Endovascular repair of aortic pseudoaneurysms.
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Biomedical subjects
J Brittenden
Publications and source records attributed to J Brittenden.
Are we still performing inappropriate carotid endarterectomy?
OBJECTIVES: the 1998 ECST final report suggests that the decision to operate on patients with greater than 70% symptomatic stenosis should be based on a statistical model incorporating age, sex and degree of stenosis. The aim of this study was to identify patients operated on the basis of the 1991 reports who would not now be offered surgery according to the 1998 ECST recommendations and to determine the surgical morbidity and mortality arising from these <<< >>> CEAs. METHODS: interrogation of a prospectively gathered database of all CEAs performed for symptomatic stenosis between 1st January 1994 and 1st May 1998. CEAs were classified as <<< >>>, <<< >>> or <<< >>> according to the 1998 ECST recommendations. RESULTS: there were 154 males and 72 females (median age (range) was 67 (39-85) and 65 (38-81), respectively). In males 101 (66%) of CEAs were <<< >>>, 51 (33%) were <<< >>> and only two (1%) were <<< >>>. In women, the corresponding proportions were 13 (18%), 45 (63%) and 14 (19%), respectively. The combined peri-operative major stroke (Rankin 3-5) and death rate was 1.8% (4 patients). Of these, three, one and zero patients were in the <<< >>>, <<< >>> and <<< >>> groups. CONCLUSIONS: strict adherence to the 1998 ECST recommendations would reduce by 50% the number of CEAs currently performed in this vascular unit and, in general, would restrict CEA to a higher risk group. The validity of the ECST model requires further evaluation.
Adult↗
The use of endovascular stents in the treatment of penetrating ulcers of the thoracic aorta.
Penetrating atheromatous ulcers of the aorta are increasingly recognized as a distinct entity. Although their natural history remains ill-defined, such ulcers may lead to pseudoaneurysmal formation, dissection, rupture, or embolization. Given the morbidity associated with open repair, endovascular repair of penetrating atheromatous ulcers may be the treatment of choice. Although stent-graft replacement of acute aortic dissections has recently been described, endovascular repair of penetrating thoracic aortic ulcers has not previously been reported. We report two cases of successful endovascular repair of penetrating atheromatous ulcers that previously ruptured.
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Carotid endarterectomy before and after publication of randomized controlled trials.
BACKGROUND: In 1991, the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) demonstrated that carotid endarterectomy (CEA), in addition to best medical therapy, significantly reduces ipsilateral stroke in patients with high-grade (70 per cent or more) carotid artery stenosis compared with best medical therapy alone. In 1995, the Asymptomatic Carotid Atherosclerosis Study demonstrated that CEA was of benefit in asymptomatic patients with stenosis greater than 60 per cent. The aim of this paper was to examine how the practice and outcome of CEA have changed since publication of these data. METHODS: A prospectively gathered computerized database comprising 634 consecutive CEAs was studied. Two time intervals were analysed: 1975-1991 inclusive (17 years) and 1 January 1992 to 1 May 1998 (6 years 4 months). RESULTS: Since 1991, there has been a fourfold increase in the number of CEAs performed annually for symptomatic disease. CEA is now performed almost exclusively for high-grade (more than 70 per cent) stenosis. There has been a significant reduction in the total peri-operative neurological event rate (12.5 versus 5.9 per cent, P < 0.05), and the 30-day combined major stroke (Rankin grade 3-5) and mortality rate has fallen to 2.0 per cent. The number of patients who have CEA for asymptomatic disease remains small with 16 of 30 being randomized within the Asymptomatic Carotid Surgery Trial. CONCLUSION: Publication of ECST and NASCET data has been associated with a major increase in the number of CEAs performed for symptomatic disease in this unit. Despite a greater proportion of high-risk patients, the results have improved progressively.
Adult↗
Vascular surgical society of great britain and ireland: long-term survival following repair of ruptured abdominal aortic aneurysm in patients over 75 years of age
BACKGROUND: Previous studies have indicated that patients over the age of 75 years have an increased in-hospital mortality rate following repair of ruptured abdominal aortic aneurysm (AAA). The long-term survival of this patient group has not been reported previously, even though this information may have a strong influence on the decision to operate. METHODS: Interrogation of a prospective database identified 272 patients aged 75 years or over (median age 78 (range 75-93) years) admitted between 1983 and 1995. Long-term patient survival data and survival curves for an age- and sex-matched population were obtained from the General Register Office through the Information and Statistics Division. RESULTS: Sixty-nine (25 per cent) of the 272 patients did not undergo operation. Eighty-eight (43 per cent) of the 203 patients who had surgery died within the same hospital admission. The 1-, 5- and 10-year survival rates for the remaining 115 patients (median age 77 (range 75-85) years) were 88, 59 and 26 per cent respectively, at a median follow-up of 54 (range 1-157) months. The median life expectancy for this patient group was 69 months. These data are comparable to those of an age- and sex-matched population. CONCLUSION: Many patients over the age of 75 years who present with ruptured AAA are considered unfit for surgery. These data demonstrate that, even in this elderly population, survivors of ruptured AAA repair enjoy a near-normal life expectancy.
Journal Article↗
Vascular surgical society of great britain and ireland: prevalence and significance of thrombophilia in patients with intermittent claudication
BACKGROUND: Thrombophilia may be associated with premature atherosclerosis, an increased susceptibility to primary arterial thrombosis and an increased failure rate for peripheral vascular or endovascular interventions. The aim of this study was to determine the prevalence of thrombophilia in patients with intermittent claudication (IC). METHODS: This was a prospective study of 116 consecutive new patients (70 men; median age 65 (range 43-84) years) referred to this regional vascular surgery unit with IC. Patients on warfarin, or who had previously undergone lower limb reconstruction and/or angioplasty, were excluded. RESULTS: Thrombophilia was demonstrated in 24 patients (21 per cent). The commonest abnormality (15 patients, 13 per cent) was a raised level of anticardiolipin antibody (ACLA) (11 immunoglobulin (Ig) M, four IgG). Other abnormalities comprised: lupus anticoagulant (one), protein C deficiency (two), protein S deficiency (two), activated protein C resistance (one) and factor V Leiden heterozygosity (three). All abnormalities were confirmed on repeat testing. No patient had a history of venous thrombosis. There was no statistically significant relationship between ACLA status and age, sex, ankle : brachial pressure index, previous myocardial infarction or stroke, previous carotid endarterectomy or coronary artery surgery, serum cholesterol, current use of antiplatelet agents or current smoking status. CONCLUSION: Almost one-quarter of new patients referred to this regional vascular unit with IC have thrombophilia; over half of those affected have a raised ACLA level compatible with the antiphospholipid syndrome. At present, the clinical significance and management implications of these abnormalities remain unknown.
Journal Article↗
Vascular surgical society of great britain and ireland: percutaneous transluminal angioplasty for lower limb ischaemia
BACKGROUND: Percutaneous transluminal angioplasty (PTA) is increasingly performed for lower limb ischaemia of all severities, despite the absence of controlled data demonstrating its efficacy. The aim of this study was to examine the indications and outcome for lower limb ischaemia over a 16-year period. METHODS: A prospectively gathered database of 1287 consecutive PTAs performed between 1982 and 1997 was analysed. Two time intervals were compared: 1982-1991 and 1992-1997. RESULTS: Since 1992 there has been a fourfold increase in the number of PTAs performed. There has been a significant increase in the number of PTAs performed for critical ischaemia, occlusive lesions and at infrainguinal sites. Although there has been a significant reduction in morbidity, the number of immediate technical and clinical failures has increased (see Table ). CONCLUSION: Despite a lack of controlled data supporting a more liberal use of PTA in the treatment of lower limb ischaemia, there has been, in this regional vascular unit, a significant increase in the perceived clinical and anatomical indications for the procedure. Randomized controlled trials are urgently required to define the role of PTA in this condition.
Journal Article↗
Vascular surgical society of great britain and ireland: outcome of iliac percutaneous transluminal angioplasty with and without the use of stents in patients with intermittent claudication
BACKGROUND: Despite the absence of controlled data supporting endovascular treatment of iliac disease in patients with intermittent claudication (IC), there has been a significant increase in iliac percutaneous transluminal angioplasty (PTA), and in particular iliac stenting, in recent years. The clinical and haemodynamic outcome of iliac PTA, with and without stenting, was assessed in patients with IC. METHODS: A prospectively gathered computerized database of iliac PTA (n = 203) and stenting (n = 88), performed between 1 January 1991 and 31 December 1997, was analysed. RESULTS: Occlusive disease was significantly more likely than stenotic disease to be treated by primary stent deployment (19 of 88, 22 per cent) than PTA alone (11 of 203, 5 per cent) (P < 0.01, chi2 test), as were lesions in the common iliac artery (common 69 of 214 (32 per cent) versus external 14 of 65 (22 per cent); P < 0.05, chi2 test). Primary stent placement was associated with a significant increase in morbidity that delayed hospital stay (13 of 88 (15 per cent) versus seven of 203 (3 per cent); P < 0.05, chi2 test). Emergency revascularization was required in four patients who underwent PTA (2 per cent) and two who had stenting (2 per cent) (P not significant). CONCLUSION: Iliac stenting is associated with a significant increase in morbidity but with no improvement in symptomatic or haemodynamic outcome. These results do not justify the increased expense associated with the routine use of iliac stents.
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A prospective study of internal carotid artery plication during carotid endarterectomy: early clinical and duplex outcome.
OBJECTIVE: internal carotid artery (ICA) plication prevents kinking and secures the distal intimal step following carotid endarterectomy (CEA). The aims of this prospective study were to quantify the proportion of patients in whom plication might be beneficial and determine whether plication is associated with an increased incidence of early restenosis and a reduction in postoperative thromboembolic complications. METHODS: analysis of a prospectively gathered computerised database. RESULTS: between 1 November 1992 and 31 December 1997, 228 consecutive CEAs were performed in 213 patients, of which 84 (37%) in 79 patients were plicated. Sixty endarterectomy sites have been examined by duplex ultrasonography at a median of 5 (range 1-44) months postoperatively. No abnormality was detected in 52 (87%), six (10%) had restenosis of <50% and two (3%) restenosis of 50-75%. All were asymptomatic. Three patients (3. 6%), one of whom died, had an intraoperative neurological event and one patient (1.2%) had a postoperative cerebral haemorrhage. No patient suffered ICA thromboembolism. During the same time period 144 non-plicated CEAs were performed in 134 patients. Of these, one (0.7%) had an intraoperative and five (3.5%) had a postoperative neurological event. Five of these six complications were due to ICA thromboembolism. There was no mortality in the non-plicated group. CONCLUSION: ICA plication can be used to prevent kinking, secure the distal intimal step, has not, to date, been associated with increased early restenosis rate and has avoided postoperative ICA thromboembolism.
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Recurrent lung shadowing in adult juvenile idiopathic arthritis.
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Adult↗
Popliteal vein reflux reduces the healing of chronic venous ulcer.
BACKGROUND: The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously. METHODS: A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic. RESULTS: At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0.001, chi 2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0.001, chi 2 test). CONCLUSION: Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.
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Changes in platelet count, coagulation and fibrinogen associated with elective repair of asymptomatic abdominal aortic aneurysm and aortic reconstruction for occlusive disease.
BACKGROUND: Mortality and morbidity following aortic surgery, particularly repair of ruptured abdominal aortic aneurysm (AAA), is frequently associated with the development of coagulopathy. OBJECTIVES: To examine changes in platelet count (PC), fibrinogen, and coagulation in patients undergoing elective repair of asymptomatic abdominal aortic aneurysm (AAA) and aortic surgery for occlusive disease. DESIGN: Prospective clinical study in a University Department of Vascular Surgery. PATIENTS: Thirty-three patients undergoing elective repair of asymptomatic AAA and 19 patients undergoing aortic surgery for occlusive disease. METHODS: Full blood count (FBC), clotting screen, and fibrinogen measured pre-operatively; 6, 12, 24, 48 h postoperatively; and thereafter as clinically indicated in 23 consecutive patient's undergoing AAA repair (Group 1). Pre- and postoperative PC measured weekly for 4 weeks following operation in a further 10 consecutive patients undergoing AAA repair (Group 2) and perioperative PC measured in 19 consecutive patients undergoing aortic surgery for occlusive disease (Group 3). RESULTS: Group 1: Preoperative haematological parameters were normal. There was no mortality. Postoperatively, 21 (91%) patients developed thrombocytopenia (PC < 150 x 10(9)/l). The postoperative fall in PC (median 90, range 12-160 x 10(9)/l) was significantly related to the duration of aortic cross-clamp (median 46, range 20-127 min, r2 = 0.33, p < 0.01). At 10 days all patients had developed thrombocytosis (PC > 350 x 10(9)/l) Postoperatively, by 48 h, 17 (74%) patients had developed hyperfibrinogenaemia. One patient suffered a myocardial infarction associated with a PC of 105 x 10(9)/l and a fibrinogen of 7.2 g/l. GROUP 2: In a further 10 patients undergoing AAA repair postoperative thrombocytosis was found to persist for several weeks in five of nine survivors. GROUP 3: Patients undergoing aortic surgery for occlusive disease had significantly higher preoperative PC than AAA patients (median 292, range 179-251 x 10(9)/l vs. median 204, range 140-293 x 10(9)/l, p < 0.01). CONCLUSIONS: Patients undergoing elective repair of AAA demonstrate similar, albeit less dramatic, changes in platelet count to those we have previously reported in patients undergoing repair of ruptured AAA. Aortic clamping leads to platelet sequestration and thrombocytopenia in the early postoperative period. Later, patients develop hyperfibrinogenaemia and thrombocytosis which may persist for several weeks. Similar changes are seen in patients undergoing aortic surgery for occlusive disease. These changes may represent a hypercoagulable state that predisposes these patients to thrombotic complications.
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Supervised training in carotid endarterectomy is safe.
BACKGROUND: The number of carotid endarterectomies (CEAs) performed in the UK, and thus the need to train surgeons in this operation, has increased markedly in recent years and may continue to do so. The aim of the present study was to assess the quality, clinical outcome and case-mix of supervised training in CEA in this unit. METHODS: The study was an analysis of a prospectively gathered database of all CEAs performed in this unit since 1975. RESULTS: Between 1 January 1975 and 31 December 1991, 247 CEAs were performed of which only 12 were done by supervised trainees. By contrast, between 1 January 1992 and 1 July 1996, 219 CEAs were performed, 92 (42 per cent) by supervised trainees (P < 0.0001). In cases performed since 1 January 1992, there was no significant difference between trainee and consultant operations with regard to age and sex of patient, smoking history, ischaemic heart disease, hypertension, diabetes, presence of preoperative infarction on computed tomography, indications for operation, degree of ipsilateral carotid stenosis, status of the contralateral carotid artery, use of a shunt or patch angioplasty. Since 1 January 1992, the total perioperative neurological event rate for supervised trainees was seven of 92 (7.6 per cent) of which one was fatal (cerebral infarction). The total neurological event rate for operations done by a consultant was nine of 127 (7.1 per cent), of which one was permanent and disabling and two were fatal (one cerebral infarction and one haemorrhage). CONCLUSION: Since 1991 there has been a tenfold increase in the proportion of CEAs being performed by supervised trainees. This has been accomplished without deterioration in clinical outcome. With adequate supervision, training in CEA can be safe, even when trainees are exposed to a true cross-section of low-, medium- and high-risk cases.
Consultants↗
Natural killer cells and cancer.
BACKGROUND: Natural cytotoxicity, mediated by natural killer (NK) cells and cell with lymphokine-activated killer (LAK) activity, is believed to play an important role in host anti-cancer mechanisms. METHODS: The authors critically review recent publications on the role of natural cytotoxicity in patients with cancer. RESULTS: In patients with cancer, several studies have noted variations in the numbers and activity of NK and cells with LAK activity in different body compartments. NK cell activity in the peripheral blood lymphocytes (PBLs) is higher than that found in lymph nodes and within tumors, and this appears to be due to the presence of suppressor factors. The natural cytotoxicity of PBLs in patients with different types of cancers varies. However, there appears to be a trend for natural cytotoxicity to be reduced in certain cancer patients, possibly related to tumor volume or dissemination. Anti-cancer treatments (e.g., surgery, hormonal modulation, radiotherapy and chemotherapy) can also result in suppression of natural cytotoxicity, although the long-term effect on response to treatment and development of metastases is at present unknown. CONCLUSIONS: NK and LAK cells, through the use of immune biologic modifiers, have been demonstrated to have a therapeutic role in the treatment of human cancers. Further studies are required to determine the optimal dosages and combinations of chemotherapeutic agents, the timing of surgery, and the adjuvant use of immune biologic response modifiers. An increasing awareness and understanding of this field, may allow for the future development of anti-cancer therapies.
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Comparison of venous reflux in the affected and non-affected leg in patients with unilateral venous ulceration.
In 54 patients with unilateral leg ulceration of purely venous aetiology the only difference in venous reflux between affected and non-affected legs was with respect to the popliteal and crural veins. Deep and superficial venous reflux is common in legs without the skin changes typical of chronic venous insufficiency. The significance of venous reflux in an ulcerated leg cannot therefore be determined without reference to the contralateral, clinically normal, limb. Surgery should be directed at correcting reflux present in the ulcerated limb but not in the unaffected limb. In a minority of patients this entails superficial venous surgery alone, but in the majority such an approach would, ideally, entail correction of deep venous incompetence.
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The crossover femoropopliteal bypass: a useful option for unilaterial iliofemoral occlusive disease.
OBJECTIVE: To study the outcome of treating critical limb ischaemia due to concurrent, unilateral iliac and femoral arterial occlusive disease by the placement of a crossover femoropopliteal bypass graft. DESIGN: Retrospective study of 10 patients unfit for aortic reconstruction whose disease was not amenable to endovascular therapy who were treated with this graft. MATERIALS: Seven grafts originated from the common femoral artery, two from aortobifemoral graft limbs and one from the common iliac artery. There was not direct revascularisation of the profunda femoris artery. The distal anastomosis was to the above-knee popliteal artery in nine cases and to the below-knee popliteal artery in one. OUTCOME MEASURES: Follow-up after discharge from hospital consisted of regular ankle-brachial index measurement and Duplex ultrasound scan assessment to record graft patency and limb salvage. RESULTS: The median duration of secondary patency was 52.5 months (range 14-84). During follow-up, there were four occlusive events. One graft had its patency restored, but in the other three patients, graft occlusion was associated with limb loss (at 18, 51 and 83 months respectively). In one of this latter group, surveillance had identified a failing graft and a jump graft prolonged patency for a further 34 months. CONCLUSION: This experience demonstrates that the crossover femoropopliteal bypass achieves satisfactory limb salvage in patients with extensive iliofemoral occlusive disease who are not suitable for major aortic reconstruction.
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Mesenteric ischaemia: a multidisciplinary approach.
Mesenteric ischaemia may result from a wide range of pathological processes, each possessing unique clinical features, diagnostic difficulties, management strategies and outcome. Regardless of aetiology, prognosis depends crucially on rapid diagnosis and institution of treatment to prevent, or at least to minimize, bowel infarction. Progress in understanding the pathophysiology of mesenteric ischaemia has led to novel methods of treatment, so that in some circumstances therapy may be purely medical. More often surgery is required and is frequently life saving. Percutaneous transcatheter techniques are increasingly employed in both diagnosis and treatment. Close cooperation between radiologists, physicians and surgeons is therefore necessary if clinical outcome is to be optimized. This paper reviews the modern interdisciplinary management of mesenteric ischaemia in the light of recent advances.
Acute Disease↗