Symptoms, stenosis and carotid plaque morphology. Is plaque morphology relevant?

Objectives:To study the relationship between carotid plaque morphology and the degree of stenosis on Duplex ultrasonography and symptoms.Design:Prospective open clinical study.Methods:2590 patients with 5180 carotid arteries were scanned, 4560 were initially analysed in terms of symptoms but 54 were excluded, leaving a total of 4258.Results:Localising symptoms were present with respect to 1342 vessels (29.4%). Two-thirds of symptomatic patients had normal carotid arteries. Tight stenosis (80–99%) was more likely to be associated with symptoms than low-grade (20–79%) stenosis (x2=28.0, p < 0.0001). Plaque type was identified in 1558 bifurcations (36.6%). Heterogeneous type I & II plaques accounted for one third of plaques. There was a relationship between plaque morphology and degree of stenosis. At < 20% stenosis only 4.4% of plaques were heterogeneous whereas at 80–99% stenosis 84.5% of plaques were heterogeneous. Amaurosis fugax was the only symptom that had any association with a particular plaque morphology. Seventy-two percent of plaques associated with this symptom were heterogeneous in nature.Conclusions:Carotid plaque morphology and degree of internal carotid stenosis are mutually dependent factors and both reflect the severity of atherosclerotic disease. Plaque morphology does not add to the sensitivity of stenosis in predicting the presence of symptoms

The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: A double-blind randomised-controlled trial

AbstractObjective: ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications. The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers. Method: eighteen diabetic patients with ischaemic, non-healing lower-extremity ulcers were recruited in a double-blind study. Patients were randomly assigned either to receive 100% oxygen (treatment group) or air (control group), at 2.4 atmospheres of absolute pressure for 90 min daily (total of 30 treatments). Results: healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group. The median decrease of the wound areas in the treatment group was 100% and in the control group was 52% (p = 0.027). Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen, there was a potential saving in the total cost of treatment for each patient during the study. Conclusion: hyperbaric oxygen enhanced the healing of ischaemic, non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible.Eur J Vasc Endovasc Surg 25, 513-518 (2003

Carotid endarterectomy in the U.K. and Ireland: Audit of 30-day outcome

Objectives and Design:A prospective study of 709 patients undergoing carotid surgery in the U.K. and Ireland was performed to evaluate the performance of vascular surgeons.Materials and Methods:Fifty-nine surgeons (range 2–39 cases each) were sampled and all patients undergoing surgery over a 6-month period (1 March 1994–31 August 1994) were included in the study. Indications for surgery were TIA (35.9%), AF (23.3%), CVA (21.4%) and “others” (19.6%).Results:Mean ipsilateral stenosis was 82% (30%–99%). Thirty-one percent of patients had preoperative neurological consults. Shunts were used in 67.6%, tacking sutures in 40.1%, drains in 71.9% and patches in 54.4% of cases. At 30 days there were nine (1.3%) deaths (four cardiac, three neurological). There were 15 ipsilateral postoperative CVAs (2.1%); 19% of patients had one or more complication, usually minor. Statistical analysis showed no independent risk factor for CVA other than seniority of the surgeon.Conclusions:A combined stroke/death rate of 3% for the series was obtained at 30 days for all cases. This large, validated study suggests that members of the Vascular Society of G.B. and Ireland currently have a very low morbidity/mortality rate for performing carotid surgery. Continued audit is required to ensure that this quality of service does not deteriorate

A Bayesian hierarchical approach to comparative audit for carotid surgery

Objectives: the aim of this study was to illustrate how a Bayesian hierarchical modelling approach can aid the reliable comparison of outcome rates between surgeons. Design: retrospective analysis of prospective and retrospective data. Materials: binary outcome data (death/stroke within 30 days), together with information on 15 possible risk factors specific for CEA were available on 836 CEAs performed by four vascular surgeons from 1992-99. The median patient age was 68 (range 38-86) years and 60% were men. Methods: the model was developed using the WinBUGS software. After adjusting for patient-level risk factors, a cross-validatory approach was adopted to identify "divergent" performance. A ranking exercise was also carried out. Results: the overall observed 30-day stroke/death rate was 3.9% (33/836). The model found diabetes, stroke and heart disease to be significant risk factors. There was no significant difference between the predicted and observed outcome rates for any surgeon (Bayesian p-value &gt; 0.05). Each surgeon had a median rank of 3 with associated 95% CI 1.0-5.0, despite the variability of observed stroke/death rate from 2.9-4.4%. After risk adjustment, there was very little residual between-surgeon variability in outcome rate. Conclusions: Bayesian hierarchical models can help to accurately quantify the uncertainty associated with surgeons' performance and rank

Disruption of Skin Perfusion Following Longitudinal Groin Incision for Infrainguinal Bypass Surgery

AbstractObjectivethe objective of our study was to investigate whether such an incision results in a reduction in blood flow, and therefore haemoglobin oxygen saturation, across the wound.Designmicrovascular oxygenation was measured with lightguide spectrophotometry in 21 patients undergoing femoropopliteal or femorodistal bypass procedures. A series of measurements were made in the groin, medial and lateral to the surface marking of the femoral artery. The mean oxygen saturation on each side was calculated, and the contra-lateral groin was used as a control. The measurements were repeated at 2 and 7 days postop.Resultsoxygen saturation in the skin of the operated groins was increased significantly from baseline at 2 days postop (f=25.80, p<0.001) and had begun to return to normal by day 7. The rise was more marked on the lateral side of the wound than on the medial (f=12.32, p<0.001). There was no such difference in the control groins. All wounds healed at 10 days.Conclusionsthese results show a significant difference in skin oxygenation between the lateral and medial sides of the groin following longitudinal incision. This may contribute to the relatively high incidence of postoperative infection in these wounds

Heat shock proteins in vascular disease - a review

IntroductionThere is growing evidence that heat shock proteins (HSPs), a family of stress-inducible proteins may be involved in the pathogenesis of atherosclerotic vascular diseases. Here, we systematically review the evidence behind this notion.MethodsA detailed literature search and extensive bibliographic review of literature relating to HSPs and atherosclerotic vascular disease.ResultsAtherosclerotic vascular disease is classified into four main areas of presentation: carotid, coronary, aortic and peripheral vascular disease, for consideration in this review. In each of these vascular diseases, the evidence linking HSPs and atherosclerosis is outlined in a systematic manner. Current evidence suggests that components of the immune system may be involved in the pathogenesis of atherosclerosis, with HSPs acting as auto-antigens in the immune response. HSPs are detected in atherosclerotic lesions and antibodies to HSPs are increased in patients with vascular disease; the rise often correlating with the severity of atherosclerosis. The levels of anti-HSP antibodies have been shown to be independent predictors of risk and have prognostic value.ConclusionThere is a strong link between heat shock protein expression and the principal manifestations of atherosclerotic vascular diseases. A better understanding of this involvement could lead to the development of new and improved treatment strategies