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Introduction An increasing number of frail older patients are undergoing surgical procedures. Frailty is an independent risk factor for increased hospital stay and adverse postoperative outcomes. This project aimed to assess frailty and its management in lower limb critical limb ischaemia patients on the vascular ward at Manchester Royal Infirmary. Method A prospective review of consecutive admissions admitted with lower limb critical limb ischaemia identified from ward list and vascular activity, and subsequently discharged. Assessment of frailty status using the Edmonton and Rockwood scales within 48 hrs of admission. Results A total of 15 patients were identified with an average age of 69.2 years. The average length of hospital stay was 19 days. 69 total days were spent in the hospital once patients were declared ‘medically fit for discharge’ across all patients. Frailty is associated with increased length of hospital stay and discharge to other institutions. Both the Edmonton and Rockwood scales were congruent in assessing frailty. Conclusions Frailty needs to be assessed and identified early so it can be flagged to therapy services and discharge arrangements commenced early. Measures need to be put in place to manage frailty and reduce the length of hospital stay.

Endothelial microparticles (EMPs) are complex submicron membrane-shed vesicles released into the circulation following endothelium cell activation or apoptosis. They are classified as either physiological or pathological, with anticoagulant or pro-inflammatory effects respectively. Endothelial dysfunction caused by inflammation is a key initiating event in atherosclerotic plaque formation. Athero-emboli, resulting from ruptured carotid plaques are a major cause of stroke. Current clinical techniques for arterial assessment, angiography and carotid ultrasound, give accurate information about stenosis but limited evidence on plaque composition, inflammation or vulnerability; as a result, patients with asymptomatic, or fragile carotid lesions, may not be identified and treated effectively. There is a need to discover novel biomarkers and develop more efficient diagnostic approaches in order to stratify patients at most risk of stroke, who would benefit from interventional surgery. Increasing evidence suggests that EMPs play an important role in the pathogenesis of cardiovascular disease, acting as a marker of damage, either exacerbating disease progression or triggering a repair response. In this regard, it has been suggested that EMPs have the potential to act as biomarkers of disease status. In this review, we will present the evidence to support this hypothesis and propose a novel concept for the development of a diagnostic device that could be implemented in the clinic.

Objectives Several plaque and lesion characteristics have been associated with an increased risk for procedural stroke during or shortly after carotid artery stenting (CAS). While technical advancements in stent design and cerebral protection devices (CPD) may help reduce the procedural stroke risk, and anatomy remains important, tailoring stenting procedures according to plaque and lesion characteristics might be a useful strategy in reducing stroke associated with CAS. In this descriptive report of the ongoing Asymptomatic Carotid Surgery Trial-2 (ACST-2), it was assessed whether choice for stent and use or type of CPD was influenced by plaque and lesion characteristics. Materials and methods Trial patients who underwent CAS between 2008 and 2015 were included in this study. Chi-square statistics were used to study the effects of plaque echolucency, ipsilateral preocclusive disease (90–99%), and contralateral high-grade stenosis (>50%) or occlusion of the carotid artery on interventionalists' choice for stent and CPD. Differences in treatment preference between specialties were also analysed. Results In this study, 831 patients from 88 ACST-2 centres were included. Almost all procedures were performed by either interventional radiologists (50%) or vascular surgeons (45%). Plaque echolucency, ipsilateral preocclusive disease (90–99%), and significant contralateral stenosis (>50%) or occlusion did not affect the choice of stent or either the use of cerebral protection and type of CPD employed (i.e., filter/flow reversal). Vascular surgeons used a CPD significantly more often than interventional radiologists (98.6% vs. 76.3%; p < .001), but this choice did not appear to be dependent on patient characteristics. Conclusions In ACST-2, plaque characteristics and severity of stenosis did not primarily determine interventionalists' choice of stent or use or type of CPD, suggesting that other factors, such as vascular anatomy or personal and centre preference, may be more important. Stent and CPD use was highly heterogeneous among participating European centres.

IntroductionCarotid endarterectomy (CEA) should be performed within two weeks of symptoms for patients with carotid stenosis >50%. Whether these standards are being achieved and causes of delay between symptoms and CEA were investigated.DesignAn analysis of prospectively collected multi-centre data.MaterialsConsecutive data for patients undergoing CEA between January-2006 and September-2010 were collected. Asymptomatic patients and those with no details on the timing of cerebral symptoms were excluded.Methods‘Delay’ from symptom to CEA was defined as more than two weeks and ‘prolonged-delay’ more than eight weeks. Univariable and multivariable analyses were used to identify factors associated with these delays.ResultsOf 2147 patients with symptoms of cerebral ischaemia, 1522(70.9%) experienced ‘delay’ and 920(42.9%) experienced ‘prolonged delay’. Patients with ischaemic heart disease were more likely to experience ‘delay’ (OR = 1.56; 95% CI 1.11–2.19, p = 0.011), whereas patients with stroke (OR = 0.77; 95%CI 0.63–0.94, p = 0.011) and those treated at hospitals with a stroke-prevention clinic (OR = 0.57; 95%CI 0.46–0.71, p

La surveillance des pontages vise a identifier ceux qui sont menaces d'echec dans la mesure ou une intervention sur un pontage dysfonctionnant mais permeable ameliore la permeabilite a long terme des pontages et le taux de sauvetage de membre par comparaison avec la desobstruction d'un pontage occlus. Une polemique persiste quant au type de materiau qui beneficie le plus de la surveillance et au role de facteurs lies au patient tels que le diabete et le tabagisme sur la durabilite des pontages. Nos objectifs etaient (1) de clarifier l'histoire naturelle de l'echec a moyen terme des pontages par hyperplasie myointimale et (2) d'identifier quels patients et quels pontages sont a risque plus eleve d'echec et a quel moment ceci a le plus de chance de survenir. Les explorations vasculaires successives et les donnees cliniques de 212 pontages des membres inferieurs sous-inguinaux chez 197 patients ont ete analysees. Le suivi dans le cadre du programme de surveillance reposait sur l'examen duplex couleur focalise a 0, 1, 3, 6, 12, et 18 mois en fonction de l'intervention. Les resultats ont ete correles avec les donnees colligees retrospectivement concernant les caracteristiques demographiques des patients, le tabagisme, les medicaments prescrits, les comorbidites, et les donnees operatoires telles que l'artere receveuse et le substitut utilise. Pendant le programme, 21,6% des pontages se sont occlus. De facon generale, 16% des pontages ont fait l'objet d'un geste de sauvetage, dont 40,5% ont ete effectues dans les six mois. Il y avait 56,6% d'occlusions precedees par une stenose. Les occlusions primaires expliquaient 95,9% des occlusions dans le groupe prothetique et 66,5% dans le groupe des pontages femoro-jambiers. Les pontages veineux avaient plus de chances de developper une stenose progressive avant l'occlusion, avec 58,3% des cas de ce groupe precedes d'une stenose. Les stenoses de moins de 75% etaient frequentes et avaient une histoire naturelle variable, plus de 40% se corrigeant ou ne progressant pas. Tout au long de la periode d'etude, 56,2% des pontages sont restes indemnes de stenose. Les stenoses etaient plus frequentes au niveau de l'anastomose proximale dans la cohorte des pontages veineux. Les taux de stenose significative etaient faibles dans le groupe prothetique. Ces lesions interessaient surtout l'anastomose distale mais elles etaient de mauvais facteurs predictifs de l'occlusion. L'utilisation postoperatoire des statines prevenait le developpement des stenoses significatives et des occlusions, en particulier des pontages sus-articulaires (p = 0,03). De maniere etonnante, le tabagisme preoperatoire n'etait predictif ni d'une occlusion ni du developpement d'une stenose significative. La presence d'un diabete n'etait pas predictive des mauvais resultats. Nos resultats suggerent que la surveillance des pontages est une methode valide pour detecter la presence des stenoses significatives des pontages veineux a haut risque d'echec en l'absence d'intervention. En depit du suivi intensif, le programme n'a pas detecte de lesions avant l'occlusion d'un grand nombre des pontages prothetiques et femoro-jambiers. Ce groupe beneficie donc sans doute peu d'une surveillance des pontages.

There is no convincing evidence that endothelial cell seeding of prosthetic grafts in humans confers any of the advantages seen in animals. However, partial endothelial coverage might exert a subtle effect not detectable with indirect end points such as patency or scintigraphy. This study examined seeded cell function by measuring fibrinolytic and platelet activation markers in patients receiving seeded and control prosthetic grafts. Thirty-two patients were randomly assigned to seeded (n = 15) and control (n = 17) groups. Preoperatively and 3, 6, and 12 months postoperatively, plasma levels of fibrinopeptide A (FPA), B beta 1-42 fragment, cross-linked fibrin degradation products (XL-FDP), thromboxane A2 (TXA2), platelet factor 4 (PF4), and beta-thromboglobulin (beta TG) were measured. Patients with seeded grafts had significantly lower levels of FPA at 6 and 12 months (p0.05) and a significant overall group effect (p0.05). These patients also tended to have higher levels of XL-FDP (p0.1). No other significant differences were seen. The lower rate of conversion of fibrinogen to fibrin and the trend toward increased fibrinolysis seen in seeded grafts may be due to the metabolic effects of viable retained seeded cells. Although comparable platelet activation indicates that endothelial coverage remains limited, seeding may exert an antithrombotic influence at the graft surface.

Indium-111 oxine labeling is widely used as a marker of endothelial cell attachment to vascular prostheses. The long term effect of labeling human adult endothelial cells (HAECs) with this isotope has not been determined. In this study the viability of labeled HAECs, leakage of isotope from labeled cells and adherence of circulating isotope to fibronectin coated prostheses were investigated over 24 h. The effect of incubation time on labeling efficiency was also assessed. There were significant differences in cell viability between the labeled and unlabeled groups beyond 4 h (p < 0.005, 2-tailed, unpaired t-test). In the control group cell numbers increased by 42% while in the labeled group this had decreased by 20% at 24 h. Spontaneous leakage increased with time but was maximal in the first 2 h. Adherence of circulating isotope to fibronectin coated expanded polytetrafluoroethylene (ePTFE) grafts was minimal but was significantly greater to gelatin impregnated Dacron (GEL-SEAL) beyond 1 hour (p < 0.05). Incubation times greater than 5 minutes during labeling do not significantly improve labeling efficiency, and may contribute to toxicity by prolonging exposure to oxine. Indium-111 oxine labeling of HAECs is a suitable technique for acute studies of endothelial cell kinetics up to 4 h, but its use in chronic studies may lead to significant underestimations of cell retention.

Indium-111 labelled platelet scintigraphy permits simple, accurate evaluation of platelet kinetics and sites of deposition. The most meaningful results are obtained from serial scans, although these are clinically useful in only a few of the many applications that have been suggested, principally in studies of acute thrombosis, prosthetic graft thrombogenicity and antiplatelet medication. Key pitfalls are associated with selection of regions and patient variation.

Graft surveillance aims to identify those grafts that are at risk of failure as intervention in a patent but failing graft results in improved long-term patency and limb salvage rates compared to rescue of an occluded graft. Controversy exists as to which types of graft benefit the most from surveillance and whether patient factors such as diabetes and smoking status have an effect on graft survival. Our aims were (1) to clarify the natural history of midterm graft failure as a consequence of myointimal hyperplasia and (2) to identify which patients and grafts are at a higher risk of failure and at what time points this is most prevalent. Serial vascular laboratory and clinical data of 212 infrainguinal lower limb grafts in 197 patients were analyzed. Follow-up within the surveillance program was by focused examination with color flow duplex ultrasound at 0, 1, 3, 6, 12, and 18 months with respect to surgery. Outcomes were correlated with retrospectively collected data regarding patient demographics, smoking status, concurrent medication, comorbidity, and operative factors such as distal target vessel and conduit. During the program, 21.6% of grafts occluded. Overall, 16% of grafts underwent a salvage procedure, 40.5% of which were carried out at the 6-month time point. There were 56.6% of occlusions preceded by a stenotic lesion. Primary occlusions accounted for 95.9% in the prosthetic group and 66.5% in the femorocrural group. As a group, vein grafts were more likely to develop a progressive stenosis prior to occlusion, with 58.3% in this group predated by a stenotic lesion. Fewer than 75% of stenoses were common and had a variable natural history, with over 40% resolving or failing to progress. Throughout the study period, 56.2% of grafts remained stenosis-free. Stenoses were more common at the proximal anastomosis in the vein graft cohort. There were low rates of significant stenoses within the prosthetic group. These lesions were more likely to occur at the distal anastomosis but were poor predictors of occlusion. Statin use postoperatively was protective against the development of significant stenosis and occlusions, particularly in the above-knee grafts (p = 0.03). Surprisingly, preoperative smoking status was predictive of neither occlusion nor development of significant stenosis. The presence of diabetes was not predictive of poor outcome. Our findings suggest that graft surveillance is a valid method for detecting the presence of significant stenoses in vein grafts at high risk of failure without intervention. Despite the intensive follow-up, the program failed to detect lesions prior to occlusion in a large percentage of prosthetic and femorocrural grafts, so perhaps this group is poorly served by graft surveillance.

Objectives: This study aimed to identify the risk factors that influence the healing process of venous leg ulcers treated with compression bandaging, with a view to predicting healing time. Method: A retrospective cohort study was performed on data collected prospectively on 325 consecutive patients presenting with 345 venous ulcers at the Salford Primary Care Trust leg ulcer clinic between January 1997 and December 1999. Use of an artificial neural network (ANN) technique accurately predicted the healing times for 68% of the patients. Results: The ANN demonstrated that healing was significantly related to a history of previous leg ulceration, ‘quite wet’ ulcer exudate, high body mass index, large initial total ulcer area, increasing age and male gender. Conclusion: The ability to identify at presentation ulcers that might be resistant to standard therapy would allow early consideration of more radical treatments such as hospitalisation, wound debridement or venous surgery. Declaration of interest: None.

There is a clinical need to develop novel biomarkers to identify patients at risk of stroke. We aim to establish a systemic signature and microparticle profile of asymptomatic patients with unstable carotid disease, for improved selection of patients for interventional surgery and stroke prevention. Blood samples were taken from 70 patients (51 symptomatic; 19 asymptomatic), undergoing carotid endarterectomy, and 20 healthy controls. Circulating endothelial microparticles (EMPs; CD31+/Annexin V+/CD42b−), together with inflammatory markers were measured using flow cytometry and Bioplex assays respectively. Carotid plaques were graded and analysed using immunohistochemistry. EMPs were elevated in asymptomatic and symptomatic patients, compared to healthy controls (p= These data could aid in the development of a diagnostic tool whereby EMPs, together with macrophage activity markers, could identify those patients with vulnerable plaques and stroke susceptibility.

Introduction Stroke is the third most common cause of death world wide. Most cases of stroke are caused by atherosclerotic plaque rupture. A challenge facing clinicians is identifying asymptomatic patients at risk of plaque instability. Locally released angiogenic growth factors may contribute to microvessel instability within plaques. Growth factors and inflammatory cytokines are potential serum biomarkers to identify patients at risk of stroke. Materials and methods Immunohistochemistry and quantitative PCR (Q-PCR) were used to establish localisation and expression of angiogenic growth factors within carotid endarterectomy specimens from symptomatic and asymptomatic patients. Stable or unstable microvessels were distinguished by CD31 and CD105 staining. Systemic levels of circulating angiogenic growth factors and inflammatory cytokines were measured in venous blood using Bio-Plex arrays. Results Hepatocyte growth factor (HGF) and its receptor c-Met were detected in CD31-positive endothelia, and α-SMA-positive cells, respectively. Q-PCR demonstrated upregulation of the angiogenic factors CD105, HGF (p Discussion Plaque instability may be mediated by HGF-induced formation of microvessels, and decreased PDGF. We will investigate the effects of inflammatory cytokines with a view to comparing symptomatic versus asymptomatic patients. Targeting surgery to those who will benefit would eliminate unnecessary risk.

Improved patency of endothelial cell seeded grafts relies on good initial adherence and cell retention when the circulation is restored. In this study human adult endothelial cells (HAECs) were used to evaluate the suitability of commercially available prostheses for seeding. Acutely seeded indium-111 oxine labeled HAECs were used to measure cell adherence to plain and fibronectin (FN)-coated expanded polytetrafluoroethylene (ePTFE), gelatin-impregnated Dacron (Gelseal), and collagen-impregnated Dacron (Hemashield) grafts. Cell loss from FN-coated prostheses, when exposed to a simulated human arterial blood flow of 200 ml/min in an artificial pulsatile circulation, was quantified from the loss of gamma activity from the graft over 24 hours, pressure in the circulation being reduced to 15 mm Hg to reduce fluid loss. Initial HAEC adherence (mean [SD]) to plain grafts was 3(1)%, 47(9)%, and 53(9)% for ePTFE, Gelseal, and Hemashield, respectively. This improved significantly with FN coating (78[6]%, 60[8]%, and 76[4]%). Cell retention after 24 hours of flow to FN-coated grafts was 16(10)%, 25(5)%, and 65(4)% and was confirmed qualitatively by scanning electron microscopy and environmental scanning electron microscopy. FN significantly improved initial cell adherence with Dacron grafts showing the better adherence. Cell retention after 24 hours of flow was better with FN-coated Dacron than with ePTFE but was best with Hemashield grafts.