R.D. Sayers

Subintimal and intraluminal recanalisation of occluded crural arteries by percutaneous balloon angioplasty

Advances in radiological techniques have allowed successful treatment of arterial stenoses situated in the distal arterial tree. This paper describes the experience at Leicester Royal Infirmary with percutaneous transluminal angioplasty (PTA) for the treatment of occluded crural arteries. Over a 27 month period, 21 patients with 24 ischaemic limbs have undergone PTA for crural artery occlusion. PTA was attempted in a total of 29 occluded crural arteries with a median length of occlusion of 6 cm (range 1-30 cm). Intraluminal recanalisation was used for short occlusions and the subintimal technique for long occlusions. Technical success with angiographic recanalisation of the artery was achieved in 25 out of 29 crural vessels (86%). Endovascular treatment of crural artery occlusion appears to be a safe and effective treatment which avoids the need for femorodistal surgery in patients with occluded calf vessels.

Surgical Management of 671 Abdominal Aortic Aneurysms: A 13 Year Review from a Single Centre

OBJECTIVE To audit the results for abdominal aortic aneurysm (AAA) repair from a single centre over a 13 year period. DESIGN Retrospective survey. SETTING Vascular unit of a major teaching hospital. MATERIALS Six hundred and seventy-one consecutive patients divided into two groups: group A (1981-87) and group B (1988-93). CHIEF OUTCOME MEASURES Mortality rates, cause of death and major complications in patients undergoing elective, urgent and ruptured AAAs. RESULTS Elective repair was performed in 313 (47%) patients, urgent repair in 80 (12%) and emergency repair for rupture in 278 (41%). A vascular surgeon performed the procedure in 94% of patients. The overall mortality was 21 patients in the elective group (6.7%), 13 in the urgent group (16%) and 148 in the ruptured group (53%). Mortality rates have not fallen during the study period but more patients in group B had ischaemic heart disease. Sixty patients (9%) required further operative procedures on 66 occasions: 24 elective cases (8%), 8 urgent cases (10%) and 28 ruptured cases (10%). There were 23 deaths in these 60 patients (38%) who underwent re-operation (5 elective, 2 urgent and 16 ruptured). Major postoperative complications included cardiac events in 212 (32%) patients, respiratory failure in 202 (30%) and renal failure in 90 (13%). Major causes of death included cardiac disease in 67 patients (37%), cardiac disease with coagulopathy in 22 (12%) and cardiac disease with respiratory failure in 16 (9%). Logistic regression analysis showed that in the elective group, cardiac or renal failure were significantly associated with death; and in the ruptured group cardiac, respiratory or renal failure were significantly associated with death. CONCLUSIONS More high risk patients with ischaemic heart disease are undergoing AAA repair. Postoperative cardiac, respiratory or renal failure are significant causes of death in AAA patients.

Chronic critical leg ischaemia must be redefined.

The Second European Consensus Document on Chronic Critical Leg Ischaemia defines critical limb ischaemia in non-diabetic patients as rest pain or tissue necrosis (ulceration or gangrene) with an ankle systolic pressure (ASP) of less than or equal to 50 mmHg, or a toe pressure of less than or equal to 30 mmHg. The aim of this study was to investigate whether this definition is able to predict the outcome of patients with severe lower limb ischaemia and thus to determine the relevance of the definition in clinical practice. We have analysed 148 severely ischaemic limbs in 133 non-diabetic patients who presented with rest pain, tissue necrosis or a combination of these symptoms. Fifty-one percent of these limbs fulfilled the current definition with an ASP < or = 50 mmHg; 49% had an ASP > 50 mmHg and were thus not defined as critically ischaemic according to the current definition. We have compared actuarial limb salvage and mortality rates in patients with an ASP < or = 50 mmHg to those patients with an ASP > 50 mmHg. The 1 year limb salvage and mortality rates for ischaemic limbs fulfilling the European Consensus Document criteria were 78.7 and 36.7% respectively, compared to rates of 73.9 and 17.3% in patients who were not defined as critically ischaemic under the current definition. There were no significant differences between 1 year limb salvage or mortality rates between the two patients groups (p = 0.843, 0.078, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Selection of Patients with Critical Limb Ischaemia for Femorodistal Vein Bypass

The merits of an aggressive policy of distal reconstruction have been questioned by some observers. To determine the factors affecting graft patency and mortality, we analysed 78 consecutive infragenicular femorodistal vein grafts performed in 72 patients with critical limb ischaemia. The primary, primary assisted and secondary graft patency rates at 36 months were 29, 57 and 64%, respectively. The limb salvage and patient survival rates at 36 months were 67 and 74%, respectively. Univariate analysis (log-rank test) was performed to identify factors affecting graft patency, limb salvage and mortality at 1 month (perioperative) and 1 year. Independent variables of age, sex, diabetes, presentation, level of anastomosis and vein technique (reversed or in situ) did not affect graft patency. The ankle systolic pressure did not predict graft patency but was an independent variable affecting mortality (p = 0.047), as did diabetes (p = 0.019). These results show that excellent limb salvage can be successfully achieved in severely ischaemic patients by adopting an aggressive approach to femorodistal bypass, and that age, gender and poor medical condition are not contraindications to femorodistal bypass. The difference between the primary and primary assisted patency rates in this series is dramatic and reflects the impact of a vein graft surveillance programme in preventing graft occlusion.

Fenestrated Aortic Endografts for Juxtarenal Aortic Aneurysm: Medium Term Outcomes

AIMS The utility of fenestrated-endovascular aneurysm repair (FEVAR) remains uncertain. This study examines the medium term outcomes of patients undergoing FEVAR for asymptomatic juxtarenal abdominal aortic aneurysm (AAA). METHODS Consecutive patients undergoing elective FEVAR for juxtarenal AAA at a single tertiary centre were studied between October 2005 and March 2010. Patients were followed up for at least six-months within a protocol including clinical examination, laboratory studies, CT and duplex imaging, and abdominal radiographs. Outcomes were assessed in terms of survival, target vessel patency and graft related complications. RESULTS Twenty-nine patients were analysed on an intention to treat basis. There were 27 men and two women of median (range) age 74 (54-86) years. Mean (SD) aneurysm diameter was 68 (7) mm. Median (range) ASA score was 3 (2-4). No procedures required conversion to an open procedure, but one procedure was abandoned. Seventy-nine visceral vessels were perfused through a fabric fenestration or scallop. All vessels remained patent at completion angiography. No patients died within 30-days of surgery. During follow up there were four (14%) deaths at a median (range) of 17 (8-21) months after aneurysm repair. None of these deaths were aneurysm related. Eighteen (62%) patients suffered one or more graft related complications, of whom 11 (38%) required one or more early or late reintervention. CONCLUSIONS Fenestrated aortic endografts can be utilized safely in the management of juxtarenal AAA in patients at high-risk for open surgery. However, the rate of graft related complication and reintervention is high at medium term follow up.

Predicting aortic complications after endovascular aneurysm repair

Lifelong surveillance is standard after endovascular repair of abdominal aortic aneurysm (EVAR), but remains costly, heterogeneous and poorly calibrated. This study aimed to develop and validate a scoring system for aortic complications after EVAR, informing rationalized surveillance.

Dual Antiplatelet Therapy Prior to Carotid Endarterectomy Reduces Post-operative Embolisation and Thromboembolic Events: Post-operative Transcranial Doppler Monitoring is now Unnecessary

BACKGROUND Thrombotic stroke following carotid endarterectomy (CEA) is preceded by high-grade embolisation (detected using transcranial Doppler (TCD)) and can be prevented by incremental doses of Dextran. However, this strategy is labour intensive and Dextran manufacture has now ceased. A randomised trial has suggested that a single 75 mg dose of Clopidogrel (administered the night before surgery in addition to daily 75 mg Aspirin) significantly reduces post-CEA embolisation. We hypothesized that this model of dual antiplatelet therapy might significantly reduce the need for adjuvant Dextran therapy. METHODS Retrospective audit of prospectively acquired data in 297 patients undergoing CEA between 01.08.2006 and 30.07.2009. All received routine Aspirin (75 mg daily) in addition to a single 75 mg dose of Clopidogrel the night before surgery. All underwent completion angioscopy and those with a temporal window (n = 270) underwent intra- and post-operative TCD monitoring. RESULTS High rate embolisation requiring Dextran (>25 emboli in any 10 min period) occurred in only 1/270 patients (0.4%), significantly less than the 3.2% rate in historical controls where Clopidogrel was not administered. There were no peri-operative deaths, but 3/297 patients suffered non-disabling strokes (intra-operative extension of a pre-existing deficit, haemorrhage into lentiform nucleus after hypertensive crisis, contralateral embolic stroke). The overall 30-day death/stroke rate (1.0%) was not-significantly lower than the 2.6% rate observed in the preceding 821 patients. CONCLUSIONS 75 mg Clopidogrel administered the night before surgery (in addition to daily 75 mg Aspirin) was associated with a significant reduction in post-operative embolisation and Dextran utilisation. No ipsilateral thromboembolic ischaemic events occurred in this series. As a consequence of this audit, one dose of 75 mg Clopidogrel will continue to be given pre-operatively (in addition to daily 75 mg Aspirin) and routine post-operative TCD monitoring has now ceased.

The histopathology of infrainguinal vein graft stenoses

The precise histopathological nature of vein graft stenoses is unclear. Some authors have suggested that these lesions are due to intimal hyperplasia and others have claimed that they are fibrous strictures. The aim of this study was to determine the histological nature of infrainguinal vein graft stenoses by examining sections of vein grafts that had developed stenoses and had been surgically revised. This was performed using a combined anti-smooth muscle actin/Millers elastin stain. The results show that vein graft stenoses are due to intimal hyperplasia whereby smooth muscle cells proliferate and cause thickening of the intimal layer.

Short Leukocyte Telomere Length is Associated with Abdominal Aortic Aneurysm (AAA)

OBJECTIVE Telomeres are specialised DNA structures present at the ends of linear chromosomes, which shorten with each successive cell division and the length of which represents cellular biological age. The aim of this study was to determine the relationship between abdominal aortic aneurysm (AAA) and white cell telomere length. METHODS Peripheral blood samples were collected from 190 patients with AAA and 183 controls. Genomic DNA was extracted from white cells and telomere lengths determined using a chemiluminescence technique. RESULTS The mean white cell telomere length was significantly lower in AAA patients compared to controls (median age 66 years in both groups), with a mean difference of 189 base pairs (bp) (95% confidence interval 77 bp to 301 bp, P=0.005). This relationship between case-control status and mean telomere restriction fragment (TRF) length did not change after adding other risk factors into a multiple regression model. The risk of having AAA doubled in patients with a mean TRF length in the lowest quartile compared to patients with a mean TRF length in the highest quartile (odds ratio 2.30, 95% Confidence Interval 1.28-4.13, P=0.005). CONCLUSION Our data show that patients with AAA have shorter leukocyte telomere length compared to controls. This suggests that vascular biological aging may have a role in the pathogenesis of AAA.

Trends in Abdominal Aortic Aneurysms: a 13 year review

AIM To assess changing trends of abdominal aortic aneurysms 1979-1991. DESIGN Retrospective study from the Leicestershire Health Authority. RESULTS 727 patients with abdominal aortic aneurysm were treated. Of these 56.4% were admitted for elective repair and 43.6% presented with rupture. There was a significant increase in the number of ruptured aortic aneurysms over this period despite an increase in the number of elective repairs. The overall 30-day mortality of elective repair (including patients with symptomatic but non-ruptured aneurysms) was 8.8%. The overall 30-day mortality of ruptured aneurysms (including patients who were deemed medically too unfit for surgery) was 57.7%. There has been no significant change in elective and ruptured mortality over the study period. There was a significant increase in the median age of patients (69.5 yrs in 1979 to 74 yrs in 1991). CONCLUSION The increasing incidence of abdominal aortic aneurysms may reflect better diagnostic methods, greater clinical awareness of the condition and increase in the proportion of elderly people in the population.