Bernard Lee

Endovenous laser treatment for long saphenous vein incompetence.

Endovenous laser treatment is a percutaneous technique used for the treatment of long saphenous vein (LSV) incompetence. This paper presents the results of an uncontrolled case series undertaken to assess the feasibility, safety and efficacy of this technique.

Role of the Hardman Index in Predicting Mortality for Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To correlate the Hardman prognostic index with perioperative mortality in patients undergoing open and endovascular repair of ruptured abdominal aortic aneurysm (rAAA). Methods: Over a 5-year period, 126 patients (109 men; mean age 74 years, range 51–91) underwent open (n=74) or endovascular (n=52) repair of rAAA in a single unit. Five Hardman factors (age >76 years, history of loss of consciousness, ECG evidence of ischemia, hemoglobin <9.0 g/dL, and serum creatinine >0.19 mmol/L) were assessed, and their association with in-hospital or 30-day mortality was evaluated retrospectively by chi-square or logistic regression analysis. Results: The mortality for open repair was 51.4% (38/74) in comparison to 32.7% (17/52) for the endovascular group (p=0.05). On multivariate analysis, loss of consciousness (p=0.03, OR 2.9, 95% CI 1.1 to 7.5) was the only significant predictor of mortality in both groups. The mortality rates for open repair patients with Hardman scores <2 were 43.5% (20/46) in comparison to 22.9% (8/35) for the endovascular group (p=0.06), whereas mortality rates for patients with scores ≥2 were 64.3% (18/28) and 52.9% (9/17) for the respective groups (p=0.54). Conclusion: The Hardman index correlates well with mortality in both the open and endovascular groups. Those with a score <2 have a trend toward better survival following endovascular repair compared to open repair, while this benefit is not obvious in patients with a score ≥2.

Delayed paraplegia after endovascular repair of abdominal aortic aneurysm

Paraplegia is rare after open repair of infrarenal abdominal aortic aneurysm, and only two cases have been reported after endovascular repair, both due to atheroembolism. Incidence of renal failure after endovascular repair of abdominal aortic aneurysm (EVAR) in patients with normal preoperative renal function is about 8.7%, but is much higher in those with preexisting renal impairment, possibly because of administration of nephrotoxic contrast media during EVAR. We report a case in which contrast medium-induced acute renal failure is believed to have led to delayed paraplegia after EVAR.

The Vascular and Biochemical Effects of Cilostazol in Diabetic Patients With Peripheral Arterial Disease

Objectives: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. Methods: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. Results: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. Conclusions: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Risk factors for abdominal aortic aneurysm and the influence of social deprivation.

Introduction: the objective of this abdominal aortic aneurysm (AAA) screening study was to determine attendance and disease prevalence patterns in Northern Ireland and the role of deprivation and other risk factors. Patients and methods: patients from primary care practices from Belfast, Lisburn, and Saintfield were screened. Past medical history and deprivation details were determined. Results: 2264 men from Belfast, 1104 men in Lisburn, and 284 in Saintfield were invited to attend. Overall, 1659 (45.3%) men attended, with 40.6% from Belfast, 55.0% from Lisburn, and 45.8% from Saintfield (P < .0001). Ninety-two (5.5%) new AAAs were diagnosed, with 6.5%, 3.8%, and 6.2% in the 3 areas (P = .055). As deprivation decreased, attendance increased and prevalence decreased. Smoking, peripheral arterial disease, number of medications prescribed, and geographical origin were independent risk factors for AAAs. Conclusion: aneurysm prevalence is influenced by geographical origin and deprivation, which should, therefore, be important factors in health care planning and screening provision.

Bilateral popliteal artery occlusion in a competitive bike rider: case report and clinical review.

Since its first description in 1879, popliteal artery entrapment syndrome remains a debilitating condition, which frequently affects young active people. Increased awareness of popliteal artery entrapment syndrome combined with improvements in investigative modalities has resulted in a more frequent diagnosis of this eminently treatable condition. In this article, a rare case of bilateral popliteal artery entrapment syndrome in a physically active 33-year-old man precipitated by competitive Bicycle Moto-Cross riding is presented. A higher index of suspicion for popliteal artery entrapment syndrome is recommended as the underlying pathology in a young active person with symptoms of lower limb claudication. Popliteal artery entrapment syndrome should be investigated with thorough radiological assessment prior to any therapeutic intervention, which is often fraught with difficulty due to chronically diseased vasculature and inherent anatomical anomalies.

Change in Aneurysm Diameter after Stent-Graft Repair of Ruptured Abdominal Aortic Aneurysms

Purpose: To compare the changes in aneurysm size following endovascular aneurysm repair (EVAR) for ruptured versus elective abdominal aortic aneurysms (AAA). Methods: Aneurysm sac diameter was measured from computed tomographic (CT) scans in 14 hemodynamically stable patients (14 men; mean age 74±7 years, range 60 to 83) prior to emergent stent-graft repair for ruptured AAA. The aneurysm diameter change was followed postprocedurally with serial CT and the outcomes compared to 74 AAA patients (58 men; mean age 74± 7 years, range 56 to 87) having elective EVAR in the same time period. The mean rate of sac decrease (mm/month) was calculated for each group. Results: There were 3 postoperative deaths in the ruptured AAA cohort, leaving 11 patients available for follow-up analysis (mean 16 months, range 2–49). Eight (73%) patients with ruptured AAA demonstrated significantly decreased (>5 mm) aneurysm diameters compared with 32 (43%) elective cases (p=0.07) followed a mean 20 months (range 3–51). The mean rate of sac diameter decrease was 1.50± 1.03 mm/month in the rupture group versus 0.73±0.86 mm/month in the elective group (p=0.04). Conclusions: This study suggests that ruptured AAAs treated with stent-graft experience sac regression at a higher rate compared with electively treated AAA. The reasons for these findings remain unclear.

Cytokine Activation and Intestinal Mucosal and Renal Dysfunction are Reduced in Endovascular AAA Repair Compared to Surgery

Purpose: To compare endovascular (EVR) to open repair (OR) of abdominal aortic aneurysm (AAA) for cytokine activation, changes in the intestinal mucosal barrier, and renal dysfunction. Methods: In a prospective nonrandomized study, 15 patients admitted to a university hospital for elective infrarenal AAA repair (8 OR and 7 EVR) were recruited. Intestinal permeability was assessed preoperatively (PO), at day 1 (D1), and at day 3 (D3) after surgery using the lactulose/mannitol differential excretion (LMR) test. Renal damage was assessed from measurements of the urinary albumin:creatinine ratio (ACR); cytokine activation was based on the urinary concentration of tumor necrosis factor receptor p55 (TNF-Rp55) at the same time points. Serum creatinine and urea concentrations were measured preoperatively and daily for 5 days postoperatively. Results: A significant increase in LMR was found in the OR group at D1 and D3 compared to PO (p<0.05). The LMR increase at D3 was significantly greater in the OR group (p<0.01). A significant difference was observed in the percentage rise in ACR on D1 in the OR group compared to the EVR group (p<0.005). The urinary TNF-Rp55 concentration was significantly elevated in the OR group at D1 (p<0.05) and D3 (p<0.05) compared to baseline; in the EVR group, it was elevated at D1 (p<0.05) compared to PO. The difference was also significant for this marker between the 2 groups at D1 (p<0.01). No significant change was observed in the serum creatinine or urea concentrations in either group perioperatively Conclusions: Endovascular AAA repair is associated with less cytokine production and less intestinal and renal dysfunction compared to the open approach.

The Effects of Cilostazol on Exercise-induced Ischaemia-reperfusion Injury in Patients with Peripheral Arterial Disease

OBJECTIVES Cilostazol improves walking distance in peripheral arterial disease (PAD) patients. The study objectives were to assess the effects of cilostazol on walking distance, followed by the additional assessment of cilostazol on exercise-induced ischaemia-reperfusion injury in such patients. METHODS PAD patients were prospectively recruited to a double-blinded, placebo-controlled trial. Patients were randomised to receive either cilostazol 100mg or placebo twice a day. The primary end-point was an improvement in walking distance. Secondary end-points included the assessment of oxygen-derived free-radical generation, antioxidant consumption and other markers of the inflammatory cascade. Initial and absolute claudication distances (ICDs and ACDs, respectively) were measured on a treadmill. Inflammatory response was assessed before and 30 min post-exercise by measuring lipid hydroperoxide, ascorbate, alpha-tocopherol, beta-carotene, P-selectin, intracellular and vascular cell-adhesion molecules (I-CAM and V-CAM), thromboxane B(2) (TXB(2)), interleukin-6, interleukin-10, high-sensitive C-reactive protein (hsCRP), albumin-creatinine ratio (ACR) and urinary levels of p75TNF receptor. All tests were performed at baseline and 6 and 24 weeks. RESULTS One hundred and six PAD patients (of whom 73 were males) were recruited and successfully randomised from December 2004 to January 2006. Patients who received cilostazol demonstrated a more significant improvement in the mean percentage change from baseline in ACD (77.2% vs. 26.6% at 6 weeks, p=0.026 and 161.7% vs. 79.0% at 24 weeks, p=0.048) as compared to the placebo. Cilostazol reduced lipid hydroperoxide levels compared to a placebo-related increase before and after exercise (6 weeks: pre-exercise: -11.8% vs. +5.8%, p=0.003 and post-exercise: -12.3% vs. +13.9%, p=0.007 and 24 weeks: pre-exercise -15.5% vs. +12.0%, p=0.025 and post-exercise: -9.2% vs. +1.9%, p=0.028). beta-Carotene levels were significantly increased in the cilostazol group, compared to placebo, before exercise at 6 and 24 weeks (6 weeks: 34.5% vs. -7.4%, p=0.028; 24 weeks: 34.3% vs. 17.7%, p=0.048). Cilostazol also significantly reduced P-selectin, I-CAM and V-CAM levels at 24 weeks as compared to baseline (p<0.05). There was no difference between treatment groups for ascorbate, alpha-tocopherol, interleukin-6 and -10, hsCRP and p75TNF receptor levels. CONCLUSIONS Cilostazol significantly improves ACD, in addition to attenuating exercise-induced ischaemia-reperfusion injury, in PAD patients.

No Difference in Medium-Term Outcome Between Zenith and Talent Stent-Grafts in Endovascular Aneurysm Repair

Background Many devices are available for endovascular aneurysm repair (EVAR). Our aim was to analyze morphological effects of the Zenith and Talent systems. Methods Patients included underwent EVAR from June 1999 to June 2005 using a Zenith or Talent stent-graft, with computed tomography follow-up. Aortic dimensions over time and clinical outcome were analyzed. Results Twenty-nine patients with Zenith stent-grafts and 33 with Talent devices were included. Mean preoperative age was similar (75.5 ± 6.0 years vs 74.2 ± 6.7 years; P = .29). Preoperative neck length was longer in the Zenith group (29.9 ± 15.2 mm vs 25.5 ± 10.8 mm; P = .10), and stent-graft oversizing was greater in the Talent patients (20.2% ± 7.9% vs 23.0% ± 11.3%). There was proximal aortic dilatation and aneurysm sac shrinkage in each group. Complication rates were comparable, with 83% of both groups free from 10-mm migration. Conclusion Although device designs differ, there is no difference in clinical outcome between Zenith and Talent stent-grafts. Migration rates were not influenced by suprarenal fixation.