Showing papers by "Andrew W. Bradbury published in 2000"

ABC of arterial and venous disease: Acute limb ischaemia.

Abstract: Limb ischaemia is classified on the basis of onset and severity. Complete acute ischaemia will lead to extensive tissue necrosis within six hours unless the limb is surgicallyrevascularised. Incomplete acute ischaemia can usually be treated medically in the first instance. Patients with irreversible ischaemia require urgent amputation unless it is tooextensive or the patient too ill to survive. View this table: Classification of limb ischaemia Apart from paralysis (inability to wiggle toes or fingers) and anaesthesia (loss of light touch over the dorsum of the foot or hand), the symptoms and signs of acute ischaemia are non-specific or inconsistently related to its completeness. Pain on squeezing the calf indicates muscle infarction and impending irreversible ischaemia. View this table: Symptoms and signs of acute limb ischaemia Acute arterial occlusion is associated with intense spasm in the distal arterial tree, and initially the limb will appear “marble” white. Over the next few hours, the spasm relaxes and the skin fills with deoxygenated blood leading to mottling that is light blue or purple, has a fine reticular pattern, and blanches on pressure. At this stage the limb is still salvageable. However, as ischaemia progresses, stagnant blood coagulates leading to mottling that is darker in colour, coarser in pattern, and does not blanch. Finally, large patches of fixed staining progress to blistering and liquefaction. Attempts to revascularise such a limb are futile and will lead to life threatening reperfusion injury. In cases of real doubt the muscle can be examined at surgery through a small fasciotomy incision. It is usually obvious when the muscle is dead. Marble white foot (left of picture) in patient with acute ischaemia View this table: Differentiation of embolus and acute arterial thrombosis (thrombosis in situ) Acute limb ischaemia is most commonly caused by acute thrombotic occlusion of a pre-existing stenotic arterial segment (60% of cases) or by embolus …

Infrainguinal bypass grafting for critical ischaemia in the hands of trainees

Abstract: Background: Changes in surgical training mean that operative experience must be gained more efficiently However, it is important to demonstrate that increasing training opportunities are not associated with inferior patient outcome The immediate and long-term outcomes of patients undergoing infrainguinal bypass surgery by consultants and trainees were compared Methods: A prospectively gathered database of 1077 infrainguinal bypasses performed on 1003 patients for chronic critical limb ischaemia between 1 January 1983 and 31 December 1998 in a single regional vascular unit was evaluated Results: Consultants performed 733 operations (68·1 per cent), 347 (47·3 per cent) above-knee, 257 (35·1 per cent) below-knee popliteal, 121 (16·5 per cent) crural and eight (1·1 per cent) other procedures Of 344 trainee operations, 170 (49·4 per cent) were above-knee, 122 (35·5 per cent) below-knee, 48 (14·0 per cent) crural and four (1·2 per cent) other operations There was no significant difference in 30-day mortality rate between consultant (2·8 per cent) and trainee (2·0 per cent) operations, nor was there any significant difference in patency or limb salvage rates at 36 months (Table) There was a trend towards reduced graft patency in trainee crural bypasses but this was not statistically significant (35·9 versus 56·2 per cent; P = 0·14, log rank test) Synthetic Synthetic + vein cuff Vein Consultant 3-year patency (%) 50·0 (n = 234) 54 (n = 83) 64·9 (n = 416) Limb salvage (%) 68·2 (n = 234) 73 (n = 83) 78·3 (n = 416) Trainee 3-year patency (%) 59·1 (n = 105) 42 (n = 55) 67·7 (n = 184) Limb salvage (%) 3·8 (n = 105) 59 (n = 55) 82·7 (n = 184) Conclusion: These data suggest that, with appropriate case selection and supervision, training in femoropopliteal and crural bypass grafting does not compromise early or long-term outcome © 2000 British Journal of Surgery Society Ltd

‘Kissing stent’ insertion is not safe or durable

Abstract: Background: The morbidity, and clinical and haemodynamic outcome of kissing stent insertion was assessed. Methods: A prospectively gathered database of endovascular procedures performed between 1 January 1993 and 31 December 1998 was analysed. Results: Bilateral kissing stents were deployed in 12 patients (median age 62 (range 43–67) years; five men and seven women). Indications were bilateral intermittent claudication (IC) in nine patients, unilateral IC with contralateral rest pain in two and bilateral rest pain/tissue loss in one. Major morbidity occurred in three patients and comprised bilateral distal iliac dissection (treated medically), distal embolization (thrombolysis and suction aspiration) and false aneurysm (surgical repair). All patients reported an immediate improvement in symptoms. However, at a median (range) follow-up of 27 (3–70) months, symptoms have deteriorated in 13 legs, the ankle: brachial pressure index has fallen by more than 0·15 (with respect to values immediately after the procedure) in 15 legs, six stents have occluded (bilaterally in two patients, unilaterally in two) and four stents have stenosed significantly (greater than 50 per cent). Four patients have undergone aortobifemoral grafting and one further patient has undergone bilateral amputation following failed revascularization necessitated by stent thrombosis. Conclusion: In contrast to the single previously published series of 20 patients which found the technique to be ‘effective’ with ‘few serious adverse events’, present data suggest that kissing stents are associated with significant morbidity and a poor outcome. © 2000 British Journal of Surgery Society Ltd

Relationship between lower limb symptoms and patterns of deep and superficial venous reflux on duplex ultrasonography

Abstract: Background: There are inconsistent and sex-dependent relationships between lower limb symptoms and the presence and severity of trunk varicose veins on clinical examination. The relationship between lower limb symptoms and patterns of venous reflux on duplex ultrasonography were investigated. Methods: This was a cross-sectional study of an age-stratified random sample of 1566 subjects (699 men and 867 women) aged 18–64 years selected from 12 family practices. Subjects completed a self-administered questionnaire regarding symptoms (heaviness/tension, a feeling of swelling, aching, restless legs, cramps, itching, tingling) and underwent duplex ultrasonographic examination of both legs. Reflux greater than 0·5 s was considered pathological. Results: Isolated superficial reflux was significantly related to the presence of heaviness/tension (P < 0·025, both legs) and itching (P = 0·002, left leg only) in women. Isolated deep venous reflux was not significantly related to any symptom in either leg in either sex. Combined superficial and deep reflux was related to a feeling of swelling (P = 0·02, both legs), cramps (P < 0·005, left leg only) and itching (P < 0·005, left leg only) in men, and aching (P = 0·03, right leg only) and cramps (P = 0·026, left leg only) in women. Conclusion: Duplex ultrasonography may be superior to clinical examination alone in identifying patients whose lower limb symptoms are truly of venous origin and thus most likely to benefit from surgery. © 2000 British Journal of Surgery Society Ltd

Exercise in claudicants is associated with systemic fibrinolysis

Abstract: Background: Claudicants have been shown to mount a potentially harmful systemic inflammatory response to exercise, characterized by vascular endothelial activation and thrombin generation. However, the fibrinolytic response to exercise remains unknown. This study aimed to determine the nature of the fibrinolytic response to exercise in claudicants and normal controls. Methods: Peripheral venous blood was drawn from 18 claudicants and eight age- and sex-matched controls before, immediately and 1, 5, 10, 20, 40 and 60 min after treadmill exercise (Gardner protocol). Claudicants exercised to the point of maximal ischaemic pain and controls to the point of fatigue. Plasma tissue plasminogen activator (tPA) activity and plasminogen activator inhibitor (PAI) 1 activity were measured by ‘Coaset’ PAI and ‘Coatest’ tPA assays (Chromogenix, Sweden). Results: There was no significant difference in tPA or PAI-1 activity between the groups at baseline. tPA activity increased significantly immediately after exercise in all claudicants (median (interquartile range) 2·8 (1·6–4·0) versus 5·6 (3·5–7·7) units ml−1; P = 0·003, Wilcoxon test) and remained significantly raised for 10 min. This was accompanied by an immediate significant fall in PAI-1 activity (8·5 (4·3–12·7) versus 8·3 (5·0–11·6) units ml−1; P = 0·04) which normalized by 10 min. Neither tPA activity or PAI-1 levels changed significantly in the control group. Conclusion: These data indicate that exercise in claudicants is associated with systemic fibrinolysis. The immediacy and short-lived nature of the response suggests that it occurs as a consequence of muscle ischaemia rather than reperfusion. © 2000 British Journal of Surgery Society Ltd

Prevalence and treatment of hypercholesterolaemia in patients with peripheral vascular disease

Abstract: Background: Hypercholesterolaemia is a recognized risk factor for the development of arteriosclerosis There is compelling evidence to support the use of lipid-lowering strategies in all hypercholesterolaemic patients with arteriosclerotic disease In peripheral arterial disease (PAD), national guidelines recommend treatment if total cholesterol exceeds 5·0 mmol l−1 The prevalence of hypercholesterolaemia in patients with PAD was determined and the adequacy of lipid management before vascular referral was examined Methods: This was a prospective study of 233 consecutive patients admitted electively to this vascular surgery unit between December 1997 and December 1998 Some 68 patients were admitted with carotid disease, 81 with an aneurysm and 84 with intermittent claudication A fasting venous blood sample was obtained from each patient Results: There were 175 men and 58 women, of median age 67 (range 37–85) and 68 (range 47–85) years respectively Only 35 patients (15 per cent) were previously known to be hypercholesterolaemic; all but one were receiving treatment (one dietary, 33 statin) Of the remaining 198 patients, 124 (63 per cent) had a serum cholesterol level above 5·0 mmol l−1 A further 17 patients (9 per cent) had total cholesterol/high-density lipoprotein: cholesterol ratio greater than 5·0; these patients may also benefit from lipid-lowering therapy In total, 141 (80 per cent) of 176 hypercholesterolaemic patients were undiagnosed at the time of hospital admission Conclusion: Hypercholesterolaemia is an important and correctable risk factor found in the majority of patients with PAD, but despite national guidelines and clear evidence from randomized controlled trials it is simply not being diagnosed in primary care All elective patients with PAD should be screened for hypercholesterolaemia during their admission © 2000 British Journal of Surgery Society Ltd