W. B. Campbell

Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins.

Surgical treatment of medically uncomplicated varicose veins is common, but its clinical effectiveness remains uncertain.

A prospective randomised controlled trial and economic modelling of antimicrobial silver dressings versus non-adherent control dressings for venous leg ulcers: the VULCAN trial.

OBJECTIVE To examine the effectiveness and cost-effectiveness of antimicrobial silver-donating dressings for venous leg ulcers compared with simple non-adherent (also known as low-adherent) dressings. DESIGN A pragmatic, prospective randomised controlled trial (RCT) and cost-effectiveness analysis of silver-donating versus low-adherent dressings in the treatment of venous leg ulcers. A non-randomised observational group was also recruited. SETTING Primary and secondary care services in the north and south of England (Sheffield and Exeter). PARTICIPANTS Consenting patients with active ulceration of the lower leg that had been present for a period of greater than 6 weeks. INTERVENTIONS Patients were randomised to receive either a silver-donating or non-silver low-adherent dressing applied beneath compression bandages or hosiery. The choice of dressing within these groups was left to clinician preference. Evaluation was by clinical assessment, supplemented by evaluation of quality of life and cost-effectiveness. MAIN OUTCOME MEASURES The primary outcome measure was complete ulcer healing at 12 weeks in the index limb. Secondary measures were costs and quality-adjusted life-years (QALYs), cost-effectiveness, time to healing, and recurrence rate at 6 months and 1 year. RESULTS In total, 304 participants were recruited to the clinical trial: 213 to the RCT and 91 to the observational arm. Within the RCT 107 were randomised to antimicrobial dressings and 106 to the control dressings. There were no significant differences (p > 0.05) between the two groups for the primary outcome measure of proportion of ulcers healed at 12 weeks (59.6% for silver and 56.7% for control dressings). The overall median time to healing was also not significantly different between the two groups (p = 0.408). A total of 24 patients had recurrent ulcers within 1 year; the recurrence rates of 11.6% (n = 11) for the antimicrobial and 14.4% (n = 13) for the control dressings were not significant. Mean utility valuations for both the EuroQol 5 dimensions (EQ-5D) quality of life questionnaire and Short Form 6 dimensions (SF-6D) utility index showed no differences for either group at 1, 3, 6 or 12 months. Compared with the control group, the antimicrobial group had an incremental cost of 97.85 pounds and an incremental QALY gain of 0.0002, giving an incremental cost-effectiveness ratio for the antimicrobial dressings of 489,250 pounds. Cost-effectiveness modelling of the results of the RCT showed that antimicrobial dressings were not cost-effective. CONCLUSIONS No significant differences in either primary or secondary end points were found between the use of antimicrobial silver-donating dressings and the control group of low-adherent dressings. Modelling showed that antimicrobial silver dressings were not cost-effective. TRIAL REGISTRATION Current Controlled Trials ISRCTN72485131.

Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial

Despite being a common procedure, the cost effectiveness of surgery for varicose veins has not been established.

Gentamicin Beads in Vascular Surgery: Long-Term Results of Implantation

The authors conducted a prospective study, with a subsequent review of case-notes and follow-up of patients, to review the results of insertion of gentamicin beads for the prevention and treatment of infection in vascular surgery. In particular, special reference was given to leaving chains of beads permanently implanted in the body. There were thirty-five patients in whom gentamicin beads were used in 62 sites. These were implanted completely in 45, left protruding for removal in 15 and in open wounds in two. Forty-two chains of beads were left permanently implanted, and these patients were followed up for 1-44 months (median 15) later. There was no further infection at 60% of the sites where gentamicin beads were used to treat proven graft sepsis, and 50% of sites in various sinuses. Infection developed at 16% of the sites where gentamicin beads were used prophylactically. Adverse effects were observed in three cases of long-term implantation: one chain of beads caused discomfort that required removal, the skin failed to heal over one chain, and one may possibly have caused a bypass graft to kink and occlude. In conclusion, gentamicin beads are a useful adjunct in the management of vascular graft infection and in prophylaxis for some high risk cases. Chains of beads can be implanted long term with few adverse sequelae.

Hand-held Doppler as a screening test in primary varicose veins.

Background Hand‐held Doppler is in common use for evaluating varicose veins, but its accuracy in identifying the exact sites of venous reflux is inferior to that of duplex scanning. It has been suggested that duplex should be used to investigate all varicose veins, but this is currently impractical, and should be unnecessary if hand‐held Doppler examination were shown to be an adequate screening test.

Amputation for acute ischaemia is associated with increased comorbidity and higher amputation level.

BACKGROUND There is some evidence that the early outcome of major amputation is worse after failed thromboembolectomy, but the risk factors and results of amputation done for acute ischaemia have never been compared with those for chronic ischaemia in a large series of patients. METHOD Retrospective review of 30 day outcome for all 322 primary amputations done for arterial disease during 1992-8. There were 286 patients (163 male; median age 76 years) who had 270 amputations for chronic ischaemia and 52 for acute ischaemia. RESULTS The acute group had higher prevalences of cardiac disease (48% versus 29%-p<0.02), limiting pulmonary disease (27% versus 13%-p<0.02) and ASA grades 4 and 5 (27% versus 14%-p<0.05). Amputation below the knee was less common after acute ischaemia (31% versus 60%-p<0.001). There were trends towards more revisions (19% versus 11%) and higher mortality (25% versus 19%) in the acute group but neither reached statistical significance. CONCLUSION Patients having major amputations for acute ischaemia have higher levels of pre-existing comorbidity than those with chronic ischaemia and are twice as likely to require amputation above the knee. They should be managed as a particularly high risk group.

Anaesthesia and analgesia for major lower limb amputation

This study describes the methods of anaesthesia and analgesia used in 349 major lower limb amputations for vascular disease over a seven year period (1992-8). The main type of anaesthesia was general in 55%, spinal in 29%, and epidural in 14%: there were no significant differences for ASA grade, age, or amputation level, nor any statistical differences in mortality for each method of anaesthesia. The main methods of analgesia in the first 48 hours changed between 1992 and 1998, with decreasing intramuscular and oral opioids (from 38% to 7%, and from 23% to 2% respectively) while epidurals became the commonest method (4% in 1992 and 63% in 1998). Thirty seven percent of patients were prescribed carbamazepine for phantom pain. There have been substantial changes in postoperative analgesia following amputation, and epidurals are now common practice, despite the controversy about their role in preventing phantom pain.

Vanishing popliteal entrapment

Entrapment of the popliteal artery is an uncommon congenital anomaly that usually affects young men (aged 30 to 40 years) as the most common of several unusual entities that can cause intermittent claudication in young adults. It has been classified by the causes of compression of the artery which include congenital abnormalities of muscle insertion and acquired hypertrophy of surrounding structures. 1 Operation is normally advised because of the risk of embolisation from mural thromus on an intimal lesion in the compressed segment or from the wall of a post stenotic aneurysm. We present an unusual case with all the features of popliteal entrapment syndrome but with spontaneous resolution. film (Fig. 1) and corresponding distortion on lateral views both in flexion and extension of the knee (Figs 2 and 3). A diagnosis of popliteal entrapment was made and the patient was admitted 6 weeks later for surgery. On admission he reported that his symptoms had disappeared completely. Foot pulses were easily palpable and repeat Doppler pressures before and after exercise were normal. Duplex scanning was performed as a non-invasive alternative to arteriography and the appearances of the popliteal artery were normal with a normal pattern of flow. The patient was reviewed 12 months later and still

Randomised controlled trial of anti-microbial agents for the treatment of venous leg ulcers

Method: Thirty patients (primary varicose veins, sapheno-femoral [SFJ] and great saphenous vein [GSV] reflux) undergoing SFJ ligation and stripping were included in the study. 3cm proximal GSV segments harvested before stripping were divided into test and control samples. One percent and 3% STD foam (Tesari) was applied to the vein lumen of test samples for 1, 2 and 5 minutes (n = 5 for each time and STD concentration). Following immediate fixation, sections underwent H&E and specific elastin and collagen staining. Results: One percent and 3% foam caused ≤ 50% endothelial cell loss after 1 and 2-minute exposure increasing to 80–90% after 5 minutes, although islands of endothelial cells remained visible in all sections. Subendothelial vacuolation (smooth muscle cell damage) only occurred after 5 minutes as did collagen bundle disorganisation. This was minimal, affecting only the inner media. Elastin was unaffected. One percent and 3% STD had similar effects. Foam started to liquify after 90 seconds. Conclusion: Persisting endothelial cells and patchy partial thickness smooth muscle/collagen injury may explain the capacity for recanalisation and high clinical recurrence rates following FS. Further, significant venous injury only occurred after a longer exposure to STD than may occur in vivo.