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Purpose: Various studies, mainly from North America, report worse outcomes in ethnic minority populations submitted to revascularization for peripheral arterial disease (PAD). Limited nationwide data in relation to ethnicity are available from Europe., Objective: The objective of the study is to compare the outcomes of femoral angioplasty/stenting procedures among different ethnic groups in England during the 10-year period from 2006 to 2015., Materials and Methods: The "Hospital Episode Statistics" database has been searched using International Classification of Diseases, Tenth Revision ( ICD-10 ) codes to identify all cases of femoral angioplasty or stenting from English NHS Hospitals between January 1, 2006, and December 31, 2015. Subsequent mortality, second open or endovascular infrainguinal procedures, and major amputations on the same side within 2 years after the first procedure have been recorded. Patients were broadly categorized according to ethnicity as whites, Asians, and blacks. Chi-square test was used to demonstrate significant differences among ethnic groups and odds ratios (ORs) were calculated using white ethnic group as reference., Results: A total number of 70 887 femoral endovascular procedures were recorded in patients from the 3 ethnic groups. Two-year mortality in whites, Asians, and blacks was 18.3%, 22.1%, and 19.5% (p<0.001); rates of second endovascular procedure were 12.1%, 13.1%, and 13.5% (p=0.24); rates of open infrainguinal procedure were 5.6%, 4.5%, and 8.0% (p<0.001); and rates of major amputation were 4.8%, 4.1%, and 7.0% (p<0.001), respectively. Mortality was higher in Asians (OR=1.26, 95% confidence interval [CI]=1.10-1.45, p<0.01) compared with whites. On the contrary, blacks underwent more open arterial operations (OR=1.48, 95% CI=1.19-1.83, p<0.01) and more amputations (OR=1.49, 95% CI=1.18-1.87, p<0.01). There were no significant differences in the rates of second endovascular procedures., Conclusion: Two-year mortality after femoral angioplasty/stenting is higher in Asians, whereas risk of limb loss is higher in blacks compared with whites. Reasons of these ethnic differences in outcomes following femoral endovascular procedures for PAD merit further study.

Background: The combination of peripheral arterial disease and atrial fibrillation is linked with high risk of mortality and stroke. This study aims to investigate the impact of atrial fibrillation on patients with diagnosed peripheral arterial disease., Methods: This is a retrospective study using The Health Improvement Network database, which contains prospectively collected data from participating primary care practices. Patients with a new diagnosis of peripheral arterial disease between January 8, 1995 and January 5, 2017 were identified in the database alongside relevant demographic information, clinical history, and medications. Every patient in the dataset with peripheral arterial disease and baseline atrial fibrillation (case) was matched to a patient without atrial fibrillation (control) with similar characteristics using propensity score matching. Cox-regression analysis was performed and hazard ratios (HR) calculated for the outcomes of death, stroke, ischemic heart disease, heart failure, and major amputation., Results: Prevalence of atrial fibrillation in this cohort was 10.2%. All patients with peripheral arterial disease and atrial fibrillation (n = 5685) were matched with 5685 patients without atrial fibrillation but otherwise similar characteristics. After multivariate analysis, atrial fibrillation was independently associated with mortality (HR 1.18; 95% confidence interval [CI], 1.12-1.26; P < .01), cerebrovascular events (HR 1.35; 95% CI, 1.17-1.57; P < .01), and heart failure (HR 1.87; 95% CI, 1.62-2.15; P < .01), but not with ischemic heart disease or limb loss., Conclusion: In peripheral arterial disease patients, atrial fibrillation is a risk factor for mortality, stroke, and heart failure. This emphasizes the need for proactive surveillance and holistic management of these patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Previous studies, mainly from the United States, have reported worse outcomes from lower limb bypass procedures in ethnic minority populations. Limited nationwide data are available from ethnic minority populations from Europe. The aim of this study is to investigate outcomes from lower limb bypass procedures in ethnic minorities from England., Methods: We enquired the "Hospital Episode Statistics" database, using ICD-10 codes to identify all cases of femoral-popliteal bypass operations from English NHS Hospitals from 01/01/2006 to 31/12/2015. Every case was followed up for 2 years for subsequent events. The primary outcomes were mortality and major leg amputation. Patients were broadly categorised according to Black, Asian and White ethnicity. Chi-square test was used to the ethnic groups and odds ratios (OR) were calculated using White ethnic group with the largest numbers of participants as a reference category., Results: In the examined 10-year period, 20825 femoral-popliteal bypass procedures (250 of Black, 167 of Asian, and 20.408 of White ethnicity) were recorded. Thirty-day and 2-year mortality were 2.8% and 16.8% with no significant ethnic differences. Patients of Black ethnicity had higher risk of limb loss compared to Whites (23.2% vs. 15.6%, OR = 1.63, 95% confidence interval (CI) 1.21-2.19, P < 0.01). There was no significant difference in amputation rates between Asians and Whites (16.2% vs.. 15.6%, P = 0.94)., Conclusions: Patients of Black ethnicity are at higher risk of limb loss after a femoropopliteal bypass procedure. Further research is needed to identify the causes of this discrepancy., (Copyright © 2021. Published by Elsevier Inc.)

Background: Peripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation., Methods: This was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups., Results: The prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874). Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016)., Conclusion: Peripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective/background: In a pilot study, a relationship between abdominal aortic aneurysm (AAA) diameter and serum interleukin (IL)-1α levels was reported, and that endothelial cell (EC) activation in vitro in response to serum from patients with AAA was blocked by anti-IL-1α antibodies. The aim of the present study was to further investigate the relationship between serum IL-1α and asymptomatic infrarenal AAA size, morphology, and growth rates., Methods: Serum IL-1α was measured using enzyme linked immunosorbent assay in 101 patients with asymptomatic, infrarenal AAA and related to aneurysm size, morphology, and growth rates., Results: IL-1α was measured in 101 patients. There was no statistically significant difference in mean age between men and women. IL-1α was detectable in 62.4% of patients; median IL-1α titre was 3.26 pg/mL. There was no statistically significant relationship between IL-1α and maximum AAA antero-posterior diameter as measured by ultrasound (p = .649), AAA morphology (aortic length [p = .394], sac [p = .369], and thrombus volume [p = .629]) as measured on computed tomography, absolute increase in AAA diameter (p = .214), or AAA growth rate (p = .230)., Conclusion: IL-1α is detectable in the majority of patients with infrarenal AAA, but the cause and clinical significance of this novel observation remains unknown., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: For a cytokine to have a role as a clinically useful biomarker, it must be measureable in a practical, reliable, and reproducible manner. Furthermore, assays from different manufacturers should produce comparable results. The aim of this paper was to examine the effect of 2 sample processing methodologies and compare 9 commercially available immunoassays for their measurement of serum interleukin (IL)-1α in patients with abdominal aortic aneurysm., Methods: Two sample processing methodologies and 9 manufacturers' immunoassays were compared. Each immunoassay was also tested for detection of both IL-1α isoforms., Results: A positive signal for IL-1α was found in all serum samples, in all immunoassays, using both processing methods. In the majority, titer concentrations were unquantifiable with values below manufacturers' detectable range. Variability in titer concentrations was seen across all immunoassays. With the exception of 1 immunoassay, all were able to detect both IL-1α isoforms., Conclusions: Researchers wishing to measure serum cytokines levels should be aware that differences in sample processing methods and manufacturers' immunoassays can affect the results. This may result in misleading conclusions being drawn about biological processes underpinning a wide range of inflammatory diseases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Previous studies have demonstrated higher rates of peripheral arterial disease (PAD) in blacks and lower in Asians compared to whites. The aim of this study is to undertake a comprehensive review of literature on ethnic differences in the epidemiology of PAD., Methods: A systemic review and meta-analysis included studies reporting PAD prevalence in general or diabetic populations, and comparing PAD prevalence in ethnic groups., Results: Mean prevalence of PAD in general population for whites, blacks and Asians was 3.5%, 6.7% and 3.7% respectively. Meta-analysis demonstrated higher prevalence of PAD in blacks (p < 0.001) and lower amongst Asians (p < 0.001), compared to whites. In diabetic population, the mean prevalence of PAD for whites, blacks, east Asians and south Asians was 17%, 25.3%, 13.5% and 7.6% respectively. In diabetic population, south Asians had a lower PAD prevalence (p < 0.001) compared to whites; there was no significant difference between blacks and whites. Overall females have higher PAD rates, in general (3.8% vs 3.2%; p < 0.001) and in diabetic population (13.7% vs 10%; p < 0.001)., Conclusion: Blacks are vulnerable to PAD, in contrast to Asians who have lower prevalence of PAD when compared to whites. Further research is needed in order to identify the factors that generate this difference.

Objective: Graft angioplasty combines the durability and ability of surgical bypasses to treat long arterial occlusions with the minimally invasive nature of endovascular procedures. The purpose of this study was to evaluate the efficacy of single and repeated graft angioplasty in revising failing infrainguinal vein bypass grafts and to determine predictors of medium- and long-term freedom from revision after graft angioplasty., Method: This was a retrospective analysis from a prospectively maintained database. Consecutive endovascular revisions of graft-threatening lesions identified by duplex ultrasound surveillance were reviewed from 2003 to 2010. Patients were followed up until death, major amputation, or the end of follow-up, with the data last updated on January 1, 2013., Results: 178 graft angioplasty procedures performed in 114 bypass grafts in 103 limbs from 98 patients were studied. At 5 years, freedom from revision was 22.6%, graft survival was 45.8%, amputation-free survival was 57.9%, and patient survival was 64.9%. Analysis of repeated angioplasties found no evidence that effectiveness diminishes significantly with the number of previous angioplasties performed (p=.892). Higher Rutherford Grade of ischemia and longer time interval from index surgery to first angioplasty were significant positive predictors of medium- and long-term patency., Conclusion: Percutaneous transluminal angioplasty of infrainguinal vein grafts is safe and effective in the treatment of failing grafts identified by duplex surveillance. Graft angioplasties do not lose effectiveness when repeated and have shown cumulative benefit in prolonging graft survival. Treatment of claudicants and time interval from graft implantation of more than 6 months at the time of first angioplasty are positive predictors of at least medium-term patency after graft angioplasty., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Cystatin C (Cyst C) is more sensitive marker for early renal injury. However, serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) are still used as the standard renal markers after endovascular aortic aneurysm repair (EVAR). The goal of this study was to compare the efficacy of Cyst C, sCr, and eGFR as markers of renal function after EVAR., Patients and Methods: This study examined 29 patients (27 men) with a mean age of 76.9 years (range, 55-89 years) undergoing standard (n = 19) and fenestrated (n = 10) EVAR for abdominal aortic aneurysm (AAA) of mean diameter 6.9 cm (range, 5.5-10 cm). Cyst C and sCr were measured and eGFR calculated before and 1 day and 1, 6, and 12 months after EVAR., Results: At 24 hours after procedure, a significant increase in Cyst C (P < 0.005) and sCr (P = 0.028) and significant decrease in eGFR (P = 0.04) were seen. Cyst C continued to increase and was significantly higher at 1 (P < 0.002), 6 (P < 0.005), and 12 (P < 0.005) months compared with baseline. By contrast, sCr and eGFR did not show any significant change at 1, 6, and 12 months from the baseline level. Cyst C increased significantly postoperatively regardless of the baseline renal function. None of the patients required renal replacement therapy., Conclusions: EVAR is associated with a significant increase in Cyst C starting 24 hours after the procedure and is maintained for 12 months. sCr and eGFR only show significant change at 24 hours and therefore may underestimate long-term renal damage after EVAR., (Copyright © 2013 Elsevier Inc. All rights reserved.)

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., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aim: Abdominal aortic aneurysm (AAA) is associated with chronic mural inflammation and a pro-thrombotic diathesis. It has been suggested that both may be related to biologically active intra-sac thrombus. The aim of this study was to examine the relationship between thrombin generation, fibrinolysis, platelet activity and AAA sac thrombus volume., Methods: 30 patients (29 men) of median (IQR) age 75 (71-82) years with an infra-renal AAA >5.5 cm in antero-posterior diameter were prospectively studied. AAA, lumen and thrombus volumes were calculated using a CT workstation (Vitrea). Plasma thrombin-antithrombin (TAT), plasminogen activator inhibitor (PAI)-1, and soluble (s) P-selectin were measured as biomarkers of coagulation, fibrinolysis and platelet activity, respectively, Results: Median (IQR) AAA total, lumen and thrombus volumes were 188 (147-247) cm(3), 80 (54.3-107) cm(3) and 97.6 (63-127) cm(3) respectively. TAT levels were significantly higher (median, QR, 7.15 [4.7-31.3] μg/L, p=<0.001) and sP-selectin levels significantly lower (median, IQR, 80.5 [68-128] ng/ml, p=<0.0001) than the normal range. PAI-1 levels (median, IQR, 20.9 [8.4-50.7] ng/ml) were normal. There was no correlation between AAA thrombus volume and PAI-1 (r=-0.25, p=0.47), sP-Selectin (r=0.26, p=0.43) or TAT plasma levels (r=-0.21, p=0.54)., Conclusion: The present study confirms that patients with AAA demonstrate haemostatic derangement, but the extent of the haemostatic derangement does not correlate with AAA sac thrombus volume., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Abdominal aortic aneurysm (AAA) is a chronic inflammatory condition associated with a prothrombotic, hypofibrinolytic diathesis that may increase the risk of cardiovascular events. The effect of endovascular aneurysm repair (EVAR) on this prothrombotic diathesis is not fully understood, especially over the medium and long term. A better understanding of these postintervention changes may improve the risk of cardiovascular complications in the long term. The purpose of this study was to examine thrombin generation, fibrinolysis, platelet and endothelial activation, and the inflammatory response during the 12 months following EVAR., Methods: Twenty-nine patients (mean age, 76.9 years) undergoing EVAR for AAA (mean diameter 6.9 cm) had prothrombin fragment (PF) 1 + 2, thrombin-antithrombin complex (TAT), plasminogen activator inhibitor (PAI) activity, tissue plasminogen activator (t-PA) activity and antigen, soluble P- and E-selectin, and highly sensitive C-reactive protein (hsCRP) measured before and at 24 hours, and 1, 6, and 12 months after surgery., Results: PF1 + 2 were markedly elevated prior to EVAR and remained so at 24 hours and 1 month, but had decreased significantly at 6 and 12 months. TAT was also elevated prior to EVAR and increased still further by 24 hours, but fell to below baseline levels thereafter. PAI activity and t-PA antigen were normal prior to EVAR, increased significantly at 24 hours, and then fell to baseline levels. t-PA activity was only detectable at 1 and 6 months; there was a significant rise in soluble P- and E-selectin after EVAR, which was sustained for 12 months. hsCRP increased transiently in response to EVAR but returned to preoperative levels by 1 month., Conclusions: The prothrombotic, hypofibrinolytic diathesis associated with AAA is normalized 12 months after EVAR. This beneficial systemic effect of EVAR for AAA disease may help protect patients against future thromboembolic cardiovascular events., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: (1) To report the incidence of myocardial injury in patients undergoing endovascular aortic aneurysm repair (EVAR) through the routine measurement of perioperative cardiac troponin-T (cTnT) and (2) to investigate and correlate changes in perioperative cTnT levels with any concomitant hemostatic derangement., Methods: Prospective study of 30 patients undergoing elective EVAR for infrarenal abdominal aortic aneurysm. Cardiac TnT was assayed at 24 hours postoperatively. Plasma thrombin antithrombin III complex (TAT), plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (t-PA) activity, and soluble P-selectin (sP-selectin) were assayed preoperatively and at 24 hours postoperatively., Results: Five (17%) patients demonstrated elevated cTnT levels at 24 hours; 3 patients had no clinical evidence of myocardial injury. There was a positive correlation between cTnT and TAT levels at 24 hours post-EVAR (r = .38, P = .039, Kendall-tau B = 0.26)., Conclusions: Endovascular aortic aneurysm repair is associated with a significant risk of perioperative myocardial injury that is underdetected clinically and associated with a procoagulopathic state.

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., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aim: Occlusion or severe stenosis of pedal and plantar arteries limits surgical options for critical limb ischaemia (CLI). Below-the-ankle (BTA) angioplasty is potentially useful as an adjunct to proximal angioplasty. In this study, the feasibility and outcome of this procedure were explored, as they have not been evaluated previously., Methods: Patients' demographics, indications, procedures and outcomes were recorded. Outcomes were determined by technical success, primary patency, limb salvage and amputation-free survival (AFS) rates., Results: Between 2004 and 2008, 42 cases of BTA angioplasty were performed for 39 patients. Forty cases (95.2%) had CLI. Technical success was achieved in 88% of cases. At 6, 12 and 24 months, AFS was 70.7%, 60.9% and 57.1%, limb salvage was 84.9%, 81.9% and 81.9% and patient survival was 83.3%, 73.8% and 67.3, respectively. Seven major amputations (16.6%) were performed, four of which had failed angioplasty. Two patients required re-intervention. Univariate analysis showed insulin-dependent diabetics, occlusive lesions, failure of angioplasty and state of the run off to be the predictors of limb loss., Conclusions: BTA angioplasty for pedal and plantar arterial occlusive disease is technically feasible. It has good medium-term clinical outcome and limb salvage in a group of patients with poor surgical options., (Copyright (c) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Pseudoaneurysm (PA) after carotid endarterectomy (CEA) is a rare complication with incidence less than 1%. There is a potential for rupture, embolization, thrombosis or compression of cranial nerves., Objective: We reviewed our experience and compare it to the literature to raise awareness of this rare though serious condition. It is crucial to treat these patients early to avoid the hazardous consequences., Methods: A review of the case records of patients who had CEA at University Hospital Birmingham (UHB) NHS Foundation Trust from 1990-2007, was undertaken. Information of patients including their aetiology, presenting features, treatment and results was collected. The English-language literature was searched using PubMed database for post CEA pseudoaneurysm., Results: Five patients developed post CEA PA. This represents 0.4% of the 1200 CEA performed at our hospital in the last 18 years. The timing of their presentation varied from three days to eight months after the original operation. All had patch reconstruction after CEA. Patches were intact at exploration of the PAs. There was one death and one stroke. The literature revealed 154 carotid PAs after CEA and two cases following carotid stenting 52 of these cases had infected PA. Patients with synthetic patches have the least incidence of infection. More than 80% had open surgery and 9% had endovascular repair., Conclusion: Post CEA surveillance is necessary to detect patients with PA early. Factors that favour infection must be avoided. Endovascular repair of carotid PA should be encouraged in specialised centres.

We describe an attempted endovascular stenting for popliteal artery stenosis secondary to adventitial cystic disease in a 56-year-old man with lifestyle-limiting claudication. Despite technical success, it remained patent only for 1 week, requiring interposition venous graft reconstruction eventually.

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; technical success, morbidity, mortality, length of hospital stay) and late (>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 > or = .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.

Exposure of endothelial cells (EC) to shear stress reduces their response to tumour necrosis factor-alpha (TNF). We tested how shear-conditioned EC responded to reduction in flow, either by spontaneously binding leukocytes, or by increasing sensitivity to TNF. Human umbilical vein EC were exposed to shear stress of 2.0 Pa (20 dyn/cm(2)) for 24 h. Shear was then reduced to stasis (30 sec perfusion each hour to exchange medium) or 0.003 Pa (creeping flow). At chosen times, neutrophils were perfused over the EC at 0.1 Pa (effective reperfusion). EC developed an ability to capture flowing neutrophils that lasted from 1 to 3 h after flow reduction, which was reduced by antibody against P-selectin or pre-treatment of EC with an inhibitor of NADPH-oxidase. Adhesion of neutrophils to TNF-treated EC was greatly suppressed by shear-conditioning, remained suppressed immediately after cessation of flow and then took 48 h to approach the level in static cultures. Interestingly, the response to TNF remained suppressed in cultures switched to creeping flow. Gene array analysis confirmed that differently recovered cells had separate phenotypes. Thus, an acute response of EC to reduction in shear may contribute to leukocyte recruitment, along with hypoxia, in ischaemia and reperfusion. Prolonged cessation of flow may increase the sensitivity of EC to inflammatory stimuli, but this effect may be suppressed by residual flow.

We present a case report of a 65-year-old gentleman who presented with an aortoenteric fistula along with a review of the literature. He was found, in addition, to have an inflammatory infrarenal aortic aneurysm with a posterior rupture. Cultures of the aneurysm sac confirmed a Streptococcus pneumoniae infection. The patient had previously presented with pneumonia. Antibody testing revealed an isolated pneumococcal IgG deficiency. The case demonstrates the diverse pathologies associated with aortic aneurysms and a need to be vigilant and occasionally expect the unusual.

Objectives: Temporal artery biopsy (TAB) is requested in an attempt to confirm the diagnosis of temporal arteritis (TA). Patients symptoms and signs are highly variable and TA is often focal and potentially missed in a small biopsy. The study aimed to determine if TAB helps in the management of patients with suspected TA., Methods: The case records of sixty-six consecutive patients who had undergone temporal artery biopsy were recalled and examined for presenting symptoms, management, therapy, results and outcome., Results: There were 23 men and 43 women with a mean age of 70.2 and 71.1 years respectively. Presenting symptoms varied with unilateral headache in 53, scalp tenderness in 16, muscle weakness in 10, visual disturbance in 16, jaw claudication in 5 and peri-orbital pain in 1 patient. The temporal artery was tender in 21 patients and thickened in 4 patients. Thirty-eight patients were commenced on steroids prior to biopsy and 6 more before the histology became available. Only 8% of biopsies were positive for TA. Of the patients started on steroids with a negative biopsy, the steroids were continued in 26 and stopped in 9. In the patients not put on steroids [22], biopsy was positive in 2; they were commenced on steroids. Therefore, the histological diagnosis resulted in a change in patient management in only 18% of patients., Conclusion: The results of TAB do not appear to affect the clinical management of most patients with suspected temporal arteritis. We must therefore question the routine use of this invasive investigation.

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

Background: Hormone replacement therapy (HRT) is recommended to post-menopausal women to control menopausal symptoms and prevent osteoporosis. The management of women with peripheral arterial disease (PAD) and who are taking HRT is controversial., Aim: To summarise what is known about HRT and its effect on the natural progression of PAD and its subsequent treatment., Methods: A MEDLINE (1966-2004) and Cochrane library search for articles relating to HRT and PAD was undertaken., Results: The potential benefits of unopposed estrogen therapy on atherosclerotic progression and limb microcirculation are outweighed by the increased risk of endometrial dysplasia and thrombotic complications. Only one major study (Rotterdam) specifically assessed the impact of HRT on the clinical course of PAD. The findings suggested a decreased risk of PAD among healthy post-menopausal women taking HRT which contrasts with the sub-group analyses of other major studies (HERS/HERS II). HRT appears to reduce the primary success rates of both endovascular and open surgical revascularisation in patients with PAD., Conclusions: Further studies are required to investigate the effects of HRT on the progression of PAD and its management.

Background: The optimal colloid for renal protection during abdominal aortic aneurysm (AAA) surgery is not known. This study compared the effects of two hydroxyethyl starch (HES) solutions and gelatine on perioperative renal function., Methods: Sixty-two patients undergoing AAA surgery were randomized to 6 per cent HES of molecular weight 200/0.62 kDa or 130/0.4 kDa, or 4 per cent gelatine for plasma expansion. Measurements were taken of serum urea and creatinine to mark glomerular filtration, urinary immunoglobulin G : creatinine ratio to mark glomerular membrane function and alpha(1)-microglobulin : creatinine ratio to mark tubular dysfunction before, and for 5 days after, surgery., Results: Serum urea was lower in both HES groups than the gelatine group. Serum creatinine was lower with HES 130/0.4 compared with gelatine at days 1, 2 and 5 after surgery (P = 0.020, P = 0.045 and P = 0.045 respectively). Urinary alpha(1)-microglobulin : creatinine ratio was lower with HES 200/0.62 compared with gelatine at 4 and 8 h (P < 0.050) and lower with HES 130/0.4 compared with gelatine at 4 to 24 h, and on days 4 and 5 (P < 0.050). Urinary immunoglobulin G : creatinine was lower in both HES groups compared with gelatine. There was no difference between the two starch groups., Conclusion: Compared with gelatine, volume expansion with both types of HES during AAA surgery improved renal function and reduced renal injury.

A quadricuspid aortic valve (QAV) is a rare congenital heart defect, previously described as an incidental finding at the time of surgery or postmortem, which is now being increasingly detected by 2D transthoracic or transesophageal echocardiogram. With advances in echocardiography, secondary cardiac anomalies are also being described in association with QAV. Herein we describe a patient with QAV with a secundum atrial septal defect.

Recent studies have demonstrated that neutrophils are not a homogenous population of cells. Here, we have identified a subset of human neutrophils with a distinct profile of cell-surface receptors [CD54(high), CXC chemokine receptor 1(low) (CXCR1(low))], which represent cells that have migrated through an endothelial monolayer and then re-emerged by reverse transmigration (RT). RT neutrophils, when in contact with endothelium, were rescued from apoptosis, demonstrate functional priming, and were rheologically distinct from neutrophils that had not undergone transendothelial migration. In vivo, 1-2% of peripheral blood neutrophils in patients with systemic inflammation exhibit a RT phenotype. A smaller population existed in healthy donors ( approximately 0.25%). RT neutrophils were distinct from naïve circulatory neutrophils (CD54(low), CXCR1(high)) and naïve cells after activation with formyl-Met-Leu-Phe (CD54(low), CXCR1(low)). It is important that the RT phenotype (CD54(high), CXCR1(low)) is also distinct from tissue-resident neutrophils (CD54(low), CXCR1(low)). Our results demonstrate that neutrophils can migrate in a retrograde direction across endothelial cells and suggest that a population of tissue-experienced neutrophils with a distinct phenotype and function are present in the peripheral circulation in humans in vivo.

Objective: To investigate the effect of HES, used as a plasma volume expander, on endothelial cell activation induced by ischaemia-reperfusion in humans., Material and Methods: Forty patients undergoing elective infrarenal aneurysm repair were randomised to receive either gelatine or hydroxyethyl starch solution as plasma expanders. The anaesthetic technique was standardised. All patients received the same crystalloid as per standard protocol. Urine samples and blood samples were collected at various times for assessment of microalbuminuria and von Willebrand factor (vWf) and CRP., Results: The peak C-reactive protein was significantly lower in the patients treated with HES than those treated with gelofusine [142 mg/L (113,196 mg/L) vs 246 mg/L (189,291 mg/L) mg/L, P < 0.01, Mann-Whitney test]. The peak ACR was also significantly lower in the HES treated patients (9.3 mg/mmol vs 23.3 mg/mmol, P < 0.05). The plasma level of vWf was significantly higher in the gelofusine treated patients than those treated with HES [173.5 U/dl Vs 80.5 U/dl, P < 0.001, at 4 hr; 160 U/dl Vs 82.5 U/dl, P < 0.001, at 8 hr; 191 U/dl Vs 100.5 U/dl, P < 0.001, at 12 hr; 209 U/dl Vs 81.0 U/dl, P < 0.001, at 24 hr]., Conclusion: HES may damp down the systemic inflammatory response and reduce endothelial cell dysfunction.

Following carotid endarterectomy (CEA), patch angioplasty provides a significant reduction in the risk of perioperative complications. The expanded polytetrafluoroethylene (ePTFE) patch is strong, is resistant to infection, and has low thrombogenicity; but it remains unpopular because of its tendency of prolonged bleeding at the suture line. We aimed to investigate whether the application of Quixil sealant to the suture line could improve the time to achieve hemostasis and reduce local blood loss when compared to a standard topical hemostat Kaltostat. A prospective, randomized trial of 20 patients undergoing CEA was undertaken. Patients were randomized to receive either Quixil sealant (treatment group) or topical Kaltostat (controls) as a hemostatic agent to the patch suture line. Hemostasis was defined as no bleeding at the suture line for 1 minute. Statistical analysis was performed using the Mann-Whitney test. The two groups had a similar age and sex distribution. The mean age was 71 years, and there were seven men and three women in each group. The time to achieve hemostasis was significantly lower in the Quixil group (median 2.5 minutes, range 1-4 minutes) compared to the controls (median 17 minutes, range 7-59 minutes) (p < 0.001). Blood loss after clamp release was also significantly reduced in the Quixil group; median 24.5 ml (range 5.5-105.0 ml) versus 203 ml (range 54.5-817.0 ml) (p < 0.001). This study has demonstrated that Quixil human surgical sealant is an effective sealant of ePTFE patch suture holes and does not compromise the patch repair. It could be used during other vascular procedures involving ePTFE.

Background: Restoring blood flow to ischaemic tissue can cause lung damage with pulmonary oedema. Hydroxyethyl starch (HES) solution, when used for volume replacement, may modify and reduce the degree of ischaemia-reperfusion injury. We compared the effects of HES solution with those of Gelofusine solution on pulmonary function, microvascular permeability and neutrophil activation in patients undergoing elective infrarenal abdominal aortic aneurysm surgery., Methods: Forty patients were randomized into two groups. The anaesthetic technique was standardized. Lung function was assessed with the PO(2)/FI(O(2)) ratio, respiratory compliance, chest x-ray and a score for lung injury. Microvascular permeability was determined by measuring microalbuminuria. Neutrophil activation was determined by measurement of plasma elastase., Results: Four hours after surgery, the median (quartile values) PO(2)/FI(O(2)) ratio was 40.3 (37.8, 53.1) kPa for the HES-treated patients compared with 33.9 (31.2, 40.9) kPa for the Gelofusine-treated patients (P<0.01, Mann-Whitney test). The respiratory compliance was 80 (73.5, 80) ml cm(-1) H(2)O in the HES-treated patients compared with 60.1 (50.8, 73.3) ml cm(-1) H(2)O in the Gelofusine-treated patients (P<0.01, Mann-Whitney test). The lung injury score 4 h after surgery was less for the patients treated with HES compared with the patients treated with Gelofusine (0.33 vs 0.71, P=0.01, Wilcoxon rank sum test). Mean (SD) plasma elastase was less in the HES-treated patients on the first postoperative day (1.96 (0.17) vs 2.08 (0.24), P<0.05). The log mean microalbuminuria was less in the HES-treated patients (0.41 vs 0.91 mg mmol(-1), P<0.05). This difference in microvascular permeability was associated with different volumes of colloid required to maintain stable cardiovascular measurements in the two groups of patients studied (3000 vs 3500 ml, P<0.01, Mann-Whitney test)., Conclusion: Compared with Gelofusine, the perioperative pulmonary function of patients treated with HES after abdominal aortic aneurysm surgery was better.

Aim: Infrainguinal bypass is an effective treatment for critical lower limb ischemia but up to 1/3 of these grafts will occlude within the 1st year. The aim of this audit was to evaluate the efficacy of aspirin in maintaining graft patency and also improving patient survival., Methods: In a single audited year (1997) 125 bypasses were carried out. Seventy-nine were on aspirin, 34 on no treatment and 12 were on other agents and hence excluded from analysis. The indication for surgery was critical ischaemia in 101 and disabling claudication in 12. Autologous vein was used in 104 and prosthetic grafts in 9., Results: The overall 2-year primary graft patency, secondary graft patency and limb salvage were 50%, 71% and 83%, respectively. The 2-year secondary patency in patients with or without aspirin was 73% and 64%, respectively (p<0.12-log rank test). The corresponding patient survival from vascular death in the 2 groups was 73% and 70% (p<0.67-log rank test). Crural/ pedal bypass (51/75 on aspirin) and smoking (51/61 on aspirin) were independent risk factors for graft failure and vascular death respectively whilst those with a previous myocardial infarct (21/28 on aspirin) reached significance in univariate analysis only (p< 0.03)., Conclusion: Aspirin was not a significant factor in preventing graft failure or vascular death in patients undergoing bypass for critical limb ischemia. Dual therapy with other antiplatelet agents needs to be considered in such patients particularly those undergoing crural/pedal bypass, smokers and those with a history of previous myocardial infarction.

Background: Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm., Patients and Methods: A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality., Results: Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24)., Conclusion: Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.

Background: microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot"., Methods: in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered., Results: twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22)., Conclusions: microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.

Background: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery., Patients and Methods: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow., Results: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test)., Conclusion: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.

Background: Gastric intramucosal pH (pHi), a surrogate marker of splanchnic oxygenation, falls following abdominal aortic aneurysm surgery., Aim: To investigate the effects of volume expansion with hydroxyethyl starch (eloHAES) on splanchnic perfusion compared to another colloid such as gelofusine., Patients and Methods: Twenty-two consecutive patients undergoing AAA repair were randomised to receive either eloHAES or gelofusine as plasma expanders. Tissue oxygenation was monitored (10 gelofusine and 12 eloHAES) indirectly by measuring pHi using a nasogastric tonometer., Results: Compared to the eloHAES group, the fall in pHi was significantly greater in the gelofusine group at clamp release (7.29 vs 7.33, P=0.003) and at 4 h following clamp release (7.29 vs 7.33, P=0.03). There was a good inverse correlation between the lowest pHi and the peak serum interleukin-6 (r(s)= -0.47, P=0.03). By multivariate analysis, the only factor that influenced the pHi was the type of colloid used (F=5.54, P=0.005). The eloHAES treated patients required significantly less colloid on the first postoperative day (3175 +/- 175 vs 4065 +/- 269 ml, P=0.01)., Conclusion: In patients undergoing abdominal aortic aneurysm repair, plasma expansion with eloHAES improves microvascular perfusion and splanchnic oxygenation.

Finger discoloration may result from recognized conditions affecting upper limb vasculature. We describe 11 patients who presented with acute pain, swelling and blue/purple discoloration in a finger. This benign condition mimicked digital ischaemia. There were 9 women and 2 men. The episode usually started with an ache/pain in the finger followed 2-3 h later by a blue/purple discoloration primarily on the volar aspect but always sparing the tip. This completely resolved after 4-7 days with no residual deficit. There was no history of trauma. Four patients had had previous episodes--2 had been started on warfarin. There was no family history and only one gave a history of spontaneous bruising of her legs. Examination of all patients--pulse rate, blood pressure, cardiac and subclavian artery auscultation and digital artery Doppler insonation--was normal. All patients had normal full blood counts, CRP, vasculitis screen and clotting (except those on warfarin). Six similar cases, all women, were reported in 1982. There was no common aetiological factor other than sex. Although of no prognostic significance, the condition is likely to concern patients and doctors in primary care. The discoloration is, however, clearly of a different distribution to that in an ischaemic finger where the tip of the digit is involved.

Three cases of true aneurysms of the profunda femoris artery are reported along with a review of 17 other cases in the literature. These aneurysms are rare and commonly present with rapid enlargement or rupture (9/20), the risk of rupture being higher than those affecting the femoral or popliteal arteries. All patients underwent successful surgical treatment except for one who required amputation. The diagnosis of an aneurysm of the profunda femoris artery must be considered in all patients with a pulsatile swelling in the groin. Surgical treatment is mandatory, and it carries a low mortality as well as a low risk of amputation.

Prosthetic small-caliber vascular grafts give poorer patency rates than autogenous vein grafts, possibly because the former never spontaneously form endothelium. Animal studies have shown that endothelialization of prosthetic grafts can be encouraged by seeding endothelial cells into the graft at the time of surgery, resulting in improved patency. Information regarding the attachment characteristics of adult human endothelial cells to prosthetic grafts is, however, sparce. Laboratory experiments were performed by use of cell culture techniques to compare the attachment characteristics of adult human endothelial cells to expanded polytetrafluoroethylene graft material, both untreated and treated, with one of four protein substrates--preclotted blood, fibronectin, laminin, and type 4 collagen. Attachment characteristics were compared quantitatively by use of attachment assays and qualitatively by scanning electron microscopy. Attachment to untreated expanded polytetrafluoroethylene was poor but could be greatly improved by preclotting or precoating with any of the proteins, particularly fibronectin. In preclotted grafts seeded endothelial cells formed a virtually confluent monolayer after 1 hour. Cell attachment to the other grafts coated with protein was patchy and inconsistent. It is concluded that a rapid confluent endothelial lining within a prosthetic vascular graft is possible, and of the substrates examined, preclotted blood best encourages cell attachment to expanded polytetrafluoroethylene.

Sixteen patients with severe occlusive vascular disease of the lower extremities were randomised to receive a five day course of combined intravenous and oral Pentoxifylline followed by three months oral treatment only, or identical treatment with a matching placebo. Nine patients received active Pentoxifylline, and 7 placebo, Follow-up by regular clinical examination and haemoreological assessment revealed a marked improvement in claudication distance and an increase in red cell deformability in those receiving Pentoxifylline, there being no change in those receiving placebo. Although both of the above parameters were improved by the treatment, there did not appear to be a direct correlation between red cell deformability and claudication distance in individual patients. A combination of intravenous and oral Pentoxifylline therapy results in an increase in both claudication distance and red cell deformability, but the former may not te a direct consequence of the latter.