ABC of arterial and venous disease. Secondary prevention of transient ischaemic attack and stroke

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A Chip Off The Old Block!

A 35 year old male presented 9 months after sustaining a penetrating injury to the neck with a false aneurysm of the common carotid artery (CCA). At exploration, a 5mm piece of granite was embedded in the posterior wall of the CCA with overlying endothelialisation. He was treated with segmental resection and an interposition vein graft. Apart from the risk of foreign body embolisation at the time of the original presentation, it seems remarkable that the patient did not suffer a stroke due to embolism of thrombus that one would normally have expected to form on the highly thrombogenic stone surface

Infrapoliteal percutaneous transluminal angioplasty: A safe and successful procedure

Aim:To review outcome of 40 consecutive infrapopliteal percutaneous transluminal angioplasty (PTA) procedures performed over a 65 month period.Chief outcome measures:The indication for PTA was intermittent claudication in 20 (50%) cases and rest pain, ulceration or gangrene in the remainder.Results:There was one technical failure; the remaining 39 limbs were all clinically improved by 24 h and this improvement was maintained at 3 months in 36 (90%). There were no deaths nor limb loss related to PTA and 2 embolic complications were successfully treated percutaneously. The primary and secondary symptomatic patencies at 24 months were 59 and 79% respectively. The actuarial limb salvage rate at 1 year for the 20 limbs presenting with critical ischaemia was 77%, and 10 of the 14 procedures performed for ulceration or gangrene resulted in healing with only minor surgical intervention.Conclusions:With modern endovascular techniques, infrapopliteal PTA is a safe, worthwhile and durable procedure

At what peak velocity ratio value should duplex-detected infrainguinal vein graft stenoses be revised?

Objectives:To determine the peak velocity ratio (PVR) threshold at which to intervene and correct duplex detected vein graft stenoses.Design:Prospective study.Materials:Infrainguinal vein grafts in patients attending the vascular studies for routine postoperative surveillance.Methods:Colour duplex detected stenotic vein graft lesions with a peak velocity ratio (PVR) between 2.0 and 2.9 were identified and monitored by serial duplex scans performed monthly for 3 months and then at 3-monthly intervals thereafter. At the end of the study period, the outcome of these lesions were analysed.Results:Thirty-eight lesions were identified from 32 grafts. Of these lesions, sixteen (42%) resolved, 11 (29%) remained stable and 11 (29%) progressed to a PVR of ≥3.0 and underwent angioplasty. There were no occlusions in any of the grafts during the period of study.Conclusion:Colour duplex detected vein graft stenoses with a PVR of less than 3.0 can be treated expectantly if grafts with stenoses with a PVR 2.0–2.9 are scanned every month for at least 3 months after detection

Bilateral infrainguinal vein grafts and the incidence of vein graft stenosis

Objectives:To elucidate the incidence of significant vein graft stenosis in patients who have undergone bilateral infrainguinal vein grafts.Materials:Between 1987 and 1996, 22 patients were identified from our vascular studies database as having undergone bilateral infrainguinal vein bypass grafting.Methods:Data was obtained from the vascular studies database and by case note review. All patients had been part of a vein graft surveillance programme.Results:Of the 22 patients with bilateral vein grafts, eight were excluded from further analysis because one or more of their grafts failed within 30 postoperative days. In the remaining 14 patients (28 vein grafts) there were 15 primary vein graft stenoses. Six patients (43%) had bilateral vein graft stenoses, which is significantly higher (p = 0.0008) than the predicted value of 9%, for developing bilateral vein graft stenoses. For those patients who developed a vein graft stenosis in their first grafted limb (9/14), 67% (6/14) subsequently developed a vein graft stenosis in their second grafted limb.Conclusion:Patients who develop vein graft stenosis in one limb are at a greater risk of developing a contralateral vein graft stenosis if that limb is grafted. This may well be due to individual vein morphology or unidentified systemic factors that play a role in the aetiology of vein graft stenosis

The increasing activity of a vascular ultrasound service

Objectives:To examine the change in activity of a vascular ultrasound service over 7 years.Design:Retrospective review.Setting:Vascular studies unit, University hospital.Method:Audit of the number of vascular ultrasound tests carried out over the last 7 years using a prospective computerised database.Results:Data shows that the overall workload has tripled over the 7-year period. In addition the complexity of investigations has increased during this time. The number of carotid scans has increased four-fold while the number of graft surveillance scans and vein scans has increased seven-fold. Assessment of lower limb arteries has developed from simple pressure measurements to detailed ultrasound scans and, as a consequence, the number of diagnostic angiograms has fallen by 75%. The factors that have influenced these changes are discussed.Conclusion:There has been an important increase in the role of colour Doppler ultrasound as it becomes the “first line” vascular diagnostic test. However this trend can only continue if vascular ultrasound services are appropriately resourced. It is therefore essential to maintain an efficient audit system

Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications

ObjectiveA daily Rapid-Access TIA Clinic was introduced in 2008, where symptomatic patients were started on 75 mg aspirin + 40 mg simvastatin by the referring doctor, before attending the clinic. Following clinic assessment, patients with 50–99% stenoses were transferred to the vascular unit for carotid endarterectomy (CEA). In two audits (n = 212 patients), the median delay from transfer to the vascular unit to undergoing CEA was 3 days, during which time 28 patients (13%) suffered recurrent neurological events. It was hypothesized that early introduction of dual antiplatelet therapy (by adding clopidogrel 75 mg once parenchymal haemorrhage was excluded in the TIA clinic) might significantly reduce recurrent events between transfer to the surgical unit and undergoing CEA.MethodsProspective audit in 100 consecutive, recently symptomatic patients receiving dual antiplatelet therapy. Endpoints were: prevalence of recurrent events between transfer from the TIA clinic and undergoing CEA; rates of spontaneous embolization prior to undergoing CEA; and prevalence of haemorrhagic complicationsResultsThe median delay from symptom to CEA was 8 days (IQR 5–15). The median delay between transfer from the TIA clinic to CEA was 3 days (IQR 2–5), during which time three patients (3%) suffered recurrent TIAs. This represents a fivefold reduction compared with previous audit data (OR 4.9, 95% CI 1.5–16.6, p = .01) and was matched by a fourfold reduction in the prevalence of spontaneous embolization from 39/189 (21%) previously to 5/83 (5%) in the current audit (OR 4.1, 95% CI 1.5–10.7, p = .0047). The 30-day death/stroke rate was 1%. There were three haemorrhagic complications: stroke caused by haemorrhagic transformation of an infarct; exploration for neck haematoma; and debridement and skin grafting for spontaneous shin haematoma.ConclusionEarly introduction of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events and spontaneous embolization prior to CEA, without incurring a significant increase in major peri-operative bleeding complications