who underwent emergency AAA repair for suspected rupture. Platelet count, fibrinogen level, prothrombin time, activated partial thromboplastin time, tissue plasminogen activator (t-PA) activity, plasminogen activator inhibitor (PAI) activity, prothrombin fragment (PF) 1+2 level, and D dimer level were measured before surgery. Results: When compared with ruptured AAAs (n = 37), acutely symptomatic nonruptured AAAs (n = 7) were associated with increased fibrinogen level ( P =.033), reduced activated partial thromboplastin time ( P =.043), increased t-PA activity ( P =.023), reduced PAI activity ( P =.005), reduced PF 1+2 level ( P =.001), and reduced D dimer level ( P =.005; all P values determined with Mann-Whitney test). The differences in t-PA activity ( P =.01), PAI activity ( P =.004), and PF 1+2 level ( P =.01) persisted in patients whose conditions were normotensive. In all patients, a PF 1+2 level of greater than or equal to 2.5 nmol/L was associated with a sensitivity, specificity, and positive and negative predictive value for rupture of 89%, 86%, 97%, and 60%, respectively. In patients whose conditions were normotensive, PAI activity of greater than or equal to 16 AU/mL was associated with a sensitivity, specificity, and positive and negative predictive value of 83%, 100%, 100%, and 88%, respectively. Conclusion: These data show that acutely symptomatic nonruptured AAA is associated with increased systemic fibrinolysis (caused by reduced fibrinolytic inhibition) and reduced thrombin generation as compared with rupture. Preoperative hemostatic markers, particularly PF 1+2 level and PAI activity, may distinguish acutely symptomatic nonruptured from ruptured AAA. (J Vasc Surg 2002;35:661-5)
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- 2002
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45. PC074 Computed Tomography Fusion Imaging-Guided EVAR Reduces Radiation: The Results of a Prospective Radiation Evaluation During EVAR (REVAR)
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Adrien Hertault, Andrew Mayes, Hisashi Tonda, Hervé Rousseau, Robert Rhee, Stéphan Haulon, and Donald J. Adam
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Image fusion ,medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,medicine ,Surgery ,Computed tomography ,Radiology ,Radiation ,Cardiology and Cardiovascular Medicine ,Nuclear medicine ,business - Published
- 2017
46. Open aortic arch replacement in high-risk patients: the gold standard
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Aaron M. Ranasinghe, Donald J. Adam, Ian McCafferty, Peter Riley, Jorge Mascaro, Mauro Iafrancesco, Vamsidhar B. Dronavalli, and Martin W Claridge
- Subjects
Pulmonary and Respiratory Medicine ,Aortic arch ,Adult ,Male ,Risk ,medicine.medical_specialty ,Databases, Factual ,Aortic Diseases ,Aorta, Thoracic ,030204 cardiovascular system & hematology ,Coronary artery disease ,03 medical and health sciences ,Coronary artery bypass surgery ,Blood Vessel Prosthesis Implantation ,0302 clinical medicine ,Postoperative Complications ,Aortic valve replacement ,Internal medicine ,medicine.artery ,Medicine ,Humans ,Myocardial infarction ,Hospital Mortality ,Stroke ,Aged ,Aged, 80 and over ,business.industry ,General Medicine ,Perioperative ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,030228 respiratory system ,Descending aorta ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
OBJECTIVES Open total aortic arch replacement (TAR) in high-risk patients is considered by some to be associated with a prohibitively perioperative risk. Recent reports describe hybrid techniques to treat this group. We reviewed our outcomes of open surgery in a 'high-risk' group of patients. METHODS All patients who underwent open TAR between 2000 and 2013 were identified from our prospectively maintained database. Patients comparable with the ones who underwent hybrid repair in previous studies (logistic EuroSCORE between 20 and 60 without intervention on the aortic root or on the mitral/tricuspid valve) were selected for analysis. RESULTS Fifty-eight patients were identified. Median logistic EuroSCORE was 27.4 (range 20-57) and median age was 76 years (34.5% male). There were 11 resternotomies (18.9%) and 20 procedures were urgent/emergency (34.5%). Preoperative comorbidities included chronic obstructive pulmonary disease (31%), coronary artery disease (22.4%), peripheral vascular disease (48.3%), previous stroke (5.2%), previous myocardial infarction (3.4%) and left ventricular dysfunction (12%). Concomitant procedures included aortic valve replacement/resuspension (58.7%), coronary artery bypass grafting (22.4%), open descending aorta replacement (10.3%) and frozen elephant trunk (19%). Overall in-hospital mortality, permanent stroke and spinal cord injury rate were 6.9, 1.7 and 0%, respectively. There were no deaths or stroke in the elective group. One-year, 5-year and 10-year estimates of survival were 82.7, 70.0 and 37.8%, respectively. CONCLUSIONS Open TAR can be performed with low mortality and morbidity and excellent long-term results even in high-risk patients. Total endovascular repair may represent an option for patients not suitable for open surgery.
- Published
- 2014
47. Current results of endovascular repair of thoraco-abdominal aneurysms†
- Author
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Martin W Claridge, Mauro Iafrancesco, Aaron M. Ranasinghe, Jorge Mascaro, and Donald J. Adam
- Subjects
Pulmonary and Respiratory Medicine ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,Aortic aneurysm ,Blood Vessel Prosthesis Implantation ,Aneurysm ,Postoperative Complications ,medicine.artery ,medicine ,Humans ,Renal replacement therapy ,Dialysis ,Aged ,Retrospective Studies ,Aged, 80 and over ,Aorta ,Aortic Aneurysm, Thoracic ,business.industry ,Endovascular Procedures ,Stent ,General Medicine ,Middle Aged ,medicine.disease ,Surgery ,Blood Vessel Prosthesis ,medicine.anatomical_structure ,Treatment Outcome ,Abdomen ,Female ,Stents ,Radiology ,Hemodialysis ,Cardiology and Cardiovascular Medicine ,business - Abstract
OBJECTIVES Fenestrated and branch endografts represent a totally endovascular solution for high-risk patients with atherosclerotic thoraco-abdominal aortic aneurysms (TAAAs). This study reports the early outcome of endovascular TAAA repair. METHODS Interrogation of a prospective database of consecutive patients who underwent endovascular repair (EVAR) for TAAA between June 2007 and October 2012. RESULTS Sixty-two high-risk patients (55 men; median age 72, range 54-84 years) underwent fenestrated (n = 39) or branch (n = 23) EVAR for non-ruptured TAAA [extent I-III (n = 26) and IV (n = 36)]. Twenty patients had undergone 22 previous aortic procedures. A total of 221 target vessels (coeliac 50, superior mesenteric 61, renal 106, left subclavian 1 and hypogastric 3) were preserved with scallops (n = 17), fenestrations (n = 140) or branches (n = 62) and 201 of these vessels were stent-grafted (coeliac 34, superior mesenteric 58, renal 105, left subclavian 1 and hypogastric 3). The 30-day mortality was 1.6% (n = 1) and one further patient died on postoperative day 62 from respiratory complications. Spinal cord injury (SCI) developed in 5 (8%) patients (3 women and 2 men). Two patients required temporary renal replacement therapy and a further two commenced planned postoperative dialysis. CONCLUSIONS In high-risk patients with TAAA, fenestrated and branch EVAR is associated with low early mortality and requirement for renal support, but the risk of SCI is not insignificant despite the use of cerebrospinal fluid drainage and blood pressure manipulation. Our current practice is to stage the repair of extent I-III aneurysms and this has significantly reduced the incidence of SCI.
- Published
- 2014
48. Comparison of cardiac troponin I and creatine kinase ratios in the detection of myocardial injury after aortic surgery
- Author
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P. C. Haggart, Andrew W. Bradbury, Donald J. Adam, and P. F. Ludman
- Subjects
Male ,medicine.medical_specialty ,Myocardial Infarction ,Aortic aneurysm ,chemistry.chemical_compound ,Postoperative Complications ,Troponin complex ,Internal medicine ,Troponin I ,medicine ,Humans ,Prospective Studies ,Myocardial infarction ,Creatine Kinase ,Aged ,Aged, 80 and over ,Creatinine ,biology ,business.industry ,Middle Aged ,medicine.disease ,Troponin ,chemistry ,Anesthesia ,biology.protein ,Cardiology ,Female ,Surgery ,Creatine kinase ,Myocardial infarction diagnosis ,Emergencies ,business ,Biomarkers ,Aortic Aneurysm, Abdominal - Abstract
Background Perioperative myocardial infarction may not be diagnosed correctly because World Health Organization criteria are often not met and creatinine kinase myocardial fraction (creatinine kinase/creatinine kinase MB isoenzyme; CK/CK-MB) ratios can be difficult to interpret. Cardiac troponin (cTn) I and cTnT are the most sensitive and specific markers of myocardial cell necrosis currently available but are not widely used in surgical practice. The aim was to compare cTnI and CK/CK-MB ratios in the detection of myocardial injury following aortic surgery. Methods This was a prospective study of 59 patients undergoing elective (n = 28) or ruptured (n = 24) abdominal aortic aneurysm repair or elective aortofemoral bypass (n = 7). cTnI level was measured before operation and at 6, 24 and 48 h after surgery. The CK/CK-MB ratio was measured where cTnI was detectable. Results Some 14 of 24 emergency and ten of 35 elective patients had detectable cTnI (greater than 0·5 ng/ml) at one or more time-points. The CK/CK-MB ratio was greater than 5 per cent in only four of 24 patients having an emergency operation and in none of the elective patients with detectable cTnI. Conclusion Over half of patients undergoing emergency operation and more than a quarter of those having elective aortic surgery suffered myocardial necrosis as determined by detectable cTnI levels. This was accompanied by a raised CK/CK-MB ratio in less than one-fifth of patients.
- Published
- 2001
49. Myocardial Injury and Systemic Fibrinolysis in Patients Undergoing Repair of Ruptured Abdominal Aortic Aneurysm: a Preliminary Report
- Author
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C.A Ludman, P.C. Haggart, Donald J. Adam, P. F. Ludman, and Andrew W. Bradbury
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Male ,medicine.medical_specialty ,Necrosis ,Blood transfusion ,Aortic Rupture ,medicine.medical_treatment ,Myocardial Ischemia ,macromolecular substances ,Tissue plasminogen activator ,Statistics, Nonparametric ,Aortic aneurysm ,Postoperative Complications ,Internal medicine ,Plasminogen Activator Inhibitor 1 ,Fibrinolysis ,Troponin I ,medicine ,Humans ,Prospective Studies ,Aged ,Medicine(all) ,Aged, 80 and over ,biology ,business.industry ,medicine.disease ,Troponin ,Tissue Plasminogen Activator ,Post-operative myocardial infarction ,cardiovascular system ,biology.protein ,Cardiology ,Female ,Surgery ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Plasminogen activator ,Biomarkers ,Aortic Aneurysm, Abdominal ,medicine.drug - Abstract
Background ruptured abdominal aortic aneurysm (AAA) is associated with inhibition of systemic fibrinolysis. HypoIfibrinolysis is a risk factor for ischaemic myocardial injury, one of the commonest complications of ruptured AAA repair. Cardiac troponin I (cTnI) is one of the most sensitive and specific marker of myocardial injury currently available. Objective to examine, for the first time, the relationship between fibrinolytic activity and myocardial injury in patients operated for ruptured AAA. Methods twenty patients (18 men and 2 women of median age 74, range 65–86 years) undergoing repair of ruptured AAA were prospectively studied. Plasma tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1) activity were measured pre-operatively, immediately before and five minutes following aortic clamp release. Serum cTnI was measured pre-operatively, 6 and 24 h following clamp release. Results cTnI was detectable at one or more sample points in 13 (65%) patients, and in 7 out of 8 patients who suffered major cardiac complications. There was a significant negative correlation between pre-operative t-PA activity and cTnI before operation (r =−0.55, p = 0.01) and 6 h ( r =−0.51, p =0.02) after clamp release. There was a significant positive correlation between pre-operative PAI activity and cTnI before operation (r =+0.50, p =0.03), 6 h ( r =+0.47, p =0.04) and 24 h ( r =+0.50, p =0.03) after clamp release. There was no correlation between pre- and intra-operative hypotension or blood transfusion requirement and cTnI release. Conclusions hypofibrinolysis during ruptured AAA repair is associated with the development of peri-operative myocardial injury. The causal mechanisms underlying this state are not clear but treatment of this prothrombotic/hypofibrinolytic diathesis may help to limit myocardial cell necrosis.
- Published
- 2001
50. Plasma endothelin levels and outcome in patients undergoing repair of ruptured infrarenal abdominal aortic aneurysm
- Author
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Andrew W. Bradbury, Stephen M. Evans, Donald J. Adam, and David J. Webb
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Male ,Multiple Organ Failure ,Aneurysm, Ruptured ,Risk Assessment ,Sensitivity and Specificity ,Statistics, Nonparametric ,Postoperative Complications ,Aneurysm ,medicine.artery ,Preoperative Care ,medicine ,Humans ,Postoperative Period ,Prospective Studies ,Myocardial infarction ,Aged ,Probability ,Aged, 80 and over ,Analysis of Variance ,Endothelin-1 ,Septic shock ,business.industry ,Vascular disease ,Abdominal aorta ,Perioperative ,medicine.disease ,Endothelin 1 ,Abdominal aortic aneurysm ,Survival Rate ,Treatment Outcome ,Anesthesia ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Aortic Aneurysm, Abdominal ,Follow-Up Studies - Abstract
Background: Endothelin-1 (ET-1) is the most potent known vasoconstrictor. Elevated plasma levels have been demonstrated in patients with myocardial infarction, cardiogenic and septic shock, and respiratory, heart, and kidney failure, as well as in those undergoing elective abdominal aortic aneurysm (AAA) repair. However, endothelin levels have not previously been examined in patients undergoing repair of ruptured AAA. We hypothesized that hemorrhagic shock, lower torso ischemia, and reperfusion associated with ruptured AAA repair lead to increased synthesis and secretion of ET-1, which, in turn, predispose to organ failure, one of the principal causes of death in this condition. Methods: Fourteen patients were studied. Plasma levels of big ET-1 and ET-1 were measured immediately before operation and immediately before, 5 minutes, and 6 hours after aortic clamp release. Results: All patients survived for at least 24 hours after operation. Big ET-1 levels were above the normal range at one or more sample points in all patients, and the ET-1 levels were above the normal range in all survivors and four of five nonsurvivors. Five patients who died of organ failure had significantly lower big ET-1 levels at all sample points and significantly lower ET-1 levels after 5 minutes of reperfusion when compared with survivors. Preoperative ET-1 levels were significantly lower in eight patients who subsequently developed kidney failure than in six patients who did not. Conclusion: Contrary to our original hypothesis, these novel data demonstrate that patients with ruptured AAA in whom fatal postoperative organ failure develops have significantly lower perioperative endothelin levels than survivors. (J Vasc Surg 2001;33:1242-6.)
- Published
- 2001
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