Comparison of duplex imaging and
arteriography in the evaluation of lower limb arteries. Aly S, Somerville
K, Adiseshiah M, Raphael M, Coldridge Smith P D, Bishop C C R.
Br J Surg 1998; 85: 1099-1102.
Arteriography is regarded by most as the gold-standard
investigation for the evaluation of peripheral vascular disease. It
provides a good anatomical representation of the vascular tree but fails
to give a functional assessment of stenotic lesions. Furthermore,
arteriography has a significant morbidity and mortality. With recent
technological advances, duplex ultrasound has been increasingly used in
vascular assessments. It is non-invasive and has replaced arteriography as
the investigation of choice in the assessment of carotid artery disease
and in post-operative graft surveillance. The aim of this study was to
assess the role of duplex ultrasound in the detection and assessment of
severity of peripheral arterial disease and to evaluate the effect on
clinical decision making. Some 177 legs were assessed in 90 patients (81
intermittent claudication, 8 rest pain, 1 ischaemic ulceration). Each
patient underwent both angiography and ultrasound. Compared with
angiography, duplex ultrasound had a sensitivity of 92%, specificity of
99%, positive predictive value 91% and negative predictive value of 100%.
Ultrasound was reliable in assessing the length of vascular lesions. Both
investigations had a similar influence on clinical decision making. It was
concluded that duplex ultrasound is reliable in the assessment of
peripheral arterial disease.
Mortality results for randomised
controlled trial of early elective surgery or ultrasonographic
surveillance for small abdominal aortic aneurysms. The UK Small Aneurysm
Trial Participants. Lancet 1998; 352: 1649-1655.
Abdominal aortic aneurysms often remain symptomless until
they rupture ands are an important cause of sudden death. The mortality of
elective aneurysm repair is about 5%. The risk of rupture increases with
aneurysm diameter and it is general accepted that the potential benefits
outweigh the risks for aneurysms greater than 6 cm. This study was
designed to assess whether prophylactic surgery decreased the long-term
mortality for small aneurysms. 1090 patients between 60 and 76 years with
symptomless infrarenal AAA with a diameter of 4.0 to 5.5 cm were
randomised to receive either early surgical repair (n=563) or ultrasound
surveillance (n=527). Patients in this latter group underwent surgery if
the aneurysms diameter increased to above 5.5 cm, increased at > 1 cm/year
or become symptomatic. Patients were followed for a mean of 4.6 years. The
primary end-point was overall mortality. Analysis was on an intention to
treat basis. More than 60% of patients randomised to surveillance
eventually underwent surgery. There were similar degrees of cardiovascular
risk factors in both groups. Overall, 93% patients adhered to their
assigned treatment group. A total of 309 patients died during the study
period. The 30-day operative mortality was 5.8 %. The hazard ratio for all
cause mortality of early treatment versus surveillance was 0.94 (95% CI
0.75-1.17. p=0.56). There was no difference in mortality between the two
groups at 2, 4 and 6 years. It was concluded that early surgery produces
no long-term survival advantages. This study does not support a policy of
open surgical repair for AAA with a diameter of 4.0 to 5.5 cm.
The use of routine duplex scanning in the
assessment of varicose veins. Wills V, Moylan D, Chambers J. Aust NZ J
Surg 1998; 68: 41-44.
Varicose veins are a common condition affecting 10-15% of
men and 20-25% of women in Western populations. They contribute to a
considerable morbidity with a prevalence of chronic venous insufficiency
of 2-7% and of venous ulceration of ~1%. Clinical assessment of venous
insufficiency has been shown to compare poorly with the results of
hand-held doppler examination or venography in the assessment of varicose
veins. Although the use of duplex scanning has been described in the
assessment of varicose vein there is little data comparing the combination
of clinical and doppler assessment with duplex scanning. In this study 315
legs were assessed in 188 patients. After clinical and doppler assessment
all patients underwent duplex scanning. The results were retrospectively
compared with the clinical and doppler findings. Of the legs assessed 39%
had recurrent varicose veins and 31% had trophic changes or skin
ulceration. On duplex scanning 63% had sapheno-femoral incompetence, 19%
sapheno-popliteal incompetence, 30% perforator incompetence and 8% deep
venous insufficiency. The respective sensitivity of the combination of
clinical and doppler assessment at these sites was 71, 36, 43 and 29%
respectively. If the patients who were felt to have sole sapheno-femoral
junction incompetence were treated by high ligation, strip and avulsions,
29% would have sites of reflux untreated. It was concluded that clinical
and doppler assessment is unreliable. Routine duplex scanning is likely to
reduce recurrence by identifying sites of reflux with greater accuracy.
Use of colour duplex imaging to diagnose
and guide angioplasty of lower limb arterial lesions. London N J M, Nydahl
S, Hartshorne T, Fishwick G. Br J Surg 1999; 86: 911-915.
Since its introduction in 1964, percutaneous transluminal
angioplasty (PTA) has become widely used in vascular radiological
practice. It has conventionally been guided by radiographic imaging with
the small but none-the-less real risks associated with the use of ionising
radiation and contrast media. High-resolution colour duplex imaging has
recently been increasingly used in arterial assessment but with subsequent
PTA guided radiographically. The aim of this study was to investigate
whether colour duplex imaging alone could be safely and effectively used
to diagnose lower limb arterial lesions and guide subsequent PTA. Patients
with lower limb arterial lesions which could be visualised with colour
duplex imaging were selected for duplex-guided PTA. No angiography was
used at any stage. In total 55 arterial lesions in 50 legs of 45 patients
were treated. The underlying clinical problems were claudication (44),
critical limb ischaemia (3) and asymptomatic vein cuff stenosis (3). There
were 53 stenoses and 2 occlusions. The lesions were in the iliac segment
(4), superficial femoral artery (40) and popliteal artery (7). There were
no complications and symptomatic improvement occurred in 46 of 47 legs.
There was a significant increase in ABPI immediately following the
procedure which was maintained at follow up. It was concluded that it was
possible to diagnose and angioplasty lower limb arterial lesions using
colour duplex imaging alone. Some may now consider that colour duplex
imaging is now the 'gold standard' imaging method in the assessment of
lower limb arterial disease.
Intermediate-term results of endoscopic
transaxillary T2 sympathectomy for primary palmar hyperhidrosis. Chiou T
S-M, Chen S-C. Br J Surg 1999; 86: 45-47.
Endoscopic transaxillary T2 sympathectomy is currently the
preferred treatment for palmar hyperhidrosis. With this technique
the T2 ganglion and its associated fibres are diathermied along the upper
border of the third rib. It is a technique that has minimal
post-operative morbidity and an early almost complete success rate.
The long-term efficacy remains unclear. This paper studied the
intermediate-term results of this operative procedure. A
retrospective review was performed of 91 consecutive patients treated
between 1992 and 1996. Patients were contacted by telephone or a
post questionnaire to ascertain their satisfaction, late complications and
morbidity. In the early postoperative period no patient developed a
Horner's syndrome. One patient developed a haemothorax that did not
require chest drainage. Overall, 16% developed recurrent sweating
but none required further surgery. 78% were satisfied with the
outcome of their operation. However, 13% were dissatisfied mainly
due to compensatory hyperhidrosis which occurred in 97% of all patients
within the first year. It was concluded that the results of
endoscopic sympathectomy deteriorated progressively from the immediate
outcome and the compensatory hyperhidrosis was the principal reason for
dissatisfaction.
Clinical examination of varicose veins -
a validation study. Kim J, Richards S, Kent P J. Ann R Coll
Surg Eng 2000; 82: 171-175.
Many aspects of clinical physical examinations have not
been prospectively evaluated and are of questionable accuracy.
Several tests have been described in the assessment of varicose veins.
More recently hand-held doppler ultrasound has become available to
supplement the clinical evaluation. The aim of this study was to
determine the accuracy of clinical tests and hand-held doppler ultrasound
in the evaluation of varicose veins by performing a comparison with colour
duplex scanning as the 'gold' standard investigation. In total, 70
limbs with primary, previously untreated varicose veins in 44 consecutive
patients were clinically assessed. The following clinical tests were
performed as described in standard surgical texts - cough test, tap test,
Brodie-Trendelenberg test, Perthe's test. Hand-held doppler and
duplex scanning were then performed. The sensitivity, specificity,
positive and negative predictive values were calculated for each test.
Reflux was detected on duplex scanning at the sapheno-femoral junction in
54% and sapheno-popliteal junction in 13% of limbs. The cough test
had a low sensitivity (0.59) and specificity (0.67). The tap test
had a low sensitivity (0.18) and high specificity (0.92). The
Trendelenberg test had a high sensitivity (0.97) but low specificity
(0.20). Hand-held doppler at the sapheno-femoral and
sapheno-popliteal junctions had a high sensitivity (0.97, 0.80) and high
specificity (0.73, 0.90) of detecting reflux. It was concluded that
clinical tests in the evaluation of varicose veins are inaccurate.
Hand-held doppler ultrasound is more accurate and its use should be taught
as part of the routine assessment of varicose veins.
Population screening reduces mortality
rate from aortic aneurysm rupture in men. Heather B P, Poskitt K R,
Earnshaw J J et al. Br J Surg 2000; 87:
750-753.
Rupture of an abdominal aortic aneurysm (AAA) is a major
cause of death in men over the age of 65 years. It accounts for over
1% of all deaths in this age group and over 6,000 deaths annually in
England and Wales. Mortality from elective and emergency surgery has
been reported to be less than 5% and over 80% respectively. This
vast difference in mortality rate has has lead to the conclusion that the
best way of reducing the number of deaths from ruptured AAA is to screen
for asymptomatic aneurysms and to increase the number of patients offered
elective surgery. The value of screening for AAA is as yet unproven.
Screening of 65 year old men for the presence of asymptomatic AAA has been
performed in one English county since 1990. Men were offered
screening by abdominal ultrasound examination via their general practice
surgeries at their 65th birthday. The aim of this study was to
assess the impact of this programme on overall community mortality rate
from all aneurysm-related causes in men offered screening. The total
number of deaths from all aortic aneurysm-related causes in the county's
population was calculated from hospital records (hospital admission
records, operating theatre logs and intensive care unit records) and death
certificate records held on a computerised database. This study
showed that the overall number of aneurysm-related deaths in men aged
65-73 years has been progressively reduced by the screening programme when
compared with that for men of all other ages. During the study
period the total number of aneurysm-related deaths decreased progressively
year by year. No changes were observed in the unscreened part of the
population. It was concluded that screening for asymptomatic AAA
results in a significant reduction in the number of deaths from all
aneurysm-related causes in the screened portion of the male population.
Safety of a single duplex scan to exclude
deep venous thrombosis. Wolf B, Nichols D M, Duncan J L.
Br J Surg 2000; 87: 1525-1528.
Despite the widespread use of thromboprophylaxis, venous
thromboembolism remains a common and often preventable cause of morbidity
and mortality in surgical patients. The clinical diagnosis of deep venous
thrombosis (DVT) is unreliable and needs to be confirmed by the
appropriate use of investigations. Venography is regarded by many as
the gold standard, but it has been replaced in recent years by
ultrasonography as the routine imaging modality in many centres. Recently
published guidelines have recommended that a negative ultrasound scan
should be followed by venography or a repeat scan after seven days so as
to detect proximal extension of calf vein thrombosis. This study
aimed to evaluate whether anticoagulation can be safely withheld on the
basis of a single negative duplex scan in patients presenting with
suspected deep venous thrombosis. Duplex scan reports, case notes
and questionnaires returned by general practioners of patients with
suspected DVT were analysed retrospectively. The main outcome
measure was occurrence of an adverse thromboembolic event (a symptomatic
DVT or pulmonary embolus) within 3 months after a negative duplex scan. In
a 12 month period 537 patients had 706 legs assessed because of leg
symptoms or indirect evidence of a pulmonary embolus. Among the 352 who
had negative scans only four possible adverse events were identified.
The rate of adverse events was 1.1% of patients and 0.9% of legs assessed.
It was concluded that withholding anticoagulation in patients who have a
single complete negative duplex scan is safe and that a repeat scan should
only be performed if there is ongoing high clinical suspicion or the calf
veins were not visualised on the initial investigation.
Outcome of femoropopliteal angioplasty.
Golledge J, Ferguson K, Sabharwal T et al. Ann Surg 1999; 229:
146-153.
Percutaneous transluminal angioplasty can be used to treat
symptomatic femoropopliteal stenoses or occlusions but the long term
success of this procedure is not as good as in the aorto-iliac segment.
The aim of this study was to prospectively assess the outcome of
femoropopliteal angioplasty and investigate prognostic indicators of
success. In total, 72 consecutive patients treated by femoropopliteal
angioplasty were studied. The indications for the procedure were
intermittent claudication (43), rest pain (4) and tissue loss (27).
Patients were followed up clinically and by assessment of ABPI and duplex
monitoring of velocity gradient at the angioplasty site. Univariate
comparisons, life table analysis and regression analysis were used to
investigate factors predicting the symptomatic and haemodynamic outcome.
Technical success was achieved in 61 (91%) of patients. At one year,
successful symptomatic improvement was achieved in 35 (51%) patents with
haemodynamic success in 41 (58%) patients. ABPI at 24 hours after
angioplasty was the most significant variable that predicted symptomatic
outcome. It was concluded that only half of the patients treated by
femoropopliteal angioplasty had symptomatic improvement at one year.
Restoration of the ABPI to > 0.9 was predictive of a favourable outcome.
In-hospital mortality from abdominal
aortic surgery in Great Britain and Ireland: Vascular Anaesthesia
Society audit. Bayly P J M, Mathews J N S, Dobson P M,
Price M L, Thomas D G. Br J Surg 2001; 88:
687-692.
Studies looking at mortality and factors predictive for an
adverse outcome following abdominal aortic surgery have often been
retrospective or performed over an extended period, making the findings
less applicable to to current practice. These studies have suggested
a mortality rate for elective infrarenal aortic surgery of between 4 and
7%, a figure which has changed little over the past 20 years.
Factors associated with increasing mortality include age, chronic renal
impairment, hypertension and a low case load. In an attempt to
obtain current information on the mortality of patients undergoing
elective infrarenal aortic surgery the audit committee of the Vascular
Anaesthesia Society of Great Britain and Ireland undertook a multicentre
study from February to May 1999 inclusive. Overall, 177 hospitals
provided data. Questionnaires were completed on all patients
undergoing surgery for infrarenal abdominal aortic aneurysms and
aorto-iliac occlusive disease. There were 933 patients recruited
into the audit with an overall mortality of 7.3%. Factors increasing
the risk of death by up to five-fold were age over 74 years, urgent
surgery, surgery for occlusive disease, limited exercise capacity, history
of angina or cardiac failure, the presence of ventricular ectopics
and abnormalities on the ECG suggestive of ischaemic heart disease.
It was concluded that although the in-hospital mortality rate was similar
to previously published figures, the rate increased considerably when
commonly encountered risk factors were present.
A single normal ultrasonographic scan at
age 65 years rules out significant aneurysm disease for life in men. Crow
P, Shaw E, Earnshaw J J, Poskitt K R, Whyman M R, Heather B P. Br J
Surg 2001; 88: 941-944.
Ruptured abdominal aortic aneurysm (AAA) is a major cause
of death in men over 65-years of age accounting for an estimated 6,000
deaths annually in England and Wales. Screening for AAA has been taking
place in Gloucestershire since 1990 with men being offered an ultrasound
scan at the age of 65 years. Subjects with an aortic anteroposterior
diameter of greater than 26 mm are considered at risk of further aortic
growth and offered annual re-imaging. Men with an aortic diameter of over
40 mm are referred to the surgical clinic where they are reviewed
biannually. Surgery is offered when the aortic diameter exceeds 55 mm. The
screening project has reduced the mortality from ruptured AAA within the
screened portion of the population. An unanswered question is whether any
further follow-up is necessary in men with a 'normal' aorta at the age of
65 years. A cohort study was performed on 223 65-year-old men who had an
aortic diameter of less than 26 mm in 1988. These men had repeat
ultrasound scans in both 1993 and 2000. The causes of death in men who
died during the interval were investigated. Overall, 8 men were lost to
follow-up. As far as it was possible to ascertain, none of the 86 men who
died over the 12-year interval did so from a ruptured AAA. There was no
clinically significant increase in mean aortic diameter in the remaining
129 who had three serial ultrasound scans. It was concluded that a single
'normal' ultrasound scan at 65 years effectively rules out the risk of
clinically significant aneurysm disease for life in men.
Randomized clinical trial comparing the
efficacy of two bandaging regimens in the treatment of venous leg ulcers.
Meyer F J, Burnand K G, Lagattolla N R F, Eastham D.
Br J Surg 2002; 89: 40-44.
Active leg ulceration has a prevalence in the UK
population of approximately 0.2%. About 70% of leg ulcers are caused
by venous disease and compression bandaging is an established form of
treatment. Debate continues as to whether compression bandaging
should be 'elastic' or 'inelastic' in nature. Also it has been suggested
that bandages capable of producing greater compression enhance ulcer
healing. The aim of this study was to compare the efficacy of two
different compression regimens. Elastic compression was achieved
using Tensopress and inelastic compression was achieved using Elastocrepe
bandages. Tensopress produces a greater degree of compression.
The study was performed as a prospective randomised trial. Overall,
112 patients were studied and all were treated with zinc-impregnated paste
applied directly to the ulcer. The paste was covered by either
Tensopress (n=57) or Elastocrepe (n=55) bandages. Both groups had a
tubular bandage applied over the compression bandage to keep it in place.
All ulcers were stratified and randomised within one of three size groups.
The venous aetiology of the ulcer was confirmed on completion by calf pump
function tests. By 26 weeks, 58% of the patients treated with
Tensopress and 62% of those treated with Elastocrepe had achieved ulcer
healing. The median times to healing were 9 and 9.5 weeks in the two
groups respectively. Large ulcers healed significantly slower than
small ulcers, irrespective of the treatment method. It was concluded
that there was no significant improvement in venous ulcer healing using
higher compression elastic bandages.
Effect of chronic renal failure on
mortality rate following arterial reconstruction. Gerrard D J,
Ray S A, Barrio E A et al. Br J Surg 2002; 89:
70-73.
The majority of patients who undergo arterial
reconstruction for peripheral vascular disease have atherosclerosis.
A complex interrelationship exists between atherosclerosis and chronic
renal failure with increasing awareness that end-stage renal disease may
be secondary to atherosclerotic renal artery stenosis. Furthermore,
patients with end-stage renal disease are more likely to develop
accelerated atherosclerosis requiring vascular intervention.
Patients with chronic renal failure who undergo arterial surgery have an
increased operative mortality and poor long-term survival. The aim
this study was to compare the hospital mortality rates in patients with
chronic renal failure and patients with normal renal function undergoing
arterial surgery. Data describing a consecutive series of 1718
patients undergoing arterial reconstruction were entered prospectively
into a computerised database. Chronic renal failure was defined as a
serum creatinine more than 400umol/l, or a patient on dialysis or after a
successful renal transplant. Mortality was assessed either in
hospital or at 30 days. There were 69 patients (4%) with chronic
renal failure. The mortality rate in this group was 23% compared
with the 1649 patients without renal failure. The mortality was
highest in those undergoing urgent or emergency surgery and in those
undergoing surgery for lower limb occlusive disease. The main causes
of death were related to the cardiovascular system. It was concluded
that patients with chronic renal failure undergoing arterial surgery had a
poor outcome compared with those with normal renal function.
Autologous versus allogeneic transfusion
in aortic surgery. Wong J C L, Torella F, Haynes S L
et al. Ann Surg 2002; 235: 145-151.
The United Kingdom is well served by the National
Transfusion Service with a low risk of transfusion-related incidents.
However, recent concerns have lead to costly changes in the preparation of
blood products. Nucleic acid testing for Hepatitis C is now required
for all plasma components and leukodepletion is required for all cellular
products. The cost of allogeneic blood has risen dramatically making
autologous transfusion more attractive for elective surgery. The aim
of this study was to evaluate the efficacy of acute normovolaemic
haemodilution (ANH) and intraoperative cell salvage (ICS) in
blood-conservation strategies for infrarenal aortic surgery. A multicentre
prospective randomised trial was performed comparing standard transfusion
practice with autologous transfusion combining ANH and ICS in 145 patients
undergoing elective aortic surgery. The primary outcome measures
were the proportion of patients requiring allogeneic blood and the volume
of blood transfused. The secondary outcome measures were the
frequency of complications and duration of hospital stay. The
combination of ANH and ICS reduced the volume of allogeneic blood
transfusion form a median of 2 units to zero. The proportion of
patients transfused was 56% in the allogeneic and 43% in the autologous
groups. There was no significant difference in complications or the
length of hospital stay. It was concluded that ANH and ICS were safe
and reduced the allogeneic blood requirement in patients undergoing
elective infrarenal aortic surgery.
Duration of prophylaxis against venous
thromboembolism with enoxaparin after surgery for cancer. Bergqvist
D, Agnelli G, Cohen A T et al. N Eng J Med 2002;
346: 975-980.
The efficacy of low-molecular-weight heparin (LMWH) in
preventing postoperative venous thromboembolism is well documented, but
the optimal duration of prophylaxis has not been clearly defined.
Prophylaxis is usually limited to the duration of hospitalisation, but the
risk of thromboembolism remains high for several weeks after major
surgery. Several randomised trials have shown that prophylaxis with
LMWH for approximately one month after orthopaedic surgery reduces the
risk of DVT as compared with LMWH given only during the first
postoperative week. The value of this approach in cancer surgery
remains unclear. This study was a double-blind multicentre trial in
patients undergoing planned curative open surgery for abdominal or pelvic
cancer. All patients received enoxaparin 40mg daily subcutaneously
for 6 to 10 days and were then randomly allocated to receive either
enoxaparin or placebo for a further 21 days. Bilateral venography
was performed between 25 or 31 days, or sooner if symptoms of venous
thromboembolism occurred. The primary endpoint with respect to
efficacy was the incidence of venous thromboembolism. The primary
endpoint with respect to safety was bleeding during the three weeks after
randomisation. Patients were followed up for three months. On
an intention-to-treat analysis of the 332 included patients, the rate of
DVT at the end of the double-blind phase was 12% in the placebo group and
5% in the enoxaparin group (p=0.02). This difference persisted at
three months. Three patients in the enoxaparin group and six in the
placebo group died within three months after surgery. There was no
significant difference in the rates of bleeding or other complications
during the follow up period. It was concluded that LMWH prophylaxis
for four weeks after surgery for abdominal or pelvic cancer is safe and
significantly reduces the incidence of venographically demonstrated
thrombosis as compared with treatment for one week.
Immediate repair compared with
surveillance of small abdominal aortic aneurysms. Lederle F A, Wilson S E,
Johnson G R et al. N Eng J Med 2002; 346: 1437-1444.
Annually in the United States, 9000 deaths occur as result
of rupture of an abdominal aortic aneurysm. A further 33,000
patients undergo elective repair of asymptomatic aneurysms to prevent
rupture which result in between 1400 and 2800 perioperative deaths.
Because most aneurysms never rupture, elective repair only needs to be
undertaken when the risk of rupture his high. The strongest known
predictor for rupture is aortic diameter but the optimal diameter at which
to recommend open surgery is unknown. The aim of this study was
compare early open surgery with surveillance in patients with small
abdominal aortic aneurysms. Patients between 50 and 79 years of age
and an aortic diameter of 4.0 to 5.4 cm who did not have high surgical
risk were randomised to undergo immediate open surgical repair or
surveillance by means of ultrasound or CT scanning every six months.
Repair was reserved for those in the surveillance group with an aneurysm
that became symptomatic or enlarged to 5.5 cm. The primary outcome
measure was rate of death from any cause. Mean follow-up was 4.9
years. Overall, 569 patients were randomised to immediate repair and
567 patients to surveillance. By the end of the study period,
aneurysm repair had been performed in 93% of patients in the immediate
group and 62% in the surveillance group. The rate of death was not
significantly different between the two groups. (RR 1.21 95% CI
0.95-1.54). Trends in survival did not favour immediate repair in
any of the prespecified subgroups defined by age or aortic diameter. These
findings were obtained despite a low total operative mortality of 2.7% in
the immediate repair group. It was concluded that survival is not improved
by elective repair of abdominal aortic aneurysms less than 5.5 cm in
diameter, even when operative mortality is low.
Duration of prophylaxis against venous
thromboembolism with enoxaparin after surgery for cancer. Bergqvist
D, Agnelli G, Cohen A T et al. N Eng J Med 2002;
346: 975-980.
The efficacy of Low-Molecular-Weight Heparin (LMWH) in
preventing postoperative venous thromboembolism is well document, but the
optimal duration of prophylaxis after surgery for cancer has not been
clearly defined. Prophylaxis is usually limited to the duration of
hospitalisation but the risk of thromboembolism remains high for several
weeks after major surgery. Several randomised, double-blind trials
have shown that prophylaxis with LMWH for approximately one month after
orthopaedic surgery significantly reduces the frequency of deep-vein
thrombosis as compared with prophylaxis only give for one week. This
paper reports a double-blind multicentre trial in which patients
undergoing planned curative open surgery for abdominal or pelvic cancer
received enoxaparin daily for 6 to 10 days and were then randomly assigned
to either enoxaparin or placebo for a further 21 days. Bilateral
venography was performed between days 25 and 30 or sooner if symptoms of
venous thromboembolism occurred. The primary end-point with respect
to efficacy was the incidence of venous thromboembolism between 25 and 31
days. The primary safety end-point was bleeding during the
three-week period after randomisation. The patients were followed up
for three months. Overall 332 patients were included in the study.
On an intention-to treat analysis, the rates of venous thromboembolism at
the end of the double-blind phase were 12% in the placebo group and 5% in
the enoxaparin group (p=0.02). The significant difference
persisted at three months. Three patients in the enoxaparin group
and six in the placebo group died within three months of surgery.
There was no significant differences in the rates of bleeding or other
complications during the double-blind or follow-up periods. It was
concluded that enoxaparin prophylaxis for four weeks after surgery for
abdominal or pelvic cancer is safe and significantly reduces the incidence
of venographically demonstrated thrombosis as compared with enoxaparin
prophylaxis for one week.
The Multicentre Aneurysm Screening Study
(MASS) into the effect of abdominal aortic aneurysm screening on mortality
in men: a randomised controlled trial. The Multicentre
Aneurysm Screening Study Group. Lancet 2002; 360:
1531-1539.
Ultrasound can reliably visualise the aorta in 99% of
people thus providing the possibility of detection of abdominal aortic
aneurysm (AAA) at a size when rupture is unlikely to occur.
Intervention at this stage could reduce the frequency of rupture and so
reduce mortality. Elective surgery for AAA is however also
associated with a mortality risk of between 2 and 6%. Thus opposing
views have been published on the importance of ultrasound screening for
AAA. The Multicentre Aneurysm Screening Study was designed to asses
whether or not such screening is beneficial. A population-based
sample of men (n=67,800) aged 65-74 years was enrolled and each individual
was randomly allocated to either receive an invitation for an abdominal
ultrasound scan (invited group, n=22,839) or not (control group, n=33,
961). Men in whom a AAA (>3 cm diameter) were detected were followed
up with repeat ultrasound scans for a mean of 4.1 years. Surgery was
considered on specific criteria (diameter >5.5 cm, expansion > 1 cm per
year, symptoms). Mortality data was obtained from the Office of
National Statistics and an intention-to-treat analysis was based on cause
of death. Quality of life was assessed with four standardised
scales. The primary outcome measure was mortality related to AAA.
27,146 of 33,839 (80%) men invited for screening accepted the invitation
and 1333 aneurysms were detected. There were 65 aneurysm-related
deaths (absolute risk 0.19%) in the invited group and 113 (0.33%) in the
control group (risk reduction 42%, 95% CI 22-58; p=0.0002)
with a 53% reduction in those who attended screening. 30-day
mortality was 6% (24 of 414) after elective surgery for AAA and 37% (30 of
81) after emergency surgery. It was concluded that there is reliable
evidence to support screening for AAA.
Randomized clinical trial and economic
analysis of four-layer compression bandaging for venous ulcers.
O'Brien J F, Grace P A, Perry I J et al. Br J Surg
2003; 90: 794-798.
Compression in the form of four-layer bandaging is the
recommended treatment for venous ulceration, but the efficacy of this
therapy remains unclear. Early studies lacked valid controls.
Three-month healing rates of between 69 and 74% have been reported in
patients treated with four-layer bandaging in specialised clinics.
These rates compared with about 20% in patients receiving traditional
care. The aim of this study was to compare the cost-effectiveness of
four-layer bandaging with that of alternative dressings available for
venous ulcers. In a randomised controlled trial, 200 patients with
venous ulceration were randomised to either to four-layer bandaging
(intervention group; n=100) or to continue their usual system of
care (control group; n=100). The follow-up for each patient
was 12 weeks. Analysis was by intention-to-treat. The main
outcome measures were time to healing and cost to the health board per leg
healed. Baseline characteristics were well matched in the two
groups. The Kaplan-Meier estimate of the healing rate at 3 months
was 54% with four-layer compression bandaging and 34% in the control
group. Throughout the 3 months, four-layer bandaging healed leg
ulcers significantly earlier (p=0.006). There was a
significant reduction in the median cost per leg healed with four-layer
bandaging. It was concluded that four-layer bandaging is currently
the most effective method of treating venous leg ulcers in a community
setting.
Prevention of disabling and fatal
strokes by successful carotid endarterectomy in patients without recent
neurological symptoms: randomised controlled trial. MRC
Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group.
Lancet 2004; 363: 1491-1502.
Patients with substantial carotid artery narrowing are at
increased risk of suffering a disabling or fatal ischaemic stroke.
The hazard i greater if they are already symptomatic. In those
patients without recent neurological symptoms, the balance of surgical
risks and long-term benefits from carotid endarterectomy (CEA) are
unclear. Between 1993 and 2003, 3120 asymptomatic patients with
substantial carotid narrowing (60-99%) were randomised equally between
immediate CEA (50% got CEA by one month and 88% by one year) and
indefinite deferral of CEA (only 4% per year got CEA) and were followed up
for 5 years. Kaplan-Meier analyses of 5-year risks were performed by
allocated treatment. The risk of stroke within 30 days of CEA was
3.1% (95% CI 2.3-4.1). Comparing all patients allocated immediate
CEA versus all allocated deferral, but excluding such perioperative
events, the 5-year stroke rate was 3.8 vs. 11% (gain 7.2%. 95% CI
5.0-9.4). The gain chiefly involved carotid territory ischaemic
strokes of which half were disabling or fatal. Combining the
perioperative events and the non-perioperative strokes, the net 5-year
risks were 6.4% vs. 11.8% for all strokes (gain 5.4%. 95% CI
3.0-7.8). Subgroup-specific analyses found no significant
heterogeneity in the perioperative hazards or in the long-term
postoperative benefits. It was concluded that in asymptomatic
patients younger then 75 years of age with carotid diameter reduction
about 70% or more on ultrasound (many of whom were on asprin,
antihypertensives and in recent years, statin therapy) immediate CEA
halved the net 5-year stroke risk form about 12% to 6% (including the 3%
perioperative hazard). Half this 5-year benefit involved disabling
or fatal strokes. Outside clinical trials, inappropriate selection
of patients or poor surgery could obviate such benefits.
Randomised clinical trial of distal
anastomotic interposition vein cuff in infrainguinal
polytetrafluoroethylene bypass grafting. Griffiths G D, Nagy
J, Black D et al. Br J Surg 2004; 91:
560-562.
An interposition vein cuff (Miller cuff) may be used to
augment the distal anastomosis of a prosthetic infrainguinal bypass.
The aim of this study was to examine the effect of a Miller cuff at the
distal anastomosis on the medium to long-term patency and limb salvage
rates of femoral to above-knee and femoral to below-knee popliteal artery
polytetrafluoroethylene (PTFE) bypasses. Outcome measures were
bypass graft patency and limb salvage. Overall, 261 bypass
operations were randomised. Full data was available on 235 patients
(120 with a Miller Cuff, 115 without). The cumulative 5-year patency
rate for above-knee bypasses with a Miller cuff was 40%, compared with 42%
for non-cuffed bypasses (p=0.702). The cumulative 3-year
patency rate for below knee bypasses with a Miller cuff was 45%, compared
with 19% for non-cuffed bypasses (p=0.018). A Miller cuff had
no significant effect on limb salvage for above-knee or below-knee
bypasses. It was concluded that 3-year patency rates of femoral to
below-knee popliteal PTFE bypasses were improved with a Miller cuff.
Miller cuffs had no effect on patency rates for femoral to above-knee
popliteal bypasses at 5 years and did not improve limb salvage in either
group.
Comparison of surgery and compression
with compression alone in chronic venous ulceration (ESCHAR study):
randomised controlled trial. Barwell J R, Davies C E,
Deacon J et al. Lancet 2004; 363: 1854-1859.
Chronic venous ulceration affects 1-2% of the population
and usually has a protracted course of healing and often recurs many
times. The disorder accounts for about 1% of the total health costs
of developed countries. It can be managed by compression therapy,
elevation of the leg and exercise. The addition of ablative
superficial venous surgery to this strategy has not been shown to affect
ulcer healing. The aim of this study was to assess healing and
recurrence rates after treatment with compression with and without surgery
in patients with leg ulceration. Venous duplex imaging of ulcerated
or recently healed legs was obtained in 500 consecutive patients from
three centres. Patients with isolated superficial venous reflux and
mixed superficial and deep reflux were randomly allocated to either
compression treatment alone or in combination with superficial venous
surgery. Compression consisted of multilayer compression bandaging
every week until ulcer healing then class 2 below knee stockings.
Primary endpoints were 24-week healing rates and 12-month recurrence
rates. Analysis was on an intention to treat basis. Overall,
40 patients were lost to follow up and were censored. The 24-week
healing rates were similar in the compression and surgery and compression
alone groups (65% vs. 65%, HR = 0.84. 95% CI 0.77 to 1.24.
p = 0.85). However, the 12-month recurrence rates were
significantly reduced in the compression plus surgery group (12% vs.
28%. HR = -2.76. 95% CI -1.78 to -4.27. p <
0.0001). Adverse events were minimal and about equal in each group.
It was concluded that surgical correction of superficial venous reflux
reduces 12-month ulcer recurrence. Most patients with chronic venous
ulceration will benefit from the addition of simple venous surgery.
Randomized clinical trial of low
molecular weight heparin with thigh-length or knee-length antiembolism
stockings for patients undergoing surgery. Howard A,
Zaccagnini D, Ellis M et al. Br J Surg 2004; 91:
842-847.
Currently the most appropriate means of preventing deep
vein thrombosis (DVT) in surgical patients are subcutaneous heparin and
antiembolism stockings, which offer increased benefit when used in
combination. Other pharmacological and physical prophylactic
measures exist but are less effective, less safe or impractical. The
aim of this study was to determine the optimal length of stocking for use
in a safe single 'blanket' protocol to prevent postoperative DVT for all
patients undergoing any surgical procedure. Of 426 patients
interviewed, 376 agreed to be randomised to receive one of three types of
antiembolism stockings. Two were thigh-length and one was a
knee-length stocking. All patients received low molecular weight
heparin (LMWH) thromboprophylaxis. Duplex ultrasonography was used
to assess the incidence of postoperative DVT. No postoperative DVT
occurred in 85 patients at low or moderate risk. Nineteen DVTs
occurred, all in the 291 high-risk patients. Eight DVTs occurred in
those with thigh-length stockings and 11 with knee-length stockings.
No patients developed a pulmonary embolus. The different stocking
groups were similar for age, sex, thromboembolic risk, type of operation
and compliance. One significant bleeding complication occurred.
It was concluded that a single protocol comprising LMWH and thigh-length
stockings abolished DVT in low and moderate-risk patients and reduced the
rate of DVT to 2% in high risk patients.
Endovascular aortic aneurysm repair in
the octogenarian. Minor M E, Ellozy S, Carroccio A et
al. Arch Surg 2004; 139: 308-314.
During the past decade, endovascular stent graft repair
(EVSG) of abdominal aortic aneurysms has emerged as a less invasive and
less morbid alternative yo open surgical repair. This study looked
at whether EVSG may become the treatment of choice among patients older
then 80 years old. The study was a retrospective case series in am
major academic medical centre with extensive experience in endovascular
and open aortic aneurysm surgery. During a 5-year period, EVSG was
performed in 595 patients at this institution. Amongst this group
150 (25%) were older than 80 years. A prospectively acquired
database was reviewed with respect to demographic, intraoperative and
outcome data of this elderly population. The main outcome measures
were technical and clinical success, aneurysm-related events
(aneurysm-related death, type I or type III endoleaks, aneurysm expansion
or aneurysm rupture) and secondary interventions. There were 119 men
(79%) and 32 women (21%). The mean age was 85 years. Mean
aneurysm diameter was 6.7 cm. Comorbidities including chronic
obstructive pulmonary disease, coronary artery disease, chronic renal
insufficiency, peripheral vascular disease, hypertension and
hypercholesterolaemia were common with an average of 2.9 comorbid
conditions in each patient. Mean follow-up was 17 months.
Overall, 146 patients (97%) received only regional anaesthesia and the
average intraoperative blood loss was 370ml. Average hospital stay
was 2.5 days. There were 5 aborted procedures and 4 conversions to
open aortic repair (2.6%). In addition these aborted procedures
there were 2 additional technical failures resulting ain a technical
success rate of 95%. Endoleaks were common including 9 type I, 35
type II and 1 type III. The majority resolved either spontaneously
or with minimally invasive secondary intervention. There were 5
perioperative deaths (3%). Forty late deaths occurred which were
unrelated to the EVSG procedure. It was concluded that EVSG repair
of abdominal aortic aneurysms can be performed safely and successfully in
the majority of octogenarians with relatively low complications rates.
Improved EVSG devices and operator experience may make this procedure the
treatment method of choice for patients in this age group who meet
specific anatomical criteria.
Randomised clinical trial of
intraoperative autotransfusion in surgery for abdominal aortic aneurysm.
Mercer K G, Spark J I, Berridge D C et al. Br J Surg
2004; 91: 1443-1448.
Over 3500 patients undergo elective repair of an abdominal
aortic aneurysm (AAA) each year in the United Kingdom. An average
blood transfusion requirement of 3.5 units amounts to a demand for more
than 12 000 units of blood per annum for these elective procedures.
Homologous blood transfusion (HBT) is associated with a risk of
transfusion reaction, disease transmission and metabolic changes relating
to the composition of stored blood. It has also been suggested that
HBT may impair immunological function. Intraoperative autologous
transfusion (IAT) is a method for blood conservation that has been shown
to be effective in reducing the requirement for blood transfusion.
The aim of this study was to investigate the benefits of IAT in reducing
the incidence of systemic inflammatory response syndrome (SIRS) in a
prospective randomised clinical trial using requirement for HBT and
postoperative infection as secondary outcome measures. Overall, 40
patients were randomised to IAT and 41 underwent surgery with HBT only.
Patients in both groups received HBT to maintain a haemoglobin level above
8 g/dl. Transfusion requirements and incidence of SIRS and infection
were compared. Significantly fewer patients in the IAT group
required HBT (21 vs. 31; p=0.038) and the median blood
requirement per patient was 2 units lower (p=0.012). There
was a higher incidence of chest infection (12 vs.4 patients; p=0.049)
and SIRS (20 vs. 9 patients; p=0.020) in the HBT group. Risk
of SIRS was related to aortic cross-clamp time in the IAT group only.
It was concluded that use of autotransfusion reduced the need for HBT and
was associated with a reduced incidence of postoperative SIRS and
infective complications in patients undergoing elective AAA surgery.
A randomized trial comparing
conventional and endovascular repair of abdominal aortic aneurysm.
Prinssen M, Verhoeven E L G, Buth J et al. N Engl J
Med 2004; 351: 1607-1618
Elective surgical repair is indicated in patients with a
large abdominal aortic aneurysm. The threshold for surgery is still
a subject of debate but varies between 5.0 and 5.5 cm in diameter.
Endovascular repair is a less invasive alternative to conventional open
repair and as a result has been used in patients for whom open repair
poses a high risk. Although the initial results of endovascular
repair of abdominal aortic aneurysm were promising, current evidence from
controlled studies does not convincingly show a reduction in 30-day
mortality relative to that achieved with open repair. The aim of
this study was to perform multicentre, randomised trial comparing open and
endovascular abdominal aortic aneurysm repair. Overall, 345 patients
with an aortic aneurysm less than 5cm in diameter and considered fit for
either open or endovascular repair, were recruited. The outcome events
analysed were operative (30-day) mortality and two composite endpoints of
operative mortality and severe complications and operative mortality and
moderate or severe complications. The operative mortality rate was
4.6% in the open-repair group (8 of 174, 95% CI 2.0-8.9%) and 1.2% in the
endovascular-repair group (2 0f 171, 95%CI 0.1-4.2%) resulting in risk
ratio of 3.9 (95% CI 0.9-32.9). The combined rate of operative
mortality and severe complications was 9.8% in the open-repair and 4.7% in
the endovascular group resulting in risk ratio of 2.1. It was
concluded that on the basis of the overall results of this trial,
endovascular repair is preferable to open repair in patients who have an
abdominal aortic aneurysm that is at least 5 cm in diameter.
Long-term follow-up is needed to determine whether the advantage is
sustained.
Protected carotid artery stenting versus
endarterectomy in high-risk patients. Yadav J S, Wholey M H,
Kuntz R E et al. N Engl J Med 2004; 351:
1493-1501.
Several trials have shown carotid endarterectomy to be
superior to medical management for the prevention of stroke in patients
with symptomatic and asymptomatic carotid-artery stenosis. During
the past decade carotid angioplasty with stenting has been used to treat
patients at high surgical risk but its use has been limited by the risks
of compression of the stent and embolisation of plaque debris.
Nickel-titanium crush resistant stents and emboli-protection devices have
been developed to address these problems. This study was a
randomised trial comparing carotid artery stenting with the use of an
emboli-protection device to endarterectomy in 334 patients with coexisting
conditions that potentially increased the risk posed by endarterectomy and
who had either a symptomatic carotid artery stenosis of at least 50% of
the luminal diameter or an asymptomatic stenosis of at least 80%.
The primary endpoint of the study was the cumulative incidence of a major
cardiovascular event at one year - a composite of death, stroke or
myocardial infraction within 30 days after the intervention or death or
ipsilateral stroke between 31 days and one year. The study was
designed to test the hypothesis that the less invasive strategy, stenting,
was not inferior to endarterectomy. The primary end point occurred
in 20 patients randomly assigned to undergo carotid artery stenting
(cumulative incidence 12.2%) and in 32 patients assigned to undergo
endarterectomy (cumulative incidence 20.1%; p=0.004). At the on
year, carotid revascularisation was repeated in fewer patients who had
received stents than in those who had undergone endarterectomy (0.6% vs.
4.3%; p=0.04). It was concluded that among patients with
severe carotid artery stenosis and coexisting conditions, carotid stenting
with the use of an emboli-protection devise is not inferior to carotid
endarterectomy.
Randomised clinical trial of four-layer
and short-stretch compression bandages for venous leg ulcers. Nelson
E A, Iglesias C P, Cullum N et al. Br J Surg 2004;
91: 1292-1299.
Leg ulceration affects 15-18 per 1000 adults in developed
countries and is associated with pain and a lower quality of life.
The majority of leg ulcers are secondary to venous insufficiency and it
has been estimated that the management of venous ulcers in the UK costs
£100-300 million per year. Systematic reviews have found that
compression therapy heals more ulcers than dressings alone and that
high-level compression systems are more effective than low compression
systems. The aim of this study was to determine the relative
effectiveness of four layer and short-stretch bandaging for venous
ulceration. A total of 387 adults with venous ulcers, who were
receiving leg ulcer treatment either in primary care or as a hospital
patient were recruited to this parallel group open study and were
randomised to either four-layer or short-stretch bandages. Follow-up
continued until the patient's reference leg was ulcer free or for a
minimum of 12 months. The primary endpoint was time to complete
healing of all ulcers on the reference leg. Secondary outcomes
included proportion of ulcers healed, health-related quality of life,
withdrawals and adverse events. Analysis was by intention to treat.
Unadjusted analysis identified no statistically significant difference in
median time to healing: 92 days for four-layer compression and 126
days for short-stretch bandages, However, when prognostic factors
were included in a Cox proportional hazard regression model, ulcers
treated with short-stretch bandage had a lower probability of healing than
those treated with four-layer bandage (HR 0.72; 95% CI 0.57-0.91).
More adverse events and withdrawals were reported with the short-stretch
bandage. It was concluded that venous leg ulcers treated with a
four-layer bandage healed more quickly than those treated with a
short-stretch bandage.
Critical appraisal of femorofemoral
crossover grafts. Pursell R, Sideso E, Magee T R et
al. Br J Surg 2005; 92: 565-569.
Femorofemoral crossover grafts have gained popularity for
unilateral iliac artery occlusion. It can also be used following
aorto uni-iliac endovascular abdominal aortic aneurysm repair. The
operation is generally well tolerated with low 30-day morbidity and
mortality rates. However, long-term patency of femorofemoral
crossover grafts is lower than that of aortofemoral bypass grafts and is
similar to that of iliofemoral bypass grafts. Success of any bypass
graft is based on patency, limb salvage and long-term survival. An
ideal result is further defined by an uncomplicated operation with primary
wound healing, relief of symptoms without recurrence and no need for
further intervention. The aim of this study was to determine how
often femorofemoral crossover grafting for critical limb ischaemia or
intermittent claudication give an ideal result. All patients
undergoing primary femorofemoral crossover grafting between January 1988
and December 2003 were studied. Some 144 operations were analysed.
Overall, 51 patients had critical ischaemia and 93 patients had
claudication. There was one postoperative death (0.7%).
Complications occurred within 30 days in 32 patients (22%) including graft
occlusion in three (2%). Six patients (4%) required early
reoperation. Primary patency for patients with critical ischaemia
was 88, 82 and 74% at one , 3 and 5 years respectively. Respective
figures for those who presented with claudication were 92, 92 and 90%.
Late symptoms included graft occlusion (20 patients), disease progression
(25 patients), ongoing ulceration (6 patients), graft infection (9
patients), false aneurysm formation (2 patients) and late donor site
stenosis (2 patients). It was concluded that when obtaining informed
consent, simply describing patency and limb salvage rates does not provide
an accurate picture of the outcome of femorofemoral grafting.
Randomized clinical trial of routine
preoperative duplex imaging before varicose vein surgery. Blomgren
L, Johansson G, Bergqvist D. Br J Surg 2006;
92: 688-694
Surgery for varicose veins is associated with high
recurrence rates and frequent reoperations, even when performed by
experienced surgeons. Residual varices, progression of disease and
neovascularisation are all causes that have been discussed in recent
studies. Another important and potentially preventable factor is
inaccurate preoperative diagnosis with respect to the source of the venous
hypertension. Duplex imaging is used increasingly for the
preoperative evaluation of varicose veins, but its value in terms of
long-term results of surgery is unclear. Patients with primary
varicose veins were randomised to operation with or without preoperative
duplex imaging. Reoperation rates, clinical and duplex findings were
compared at 2 months and 2 years after surgery. Overall, 293
patients (343 legs) had varicose vein surgery after duplex imaging (Group
1, n=166 legs) or no imaging (Group 2, n=177 legs). In 44 legs (27%)
duplex imaging suggested a different surgical procedure than had been
considered on clinical grounds. The procedure was changed
accordingly for 29 legs. At 2 months, incompetence was detected at
the saphenofemoral or sapheno-popliteal junction (or both) in 14 legs (9%)
in Group 1 and 44 legs (26%) in Group 2 (p<0.001). At 2
years, two legs (1.4%) had undergone or were awaiting reoperation in Group
1 and 14 legs (9.5%) in Group 2 (p=0.002). In the remainder,
major incompetence was found in 19 legs (15%) in Group 1 and 53 (41%) in
Group 2 (p<0.001). It was conclude that routine preoperative
duplex examination led to improvement in results 2 years after surgery for
patients with primary varicose veins.
Randomized clinical trial of the effects
of methylprednisolone on renal function after major vascular surgery.
Turner S, Derham C, Orsi N M et al. Br J Surg
2008; 95: 50-56.
Up to 25% of patients with abdominal aortic aneurysm (AAA)
have chronic renal failure and those who undergo elective repair have a
risk of acute renal failure. Vascular surgical patients are
particularly venerable to excess morbidity and mortality from
postoperative increases in serum creatinine concentrations.
Perioperative renal dysfunction following AAA repair is multifactorial and
may involve hypotension, hypoxia and ischaemia-reperfusion injury.
Studies of hepatic and cardiac transplant patients have demonstrated
beneficial effects on renal function of high-dose methylprednisolone
administered before surgery. The aim of this study was to test the
hypothesis that in the setting of elective open AAA repair,
methylprednisolone give before the onset of ischaemia and subsequent
reperfusion might attenuate sub-clinical renal dysfunction. Twenty
patients undergoing elective open AAA repair were randomised to receive
either methylprednisolone 10mg/kg or dextrose before induction of
anaesthesia. Blood was analysed for a panel of cytokine
representatives of T helper type 1 and 2 subsets. Data was analysed
from 18 patients. Both groups demonstrated glomerular and proximal
tubular dysfunction that was unaffected by steroid treatment.
Steroid administration increased serum levels of urea and creatinine (both
p<0.001). The steroid group had increased levels of
interleukin 10 levels (p=0.005). There was no difference
between groups in overall surgical complications, length of ICU stay, or
30-day mortality. It was concluded that methylprednisolone alter the
cytokine profile favourably but adversely affected postoperative renal
function
Randomized clinical trial comparing
endovenous laser ablation with surgery for the treatment of primary great
saphenous varicose veins. Darwood R J, Theivacumar N,
Dellagrammaticas D et al. Br J Surg 2008; 95:
294-301.
Varicose veins affect up to 32% of women and 40% of men.
The majority are due to saphenofemoral and great saphenous vein (GSV)
incompetence. Conventional surgery involves saphenofemoral ligation,
GSV stripping and phlebectomy of residual varicosities. This is
usually performed as a day case procedure under general anaesthesia.
Recently, minimally invasive endovenous techniques have been developed as
alternatives to conventional surgery. The potential advantages of
these include a reduction in postoperative morbidity and a shorter
recovery period. Endovenous laser ablation (EVLA) is usually
performed on an outpatient basis using local anaesthesia ad results
in thermal ablation of the GSV. Although previous series report GSV
occlusion rates of 95-98% with EVLA only one randomised clinical trial has
compared the outcome with surgery. The aim of this study was to
compare EVLA with surgery for the treatment of varicose veins associated
with saphenofemoral and GSV incompetence. Consecutive patients with
symptomatic varicose veins were randomised to EVLA or surgery.
Principle outcome measures were abolition of GSV reflux and improvement in
Aberdeen Varicose Vein Symptom Score (AVVSS) 3 months after treatment.
GSV was abolished in 41 of 42 legs treated with EVLA and 28 of 32 after
surgery (p=0.227). The median AVVSS improvements were similar
between the two groups. Return to normal activity was quicker after
EVLA. It was concluded that abolition of reflux and improvement in
disease-specific quality of life was comparable following both EVLA and
surgery. The earlier return to normal activity following EVLA may
confer important socioeconomic advantages.
Long-term results of carotid stenting versus
endarterectomy in high-risk patients. Gurm H S, Yadav J S,
Fayad P F et al. N Engl J Med 2008; 358:
1572-1579.
There is a direct relationship between the degree of
carotid artery stenosis and the risk of ipsilateral stroke. Carotid
revascularisation by means of carotid endarterectomy has proved highly
successful in reducing the incidence of stroke among patients with
moderate to severe symptomatic carotid stenosis, as well as those with
severe asymptomatic carotid stenosis. Although carotid
endarterectomy has been considered the gold standard for the treatment of
carotid stenosis, carotid artery stenting has emerged as emerged as an
alternative treatment for this common disorder. The Stenting and
Angioplasty with Protection in Patients at High Risk for Endarterectomy
(SAPPHIRE) study randomised high surgical risk patients to undergo
protected carotid arterial stenting or endarterectomy.
Early results showed that stenting was not inferior to surgery. This
paper publishes the 3 year follow-up results. The trial evaluated
carotid artery stenting with the use of an emboli-protection devise as
compared endarterectomy in 334 patients at increased risk for
complications from endarterectomy who had either symptomatic stenosis of
at lease 50% of the luminal diameter or an asymptomatic stenosis of at
lease 80%. The prespecified major secondary endpoint at 3 years was
a composite of death, stroke, or myocardial infarction within 30 days of
the procedure or death or ipsilateral stroke between 31 days and 3 years.
At 3 years data was available for 260 patients (78%) including 85% of
patients in the stenting groups and 70% of those in the endarterectomy
group. The prespecified secondary endpoint occurred in 41 patients
in the stenting group (cumulative incidence 24%, Kaplan-Meier estimate
26%) and 45 patients in the endarterectomy group (cumulative incidence
27%, Kaplan-Meier estimate 30%). The absolute difference in the
cumulative incidence for stenting was -2.3% (95% CI -11.8 to 7.0).
There were 15 strokes in each group. It was concluded that in
patients with severe carotid stenosis and increased surgical risk, there
was no difference in long-term outcome between patients undergoing carotid
artery stenting and those undergoing endarterectomy
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