Carotid plaque morphology: A review

The recent North American Symptomatic Carotid Endarterectomy Trial has answered fairly conclusively the questions concerning the optimal management of patients with symptoms who have a > 70% stenosis of the internal carotid artery. It has also had the effect of refocusing attention on carotid pathology. The main question still to be answered is whether surgical management is the optimum treatment for other groups of patients with carotid disease. From various studies done on the natural history of carotid plaques it is apparent that there are subgroups who may benefit from surgery, namely those who will progress to stroke if not treated. The problem comes in identifying these subgroups by the factors which cause them to progress. This paper aims to review the role that plaque morphology has in the development of symptoms and whether it should be included with degree of stenosis in assessing the risk of a carotid plaque. The non-invasive assessment of plaque morphology is also reviewed. The evidence from this review does not support the use of plaque morphology as a discriminating factor for carotid endarterectomy at present

Late reoperation in vascular surgery

Objectives:Assessment of late reoperation (after 30 days) following vascular surgery.Design:Analysis of a prospectively collected database of consecutive patients undergoing vascular surgery.Setting:A single teaching unit's experience between 1986–1993.Materials:Patients undergoing 2501 primary arterial reconstructions.Chief outcome measures:Reoperation after 30 days.Main results:One hundred and fifty eight patients (6%) underwent further operations, at more than 1 month after the primary procedure. Primary procedures at highest risk for reoperations were axillobifemoral bypasses and femorodistal bypasses with respective late reoperation rates of 20% and 16%. The majority of patients required late reoperation because of graft occlusion or stenosis. Overall, of the 158 late reoperations performed, 114 were related to the same arterial segment with the same presenting symptoms as the primary operation, and 44 for a different indication. A second or subsequent reoperation was required in 54 patients and the overall operative mortality was 11%.Conclusion:Patients undergoing certain vascular procedures, should be informed of the high risk of a subsequent procedure when consent is obtained

Compression ultrasonography for false femoral artery aneurysms: Hypocoagulability is a cause of failure

Objectives:false femoral artery aneurysm is an occasional complication of percutaneous cardiovascular radiological procedures. Compression ultrasonography causes thrombosis non-invasively, reducing need for operative intervention. The technique fails in a proportion of cases. Analysis was undertaken to identify causes of failure.Design:prospective open study.Materials and Methods:patients presenting with false femoral artery aneurysm since 1984 were identified from a computerised database (BIPAS). Since 1993 compression ultrasonography has been performed as first line treatment according to a standard protocol. Prospectively collected ultrasonographic data and case notes were reviewed to identify causes of failed compression.Results:false femoral artery aneurysm occurred as a complication in 32/26 687 (0.12%) cardiovascular radiological procedures. Eighteen aneurysms were treated by compression. The technique was successful in 11/18 (61%) cases but primary failure occurred in seven cases. Six out of seven had bleeding abnormalities (Chi-squared analysis with Yates correction 10.55, p=0.0012), four were anticoagulated and compression was subsequently successful following reversal of warfarin therapy in three of these patients. In 4/18 cases surgical repair was necessary.Conclusions:compression ultrasonography is an effective treatment of false femoral aneurysms, however, hypocoagulability is a significant cause of failure. For patients in whom anticoagulation cannot be reversed, primary surgical repair should be considered

Sympathetic skin response and patient satisfaction on long term follow up of thoracoscopic sympathectomy for hyperhidrosis

Objectives:To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted.Design:Prospective, Open, Non-randomised study.Materials and Methods:Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionaire and visual analogue score (0–1.0).Results:Of 26 patients, 21 were female. Mean (range) age was 23 (9–36) years. Mean (range) follow up was 39 (4–138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06–1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F=0.48; p=0.49) and incidence of compensatory sweating (F=2.38; p=0.14).Conclusion:Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy