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Biomedical subjects

M A Mansour

Publications and source records attributed to M A Mansour.

At least 19 recordsLinked to original sources
PubMed2001

Short stay carotid surgery for veterans: an emerging standard.

We have taken the short stay approach to carotid artery surgery to our VA setting over the past 5 to 6 years. Retrospectively, we reviewed the efficacy and safety of that approach in 201 consecutive carotid operations over the recent 4-year period (January 1, 1996-December 31, 1999). In 1996 we had already begun the transition to an algorithm to (1) utilize carotid color flow Doppler duplex exams for diagnosis, (2) same-day admission (SDA), (3) intensive care unit (ICU) only when deemed medically necessary, and (4) next-day discharge. Results of this approach have been a decrease in the utilization of diagnostic arteriograms and utilization of the ICU from 100% previous to the onset of this approach to 17 and 22%, respectively. SDA increased from 24 to 89%. Mean LOS decreased from 5.13+/-0.9 to 1.97+/-0.4 days. The percentage of patients completing the algorithm went from 15 to 72%. Stroke and/or death varied from 0 to 3.7% each year and was only 2.4% over the 4-year period. In conclusion, this approach to short stay carotid surgery in the veteran population has proven both efficacious and safe with results similar to those in university and community practices.

Aged↗
PubMed2001

Decreased recurrent carotid stenosis by routine patching and intraoperative scanning.

Our objective was to review the results of carotid endarterectomies (CEAs) with Dacron patch angioplasty and intraoperative color-flow duplex scanning (CFS). In a 3-year period, patients who underwent CEA with Dacron patch angioplasty and intraoperative CFS were studied. We excluded patients who had primary closure, vein patch, and redo endarterectomy. Serial CFS was obtained first in the early postoperative period (one day to 3 weeks), then at 6 months, and then yearly. Intraoperative CFS abnormalities were classified as major, requiring immediate revision, or minor, which were observed. The diagnosis of recurrent stenosis by US was based on the detection of an increased peak systolic frequency (>8000 MHz) or velocity (>250 cm/second) in the internal carotid artery. There were 212 CEAs performed in 200 patients (128 men and 84 women) included in this study. Three patients (1.4%) awoke with a stroke, two (0.94%) had transient ischemic attacks, and three (1.4%) developed transient hypoglossal nerve paresis. Intraoperative CFS showed a major defect that required an immediate revision in six patients (2.8%). Minor abnormalities were detected in another 41 patients (19.3%), but no revision was necessary. In follow-up three patients were identified with a severe recurrent carotid stenosis (>80%) and they underwent redo CEA. This rate of recurrence (1.4%) is significantly lower than the rate we had previously reported in a larger study (82 of 1209, 6.8%; P = 0.003). We conclude that the combined use of Dacron patch angioplasty and intraoperative CFS after CEA is associated with a low perioperative morbidity and a low incidence of recurrent stenosis in the first 2 years after operation.

Aged↗
PubMed2000

A gold(I) mononuclear complex and its association into binuclear and cluster compounds by hydrogen bonding or metal ion coordination.

The mononuclear Au(I) complex, Au(Spy)(PPh2py) (1), has been synthesized and characterized structurally. The complex possesses the expected linear coordination geometry with a S-Au-P bond angle of 176.03(6) degrees and no evidence of aurophilic interactions between nearest neighbor Au(I) ions in the solid state. Protonation of the pendant pyridyl groups of 1 leads to the formation of the H-bonded dimer [(Au(SpyH)(PPh2py))2](PF6)2 (2), which has also been structurally characterized. A linear coordination geometry at the Au(I) ions in 2 with a S-Au-P bond angle of 173.7(2) degrees is augmented by evidence of a strong aurophilic interaction with a Au...Au distance of 2.979(1) A. The pendant pyridyl groups of 1 have also been used to bind Cu(I) by reactions with [Cu(NCMe)4](PF6) and Cu(P(p-tolyl)3)2(NO3) leading to the formation of the heterobimetallic complexes [(AuCu(mu-Spy)(mu-PPh2py))2](PF6)2 (3) and [AuCu(P(p-tolyl)3)2(mu-Spy)(mu-PPh2py)](NO3) (4), respectively. A structure determination of 3 reveals a tetranuclear complex composed of two AuCu(mu-Spy)(mu-PPh2py)+ units held together by bridging thiolate ligands. A strong metal-metal interaction is noted between the two different d10 ions with nearest Au-Cu distances averaging 2.6395 A. The S-Au-P bond angles in 3 deviate slightly from linearity due to the Au...Cu interactions, while the coordination geometries at Cu(I) are distorted tetrahedral consisting of the two pyridyl nitrogen atoms, a bridging thiolate sulfur, and the interacting Au(I) ion. While mononuclear complex 1 is only weakly emissive in the solid state and in fluid solution, complexes 2-4 show stronger photoluminescence in the solid state and rigid media at 77 K, and in fluid solution. The emission maxima for 2-4 in ambient temperature fluid solution are 470, 635, and 510 nm, respectively. A tentative assignment of the emitting state as a S(p pi)-->Au LMCT transition is made on the basis of previous studies of Au(I) thiolate phosphine complexes. Shifts of lambda em result from the influence of H bonding or Cu(I) coordination on the filled thiolate orbital energy, or on the effect of metal-metal interaction on the Au(I) acceptor orbital energy. Crystal data for Au(Spy)(PPh2py) (1): triclinic, space group P1 (No. 2), with a = 8.3975(4) A, b = 11.0237(5) A, c = 12.4105(6) A, alpha = 98.6740(10) degrees, beta = 105.3540(10) degrees, gamma = 110.9620(10) degrees, V = 995.33(8) A3, Z = 2, R1 = 3.66% (I > 2 sigma(I)), wR2 = 9.04% (I > 2 sigma(I)) for 2617 unique reflections. Crystal data for [(Au(SpyH)(PPh2py))2](PF6)2 (2): triclinic, space group P1 (No. 2), with a = 14.0284(3) A, b = 14.1093(3) A, c = 15.7027(2) A, alpha = 97.1870(10) degrees, beta = 96.5310(10) degrees, gamma = 117.1420(10) degrees, V = 2692.21(9) A3, Z = 2, R1 = 7.72% (I > 2 sigma(I)), wR2 = 15.34% (I > 2 sigma(I)) for 5596 unique reflections. Crystal data for [(AuCu(mu-Spy)(mu-PPh2py))2](PF6)2 (3): monoclinic, space group P2(1)/c (No. 14), with a = 19.6388(6) A, b = 16.3788(4) A, c = 17.2294(5) A, beta = 91.48 degrees, V = 5540.2(3) A3, Z = 4, R1 = 3.99% (I > 2 sigma(I)), wR2 = 8.38% (I > 2 sigma(I)) for 10,597 unique reflections.

Journal Article↗
PubMed2000

Protective effects of thymoquinone and desferrioxamine against hepatotoxicity of carbon tetrachloride in mice.

The effects of thymoquinone (TQ) and desferrioxamine (DFO) against carbon tetrachloride (CCl4)-induced hepatotoxicity were investigated. A single dose of CCl4 (20 microl/kg, i.p.) induced hepatotoxicity, manifested biochemically by significant elevation of activities of serum enzymes, such as alanine transaminase (ALT, EC: 2.6.1.2) , aspartate transaminase (AST, EC: 2.6.1.1) and lactate dehydrogenase (LDH, EC: 1.1.1.27). Hepatotoxicity was further evidenced by significant decrease of total sulfhydryl (-SH) content, and catalase (EC: 1.11.1.6) activity in hepatic tissues and significant increase in hepatic lipid peroxidation measured as malondialdhyde (MDA). Pretreatment of mice with DFO (200 mg/kg i.p.) 1 h before CCl4 injection or administration of TQ (16 mg/kg/day, p.o.) in drinking water, starting 5 days before CCl4 injection and continuing during the experimental period, ameliorated the hepatotoxicity induced by CCl4, as evidenced by a significant reduction in the elevated levels of serum enzymes as well as a significant decrease in the hepatic MDA content and a significant increase in the total sulfhydryl content 24 h after CCl4 administration. In a separate in vitro assay, TQ and DFO inhibited the non-enzymatic lipid peroxidation of normal mice liver homogenate induced by Fe3+/ascorbate in a dose-dependent manner. These results indicate that TQ and DFO are efficient cytoprotective agents against CCl4-induced hepotoxicity, possibly through inhibition of the production of oxygen free radicals that cause lipid peroxidation.

Alanine Transaminase↗
PubMed2000

Protective effect of thymoquinone against doxorubicin-induced cardiotoxicity in rats: a possible mechanism of protection.

Administration of thymoquinone (10 mg kg(-1)day(-1), p.o.) with drinking water starting 5 days before a single injection of doxorubicin (15 mg kg(-1)i.p.) and continuing during the experimental period ameliorated the doxorubicin-induced cardiotoxicity in rats. This protection was evidenced from the significant reduction in serum enzymes: lactate dehydrogenase elevated level, 24 h and creatine phosphokinase elevated levels, 24 h and 48 h after doxorubicin administration. The cardiotoxicity of doxorubicin has been suggested to result from the generation of superoxide free-radical. The protective action of thymoquinone was examined against superoxide anion radical either generated photochemically, biochemically or derived from calcium ionophore (A23187) stimulated polymorphonuclear leukocytes. The results indicate that thymoquinone is a potent superoxide radical scavenger, scavenging power being as effective as superoxide dismutase against superoxide. In addition thymoquinone has an inhibitory effect on lipid peroxidation induced by Fe(3+)/ascorbate using rat heart homogenate. The superoxide scavenging and anti-lipid peroxidation may explain, in part, the protective effect of thymoquinone against doxorubicin-induced cardiotoxicity. 2000 Academic Press@p$hr

Animals↗
PubMed2000

Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms.

PURPOSE: We previously reported preliminary data on a new procedure that we developed for the treatment of femoral pseudoaneurysms after catheterization. This study presents our current results of percutaneous ultrasound-guided thrombin injection for treating pseudoaneurysms that arise from various locations and causes. METHODS: Between February 1996 and May 1999, we performed thrombin injection of 83 pseudoaneurysms in 82 patients. There were 74 femoral pseudoaneurysms: 60 from cardiac catheterization (36 interventional), seven from peripheral arteriography (four interventional), five from intra-aortic balloon pumps, and two from dialysis catheters. There were nine other pseudoaneurysms: five brachial (two cardiac catheterization, two gunshot wounds, one after removal of an infected arteriovenous graft), one subclavian (central venous catheter insertion), one radial (arterial line), and one distal superficial femoral and one posterior tibial (both after blunt trauma). Twenty-nine pseudo-aneurysms were injected while on therapeutic anticoagulation. Patients underwent repeat ultrasound examination within 5 days and after 4 weeks. RESULTS: Eighty-two of 83 pseudoaneurysms had initial successful treatment by this technique, including 28 of 29 in patients who were undergoing anticoagulation therapy. The only complication was thrombosis of a distal brachial artery, which resolved spontaneously. There were early recurrences in seven patients: four patients underwent successful reinjection; reinjection failed in two patients, who underwent surgical repair; and one patient had spontaneous thrombosis on follow-up. After 4 weeks, ultrasound examinations were completely normal or showed some residual hematoma, and there were no recurrent pseudoaneurysms. CONCLUSION: Ultrasound-guided thrombin injection of pseudoaneurysms has excellent results, which support its widespread use as the primary treatment for this common problem.

Adult↗
PubMed2000

Optimising the performance of intermittent pneumatic compression devices.

OBJECTIVES: this study was designed to determine whether an intermittent pneumatic compression device (IPC) with an increased maximal inflation pressure, a decreased time to maximal pressure and a longer duration of compression would improve venous return compared to a standard IPC device. METHODS: thirty limbs in 15 volunteers without evidence of venous disease were studied using duplex scanning at rest and during the application of two different IPC devices with different compression parameters. The first device IPC-1 (SCD 5325, Kendall) has a six-chambered cuff applying 45 mmHg after 12 s, sequentially from ankle to thigh followed by 60 s of non-compression. The second device IPC-2 (Vena-Assist(R), ACI Medical) has a foot, ankle and calf cuff, applies a pressure of 80 mmHg, has a pressure rise time of 0.3 s, maintains inflation for 5.5 s, and has a cycling time of 1 min. Peak venous velocity and acceleration time were measured at rest and during the IPC application. Measurements were obtained in supine position from the common femoral vein 1 cm above the saphenofemoral junction to include the entire venous outflow from the limb. RESULTS: peak venous velocity at rest was significantly higher in the right limb than in the left limb (26+/-7.2 vs. 22+/-5.7 cm/s, p<0.01). Peak venous velocity was significantly increased by both IPC devices (p <0.0001). IPC-2 achieved significantly higher peak venous velocity than IPC-1 (55.1+/-17.8 vs. 37.4+/-6.9 cm/s, p<0.0001). Acceleration time was also found to be significantly shorter (370+/-93.4 vs. 560+/-83.5 ms, p<0.0001) in IPC-2 than in IPC-1, respectively. CONCLUSIONS: we have demonstrated that progressive inflation at the foot, ankle and calf, increasing maximal inflation pressure and decreasing time to maximal pressure result in increased venous return. These changes may improve the efficacy of IPC devices in the prevention of deep-venous thrombosis (DVT) formation.

Adult↗
PubMed2000

Prevalence of deep venous reflux in patients with primary superficial vein incompetence.

PURPOSE: This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT). METHODS: We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site. RESULTS: Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration. CONCLUSIONS: The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.

Adult↗
PubMed2000

The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease.

PURPOSE: The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD). METHODS: During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system. RESULTS: There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%). CONCLUSIONS: Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.

Adolescent↗
PubMed1999

Management of acute mesenteric ischemia.

Acute mesenteric ischemia is a serious illness requiring prompt surgical attention. The clinical presentation, diagnostic strategy, and management of this disease are reviewed. Options for revascularization are briefly outlined.

Acute Disease↗
PubMed1999

Effect of captopril on doxorubicin-induced nephrotoxicity in normal rats.

Biochemical evaluations of the effects of the sulfhydryl-containing angiotensin-converting enzyme inhibitor (captopril) on the nephrotoxicity induced by doxorubicin in normal rats were carried out. A single dose of doxorubicin (15 mg kg-1) which caused nephrotoxicity was manifested biochemically by the elevation of serum urea after 24 and 48 h of administration. Also a severe decrease in total proteins and albumin after 4, 24 and 48 h was observed. Moreover, a decrease of non-protein sulfhydryl (-SH) concentrations in the kidney tissues after 24 h and an increase in the lipid peroxidation was observed after 4 h administration of doxorubicin. Captopril (60 mg kg-1 i.p.) injection did not induce any change in the biochemical parameters measured, however, captopril administered 1 h before doxorubicin ameliorated the biochemical toxicity induced by doxorubicin. This was evidenced by a significant reduction in serum urea and the lipid peroxidation after 4 and 24 h and a significant reduction in creatinine after 48 h. Also, the captopril amelioration was evidenced by an increase in total proteins and albumin after 4 and 24 h of doxorubicin administration. Captopril did not change non-protein sulfhydryl (-SH) concentrations or protein content in the kidney tissues. These results suggest that captopril may be beneficial as a protective agent against nephrotoxicity induced by doxorubicin.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1999

The new operating room environment.

As endovascular procedures become more complex, the need for a suitably equipped endovascular suite is recognized. This specialized theater combines the features of the traditional operating room and the interventional radiology suite. The availability of high-resolution digital fluoroscopy facilitates the precise deployment of endovascular grafts and stents. In addition, combined open and endovascular procedures can be performed simultaneously. In this new environment, vascular surgeons are able to select the most appropriate operation without hindrance.

Angiography↗
PubMed1999

Patterns and distribution of isolated calf deep vein thrombosis.

PURPOSE: In the search for calf deep vein thrombosis (DVT) with color-flow duplex scanning (CFDS), most vascular laboratories investigate only the posterior tibial and peroneal veins. Few laboratories assess the soleal and gastrocnemial veins. This study was designed to determine the patterns and distribution of isolated calf DVT, including the soleal and gastrocnemial veins. METHODS: In the last 3 years, 5250 patients (mean age, 66 +/- 15 years; range, 22 to 93 years) were referred to the vascular laboratory for clinical suspicion of DVT and underwent examination with CFDS. All superficial and deep named veins, excluding the anterior tibial from groin to ankle, were imaged. Of the deep veins in the calf, the peroneal, the posterior tibial, the gastrocnemial, and the soleal veins were examined throughout their length. RESULTS: DVT was detected in 14% of the patients. Isolated calf DVT was detected in 282 limbs of 251 patients (4.8%). No significant difference was noted for the sex (114 men vs 137 women; P =.15) or the limb preference (145 left vs 137 right; P =.5). The peroneal veins were most frequently involved, with 115 limbs (41%) affected. The soleal veins were involved in 109 limbs (39%), followed by the posterior tibial in 105 limbs (37%) and the gastrocnemial in 79 limbs (29%). Thrombus in the soleal vein alone was found in 57 limbs (20%), in the gastrocnemial in 48 limbs (17%), in the peroneal in 41 limbs (15%), and in the posterior tibial vein in 35 limbs (12%). Thrombus confined to a single or paired vein was found in 181 limbs (64%). Thrombus involving two different veins (27%) was the second most frequent pattern, and thrombus in three (7%) or four (1.4%) different veins was less prevalent. Isolated thrombosis in veins not routinely investigated was found in 113 limbs (40%; soleal, n = 57; gastrocnemial, n = 48; soleal + gastrocnemial, n = 8). Multifocal origin of thrombosis, defined as thrombi in two different veins that do not anatomically communicate, was identified in 63 limbs (22%). CONCLUSION: Forty percent of the patients with acute isolated calf DVT would be judged to have normal CFDS examination results if the muscular veins in the calf were not imaged. Multifocal origin of thrombosis was found in 22% of the involved limbs. The prevalence of thrombosis in any calf vein either alone or in combination is comparable. Accordingly, the soleal and gastrocnemial veins should be examined routinely.

Adult↗
PubMed1999

Timing and frequency of perioperative carotid color-flow duplex scanning: A preliminary report.

PURPOSE: The results of intraoperative and early postoperative carotid color-flow duplex scanning (CFS) after endarterectomy were reviewed to determine whether any perioperative studies could be eliminated. METHODS: Patients undergoing carotid endarterectomy with intraoperative CFS between 1986 and 1997 were identified. Early postoperative CFS was performed between 1 day and 3 weeks postoperatively, then it was performed again at 6 months postoperatively. RESULTS: During the study period, 560 patients, 325 men and 235 women, underwent 621 carotid endarterectomies. A satisfactory intraoperative carotid CFS was completed in 611 (98.4%) patients. There were 20 (3.2%) vessels with a major defect that required revision for fronds or flaps (n = 11), retained atheroma (n = 5), low flow (n = 2), high velocity or turbulence (n = 1), or dissection (n = 1). Another 146 vessels (23.5%) had minor defects, such as retained proximal atheromas or small (less than 3 mm) fronds, but were not revised. The remaining 445 vessels were normal. The first postoperative CFS was normal in all the revised carotids and in 138 (94.5%) vessels with minor intraoperative defects. At 6 months, recurrent stenosis (more than 75% area reduction) was identified in 1 of 18 revised carotids (5.5%), 4 of 138 vessels (2. 9%) with minor defects, and 17 of 406 vessels (4.2%) that were normal intraoperatively. The incidence of recurrent stenosis was not significantly different in the three groups (P =.7). CONCLUSION: Intraoperative CFS is useful because major unsuspected defects can be corrected immediately, thus avoiding potential neurologic morbidity. However, the postoperative day 1 CFS can be eliminated in most cases, because it does not provide any relevant clinical information.

Aged↗
PubMed1999

Outcome of moderate carotid artery stenosis in patients who are asymptomatic.

PURPOSE: The incidence rate of disease progression and stroke after the diagnosis of a moderate (50% to 79%) carotid stenosis was determined by means of color-flow duplex scanning. METHODS: During a 4-year period, 344 male veterans with moderate internal carotid artery stenoses, on one or both sides, were examined at regular intervals for a mean period of 25 months. Carotid color-flow scans were obtained semiannually. Clinical follow-up was performed to determine the incidence rate of amaurosis fugax, transient ischemic attacks, nonhemispheric symptoms, and strokes. RESULTS: New neurologic symptoms developed in 75 patients (21.8%). Fifty-one (14.8%) had ipsilateral symptoms during follow-up: 18 amaurosis fugax (5.2%), 14 transient ischemic attacks (4%), 5 nonhemispheric symptoms (1.4%), and 14 strokes (4%). Twenty-four patients (6.9%) had contralateral symptoms: 20 strokes (5.8%) and 4 transient ischemic attacks (1.2%). Life-table analysis showed that the annual rate of ipsilateral neurologic events was 8.1%, and the annual rate of stroke was 2.1%. Seventy-five patients (22%) died in the follow-up period. Disease progression to 80% to 99% stenosis or occlusion occurred in 71 of 458 vessels (15.5%). The internal carotid arteries that showed evidence of disease progression had a significantly higher initial peak systolic velocity (251 vs 190 cm/s; P <.0001) and end diastolic velocity (74 vs 52 cm/s; P < 0.0001). Black patients and patients with ischemic heart disease were at a higher risk for disease progression. We could not identify any atherosclerotic risk factors that reliably predicted patients in whom future ipsilateral neurologic symptoms were more likely to develop. However, there was an increased risk of stroke associated with progression of disease. CONCLUSION: Patients who are asymptomatic and who have moderate carotid stenoses are at significant risk for neurologic symptoms and death, but have a relatively low incidence rate of ipsilateral events. The initial flow characteristics in the stenotic vessel are predictive of future disease progression, but they are not helpful in identifying patients in whom symptoms will develop.

Adult↗
PubMed1999

Primary superficial vein reflux with competent saphenous trunk.

OBJECTIVES: because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD). PATIENTS AND METHODS: eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD. RESULTS: the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux. CONCLUSIONS: these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.

Adolescent↗
PubMed1999

New insights into perforator vein incompetence.

BACKGROUND: there has been much controversy on the role of perforator veins in the development of chronic venous disease (CVD). This study was designed to determine the duration and direction of flow of lower limb perforator veins (PVs) in relation to their location, diameter and competency status of superficial and deep veins, in healthy volunteers and patients with different grades of CVD. PATIENTS AND METHODS: thirty limbs in 15 symptom-free volunteers and 103 limbs in 75 patients with signs and symptoms of CVD were examined with colour-flow duplex scanning. Superficial, perforator and deep veins were studied in the standing and sitting positions. Flow-velocity characteristics, the number and maximum PV diameter at the deep fascia and subfascially were determined. A PV was considered incompetent when the outward flow lasted >0.5 s. RESULTS: 581 PVs were found in the patients and 106 in the volunteers. 163 PVs (28%) were incompetent in the first group and none in the latter. The total number of PVs and the number of incompetent PVs per limb increased significantly with the severity of CVD. The mid-calf area had more competent and incompetent PVs in patients (p <0.01). Mean diameter of incompetent PVs in all the CVD classes was significantly larger than that of competent PVs. Competent PVs tended to be larger with increasing severity of CVD and they were significantly larger in the CVD classes 4 to 6 compared to controls (p <0.01). Subfascial PV diameter was markedly larger than that at the fascial level (p <0.001) regardless of the CVD class. A subfascial PV diameter of >3.9 mm (95% CI 3.4 to 4.4 mm) indicated incompetence. However, the reverse was not true, because about a third of incompetent PVs had a subfascial diameter of <3.9 mm. Both competent and incompetent PVs were smaller when located at the lower thigh, knee, ankle and anterior aspect of the calf than those found in the rest of the calf and mid-thigh (p =0. 03). Both inward and outward flow was found more often in patients than in controls (70/418 vs. 9/106, p =0.048). Most incompetent PVs had outward flow alone (126, 77%). PV incompetence was most frequently associated with reflux in superficial veins (120, 74% (p <0.0001), followed by reflux in both the superficial and deep veins (34, 21%) and reflux in the deep veins alone (9, 5%). The mean duration of outward flow was markedly longer in the presence of both superficial and deep vein reflux compared to superficial (p <0.001) or deep vein reflux alone (p <0.0001). CONCLUSIONS: the number of incompetent PVs and the diameter of both competent and incompetent PV increases with the severity of CVD. Bidirectional PV flow is more common in patients than in normal volunteers, while 77% of the incompetent PVs have outward flow alone. PV incompetence is most often associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of PV insufficiency.

Adolescent↗