Evidence for Ethylene-Vinyl-Alcohol-Copolymer Liquid Embolic Agent as a Monotherapy in Treatment of Endoleaks.

OBJECTIVE: Endoleak remains the Achilles heel of endovascular aneurysm repair and the exclusion of Type II endoleaks, in particular, remains challenging. This systematic review presents the evidence for ethylene-vinyl-alcohol-copolymer liquid embolic agent as a monotherapy in the treatment of endoleaks. METHODS: A systematic literature search was performed for all studies reporting the use of liquid embolic agent as a sole agent in the treatment of endoleaks. Patient numbers, clinical details (endoleak type, route of delivery) and outcome in terms of survival, technical and clinical success with freedom from endoleak together with follow-up period were examined. RESULTS: Only 12 articles reporting the use of liquid embolic as the sole treatment modality for endoleaks in 174 patients were identified. All but 21 patients had a Type II endoleak. Transarterial embolization was attempted in 73% of patients with 48 patients having direct sac puncture. Technical success was high at 96%, but in patients with adequate imaging, the clinical success rate dropped to 79%. Complications were sparsely reported and follow-up ranged from 0 to 75 months. CONCLUSIONS: This review highlights the lack of data regarding the use of liquid embolic agent as a monotherapy with only 4 studies including more than 10 patients. Data from the largest series suggests a learning curve exists and no study reports on cost effectiveness. Technical success does not always translate into clinical success and with the largest series only reporting median 4-month follow-up no claims regarding durability can be made. In problematic Type II endoleaks, however, liquid embolic agent is a welcome addition to the treatment armamentarium.

Influence of rurality, deprivation and distance from clinic on uptake in men invited for abdominal aortic aneurysm screening.

BACKGROUND: Effective abdominal aortic aneurysm (AAA) screening requires high uptake. The aim was to assess the independent association of screening uptake with rurality, social deprivation, clinic type, distance to clinic and season. METHODS: Screening across Grampian was undertaken by trained nurses in six community and three hospital clinics. Men aged 65 years were invited for screening by post (with 2 further reminders for non-responders). AAA screening data are stored on a national call-recall database. The Scottish postcode directory was used to allocate to all invited men a deprivation index (Scottish Index of Multiple Deprivation), a Scottish urban/rural category and distance to clinic. Multivariable analysis was undertaken. RESULTS: The cohort included 5645 men invited for screening over 12 months (October 2012 to October 2013); 42·6 per cent lived in urban areas, 38·9 per cent in rural areas and 18·5 per cent in small towns (uptake 87·0, 89·3 and 90·8 per cent respectively). Overall uptake was 88·6 per cent with 76 new AAAs detected: 15·2 (95 per cent c.i. 11·8 to 18·6) per 1000 men screened. Aberdeen city (large urban area) had the lowest uptake (86·1 per cent). Uptake declined with increasing deprivation, with the steepest decline in urban areas. On multivariable analysis, a 1-point increase in deprivation deciles was associated with a 0·08 (95 per cent c.i. 0·06 to 0·11) reduction in the odds of being screened (P < 0·001). Clinic type (community versus hospital), distance to clinic and season were not associated independently with uptake. CONCLUSION: Both urban residence and social deprivation were associated independently with uptake among men invited for AAA screening.

Real-world performance of the new C3 Gore Excluder stent-graft: 1-year results from the European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT).

OBJECTIVES: The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) provides "real-world" outcomes for the new C3 Gore Excluder stent-graft, and evaluates the new deployment mechanism. This report presents the 1-year results from 400 patients enrolled in this registry. METHODS: Between August 2010 and December 2012, 400 patients (86.8% male, mean age 73.9 ± 7.8 years) from 13 European sites were enrolled in this registry. Patient demographics, treatment indication, case planning, operative details including repositioning and technical results, and clinical outcome were analyzed. RESULTS: Technical success was achieved in 396/400 (99%) patients. Two patients needed intraoperative open conversion, one for iliac rupture, the second because the stent-graft was pulled down during a cross-over catheterization in an angulated anatomy. Two patients required an unplanned chimney renal stent to treat partial coverage of the left renal artery because of upward displacement of the stent-graft. Graft repositioning occurred in 192/399 (48.1%) patients, most frequently for level readjustment with regard to the renal arteries, and less commonly for contralateral gate reorientation. Final intended position of the stent-graft below the renal arteries was achieved in 96.2% of patients. Thirty-day mortality was two (0.5%) patients. Early reintervention (≤30 days) was required in two (0.5%) patients. Mean follow-up duration was 15.9 ± 8.8 months (range 0-37 months). Late reintervention (>30 days) was required in 26 (6.5%) patients. Estimated freedom from reintervention at 1 year was 95.2% (95% CI 92.3-97%), and at 2 years 91.5% (95% CI 86.8-94.5%). Estimated patient survival at 1 year was 96% (95% CI 93.3-97.6%) and at 2 years 90.6% (95% CI 85.6-93.9%). CONCLUSIONS: Early real-world experience shows that the new C3 delivery system offers advantages in terms of device repositioning resulting in high deployment accuracy. Longer follow-up is required to confirm that this high deployment accuracy results in improved long-term durability.

Systematic review of chimney and periscope grafts for endovascular aneurysm repair.

BACKGROUND: Conventional endovascular aneurysm repair (EVAR) needs a proximal aortic seal zone that is free from aortic branch vessels. The modified application of conventional EVAR devices using adjuvant chimney or periscope grafts is described as a pragmatic alternative to custom-made fenestrated and branched endografts. This systematic review examined the application and outcomes of chimney or periscope grafts for aortic aneurysm. METHODS: A search was performed for all studies of chimney or periscope grafts for EVAR. Clinical details and outcome in terms of technical success, survival, freedom from endoleak and branch vessel patency were examined. RESULTS: Twenty-four studies describing 234 patients who underwent EVAR with one or more chimney or periscope grafts for aortic branch vessels were identified. Most procedures were elective; only 62 (26.5 per cent) were performed urgently. There were 176 patients with an abdominal aortic aneurysm and 58 with a thoracic or thoracoabdominal aortic aneurysm. Three hundred and seventy-six branch vessels were perfused. Twelve patients (5.1 per cent) died within 30 days of aneurysm repair. Twenty-seven patients (11.5 per cent) developed a type I endoleak. After a mean(s.d.) follow-up of 12(5) months, seven branch vessels stents had occluded. CONCLUSION: These highly selected data support the potential value of chimney and periscope graft techniques for patients with challenging aortic aneurysm morphology. There is a lack of medium- and long-term follow-up data.

The Aberdeen varicose vein questionnaire, patient factors and referral for treatment.

OBJECTIVES: It has been suggested that the Aberdeen Varicose Vein Questionnaire (AVVQ) could be used to help inform a patient pathway for referral and treatment of varicose veins. We aimed to determine 1) which patient and vein characteristics affected the AVVQ score, and 2) whether scores differed between those who were and were not offered treatment. METHODS: Patients completed the AVVQ at the clinic prior to being seen. Treatment was offered to patients with symptoms, and duplex detected truncal incompetence by surgeons blinded to the score. RESULTS: A total of 228 consecutive patients completed the AVVQ: 199 were valid questionnaires. On multivariate analysis, factors associated with a worse quality of life were female gender (p = .034, 3.14 mean unit increase in AVVQ), and bilateral varicose veins (10.25 unit increase, p < .001). For patients with C2 disease, only the presence of bilateral veins was significant. Overall, the AVVQ score was higher in those patients offered treatment than in those who were not (mean 20.3 [SD = 9.9] vs. 17.3 [SD = 10.3], p = .023), which equates to a 2.74 unit increase. This was not significant in patients with C2 disease. CONCLUSION: It is unlikely that a threshold AVVQ score could be used to aid referral of patients with C2 disease. The distribution of veins (unilateral vs. bilateral) must be adjusted for when reporting AVVQ scores.

Early outcome of endovascular aneurysm repair in challenging aortic neck morphology based on experience from the GREAT C3 registry.

AIM: The aim of this paper was to evaluate early outcome of the GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System in subjects with aortic neck anatomy outside IFU. METHODS: Individual patient data prospectively collected over a 2 year period from the Global Registry for Endovascular Aortic Treatment (GREAT). For each subject a minimum data set was collected containing demographic, pre/intra- and postoperative variables. Main outcome measures were successful exclusion of the AAA and occurrence of any major endoleak at 1 month. In this study, outside IFU was defined as aortic neck length less than 15 mm and/or aortic neck angle greater than 60 degrees. RESULTS: A total of 400 subjects, (86.6% male, mean age 73.9 years). Primary pathology was AAA in 94.2% with 98.2% undergoing EVAR as a primary procedure. Sixty-eight subjects underwent EVAR outside IFU (neck length <15 mm N.=32, neck angle >60˙N.=47 and neck length <15 mm and angle >60° N.=11). The graft was successfully deployed within 5 mm of its intended location in 63 (94%) cases utilising a total of 33 repositioning episodes. Eight aortic cuffs were used, 5 to treat a type 1 endoleak. At 30 days we recorded 2 type 2 endoleaks both successfully treated and 1 type 1b also successfully treated. There were 2 deaths, one in each group. CONCLUSION: GORE® EXCLUDER® AAA Endoprosthesis featuring C3 Delivery System allows re-positioning to be performed safely in cases outside IFU. Repositioning is an effective operative manoeuvre and facilitates EVAR in challenging anatomy. Longer follow-up is required to evaluate the durability of these results at 30 days.

N-terminal pro-B-type natriuretic peptide is an independent predictor of all-cause mortality and MACE after major vascular surgery in medium-term follow-up.

OBJECTIVE: Recent interest has focussed on the role of biomarkers to predict outcome in patients undergoing major vascular surgery. We wished to determine if pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels could predict all-cause mortality (ACM; primary aim) and major adverse cardiac event (MACE) (secondary aim) in the medium-term follow-up in patients who have undergone elective major vascular surgery. METHOD: Patients who underwent major elective vascular surgery (n = 136) were followed up for up to 2 years. ACM and first MACE episode were identified from the case notes and the patient management system database of the hospital intranet. RESULTS: One patient was lost to follow-up. In the mean follow-up of 654 days, 27 (20%) died and 23 (17%) patients suffered a MACE. Receiver operator curve (ROC) analysis showed that a pre-operative NT-pro-BNP level with a cut-off of 359 pg ml(-1) had a sensitivity and specificity of 73% each (area under the curve (AUC) 80%, p < 0.001) in predicting ACM and sensitivity of 74% and specificity of 71% (AUC 75%, p < 0.001) to detect a MACE. The overall 2-year survival rate was 84%, 93% in the <359 pg ml(-1) group and 68% in the ≥359 pg ml(-1) group (p < 0.001). Following multivariate analysis, pre-operative NT-pro-BNP at a value of ≥359 pg ml(-1) remained an independent predictor of ACM (odds ratio 3.6 (confidence interval (CI): 1.6-8.1), p = 0.002) Postoperative NT-pro-BNP was a predictor of mortality but not a MACE. CONCLUSION: This study has shown that pre-operative NT-pro-BNP is an independent predictor of ACM and MACE on medium-term follow-up.

Introducing endovenous laser therapy ablation to a national health service vascular surgical unit - the Aberdeen experience.

OBJECTIVES: To report early clinical outcomes and learning experience following the introduction of endovenous laser ablation (EVLA) to an NHS vascular unit. DESIGN: Prospective observational study. RESULTS: Between February 2006 and January 2008, 631 consecutive patients underwent EVLA to 704 refluxing truncal veins - 579 GSV, 119 SSV and 6 straight segments of anterior accessory GSV. 275/631 (44%) patients had local anaesthesia (LA) plus sedation, 237 (38%) had LA only and 119 (18%) had general anaesthesia. All were treated using the 810 nm diode laser. Adjuvant procedures on-table included foam sclerotherapy 129/704 (18%), multiple stab avulsions 53/704 (8%) and 3 limbs had both. Three-month follow-up with duplex examination is complete in 635/704 limbs (90%). Complete occlusion was noted in 610 veins (96%), 14 (2.2%) were partially occluded and 11 (1.7%) showed no occlusion. 193 (30%) of the 635 limbs seen at follow-up required further treatment for residual varicosities using foam sclerotherapy. There has been one non-fatal pulmonary embolus associated with EVLA and no other complications. CONCLUSIONS: EVLA is safe and technically effective. It has a defined learning curve requiring new operator skills which can be readily acquired.

Interventions for uncomplicated varicose veins.

OBJECTIVE: To review the evidence regarding interventions (compression, sclerotherapy, surgery and endoluminal) for uncomplicated venous disease. METHOD: A literature search of MEDLINE and EMBASE was performed. In addition, bibliographies of published data and the Cochrane Peripheral Vascular Review Group Specialist Register were examined. Publications describing an intervention for uncomplicated venous disease or trials comparing one intervention against another were considered. RESULTS: Uncomplicated but symptomatic varicose veins are associated with a significant reduction in quality of life (QoL). Evaluation must include a detailed history and examination supported by non-invasive imaging. Although HHD is useful, its utility is limited in the popliteal fossa. It can not provide morphological/anatomical detail when considering an endoluminal treatment option. Regardless of intervention, all treatments considered are associated with a significant improvement in QoL at acceptable cost. CONCLUSION: Uncomplicated symptomatic varicose veins lead to a reduced QoL, which can be significantly improved by all interventions considered.

The role of subintimal angioplasty in the management of arterial disease of the lower limb: the North-East of Scotland experience.

INTRODUCTION: The management of occlusive femoropopliteal disease continues to evolve and a definitive strategy remains to be defined. We examine the utility ofsubintimal angioplasty (SIA) in our institution. METHODS: A retrospective study with predefined end-points, including technical success and primary patency. RESULTS: 61 consecutive cases were identified (claudicants n=29 and critical ischaemia n=32). Sixty-four percent of occlusions were greater than 10 cm with poor run-off (60% with two vessels or less). Technical and physiological success was 95% and 79% respectively, with clinical improvement reported by 72%. At a mean follow-up of 20 months twelve-month primary patency (assessed clinically, with ABPI and selective duplex scanning) was 67% (subgroup analysis: claudicants 83%, criticals 53%, p=0.02) and morbidity 8% with no limb loss or procedure related mortality. CONCLUSION: SIA is an effective procedure for chronic lower limb ischaemia with acceptable outcome. Our experience correlates well with evidence in the current literature.

Platelet activation, myocardial ischemic events and postoperative non-response to aspirin in patients undergoing major vascular surgery.

OBJECTIVES: Myocardial ischemia is the leading cause of postoperative mortality and morbidity in patients undergoing major vascular surgery. Platelets have been implicated in the pathogenesis of acute thrombotic events. We hypothesized that platelet activity is increased following major vascular surgery and that this may predispose patients to myocardial ischemia. METHODS: Platelet function in 136 patients undergoing elective surgery for subcritical limb ischemia or infrarenal abdominal aortic aneurysm repair was assessed by P-selectin expression and fibrinogen binding with and without adenosine diphosphate (ADP) stimulation, and aggregation mediated by thrombin receptor-activating peptide and arachidonic acid (AA). Cardiac troponin-I (cTnI) was performed. RESULTS: P-selectin expression increased from days 1 to 3 after surgery [median increase from baseline on day 3: 53% (range: -28% to 212%, P < 0.01) for unstimulated and 12% (range: -9% to 45%, P < 0.01) for stimulated]. Fibrinogen binding increased in the immediate postoperative period [median increase from baseline: 34% (range: -46% to 155%, P < 0.05)] and decreased on postoperative day 3 (P < 0.05). ADP-stimulated fibrinogen binding increased on day1 (P < 0.05) and thereafter decreased. Platelet aggregation increased on days 1-5 (P < 0.05). Twenty-eight (21%) patients had a postoperative elevation (> 0.1 ng mL(-1)) of cTnI. They had significantly increased AA-stimulated platelet aggregation in the immediate postoperative period and on day 2 (P < 0.05), and non-response to aspirin (48% vs. 26%, P = 0.036). CONCLUSIONS: This study has shown increased platelet activity and the existence of non-response to aspirin following major vascular surgery. Patients with elevated postoperative cTnI had significantly increased AA-mediated platelet aggregation and a higher incidence of non-response to aspirin compared with patients who did not.

Completing the audit cycle: comparison of cardiac risk factor management in patients with intermittent claudication in two time periods.

AIM: The first line treatment of patients with intermittent claudication (IC) is to prolong life via cardiac risk factor management. We aimed to compare current standards of secondary prevention with those in a previously published audit. METHODS: Risk factor data was prospectively collated on 304 consecutive new referrals attending the claudication clinic over a 1-year period (2004/2005) and compared to the 104 patients assessed in 2000. RESULTS: In 2004/5 30%, (n=91) of patients did not have a diagnosis of IC confirmed (p<0.01). The use of antiplatelet therapy remained static at 73%. Statin therapy increased in 2004/5 (62% versus 38%, p<0.01) but blood pressure control remained poor with 65% failing to achieve the target levels. Smoking cessation therapy continues to be offered to a minority of patients and 17% of patients have previously undiagnosed diabetes in 2004/2005 (p-value 0.353). The number of patients who have been advised to increase physical activity significantly has fallen from 15% to 2% in the 2004/5 (p<0.01). CONCLUSIONS: Difficulties exist in diagnosing intermittent claudication in primary care and cardiac risk factor management continues to be sub-optimally managed.

Variability in responsiveness to clopidogrel in patients with intermittent claudication.

OBJECTIVE: The concept of clopidogrel resistance is frequently evoked in the cardiac literature. The variability of antiplatelet response in patients with intermittent claudication has not been investigated. The aim of this study was to describe the effect of the addition of clopidogrel to aspirin using ex vivo measures of platelet activation in patients with life-style limiting intermittent claudication. DESIGN OF STUDY: Data from randomised controlled trial. MATERIALS: Data from 67 patients with intermittent claudication taking part in a randomised controlled trial and who received clopidogrel in addition to aspirin was analysed. METHODS: Platelet activation was measured using whole-blood flow cytometric measurement of ADP-stimulated fibrinogen binding at baseline and 12h after administration of a loading dose of 300 mg clopidogrel. Patients continued to receive 75 mg clopidogrel daily for 30 days and platelet activation was again measured at day 30. Compliance with treatment was assessed by counting returned tablets. RESULTS: Six patients were excluded from analysis because of incomplete compliance with treatment. Six of the sixty-one patients (9.8%) showed no reduction in platelet activation 12h after administration of the loading dose of clopidogrel. At 30 days these six patients still showed no response to clopidogrel. Amongst the remaining 55 patients, the mean reduction in fibrinogen binding after clopidogrel administration was 51.5% (95% CI: 43.8-59.2). Amongst responders there was a wide variability in reduction of fibrinogen binding in response to clopidogrel (range 8.11-97.7%). Four of these patients (6.6%) showed a reduction of more than 95% in fibrinogen binding. CONCLUSIONS: Patients with intermittent claudication show a wide variability in their response to clopidogrel. While a small proportion of these patients shows no response at all, another small group appears to respond excessively to clopidogrel. Clinical studies are required to identify whether hyper-responders are at increased risk of bleeding complications and whether hyporesponders are at a higher risk of thrombotic events.

Is carotid duplex scanning sufficient as the sole investigation prior to carotid endarterectomy?

Carotid endarterectomy (CEA) is the accepted treatment for certain patients who have had, or who are at risk of having, a stroke if they have a significant narrowing of the internal carotid artery. Rapid and accurate classification of the degree of stenosis is important as the benefit of surgery is highly dependent on this. The aim of this study was to assess whether the addition of angiography to duplex scanning resulted in a change in patient management in a unit where duplex scanning was used as the sole imaging investigation prior to CEA. The study population consisted of 64 patients with significant internal carotid artery stenosis on duplex scanning who were suitable for, and wished to be considered for, CEA. All patients underwent an angiogram. In this study 9 (14%) patients did not proceed to surgery on the basis of angiography and in a further 11 (17%) patients insufficient views of the distal vessel were obtained on duplex scanning. Three of these patients had extensive disease which excluded surgery. One patient experienced a transient ischaemic attack (TIA) at the time of angiography. In conclusion, this audit has highlighted the limitations in performing duplex scanning alone, and the costs that this can incur on the patient who may undergo an unnecessary operation. We cannot recommend duplex scanning as the sole investigation prior to CEA. There is need to evaluate the role of additional non-invasive carotid imaging such as magnetic resonance angiography or CT angiography in the assessment of these patients.

Botulinum toxin type B: a new therapy for axillary hyperhidrosis.

UNLABELLED: Primary axillary hyperhidrosis is a disorder affecting mainly adolescents with significant adverse effects on quality of life. No ideal treatment exists, although recent data has demonstrated Botulinum toxin type A (Botox) as a treatment option. However, antibody formation may lead to loss of clinical benefit over time. Botulinum toxin type B (Neurobloc) has recently been introduced and may induce less immunogenic response. OBJECTIVE: To investigate the efficacy of Neurobloc for axillary hyperhidrosis. METHOD: Thirteen patients (22 axillae) were recruited to the study. The hyperhidrotic area was defined using the iodine-starch test then measured and photographed. 5000 MU of Neurobloc was administered subdermally. Patients were reviewed at 4, 8 and 12 weeks to assess outcome objectively (hyperhidrotic area measurements and photographs) and subjectively (sweat production and patient satisfaction). RESULTS: There was a significant reduction in hyperhidrotic area at follow-up compared to baseline. Mean percentage reduction in hyperhidrotic area was 84, 87 and 81% at 4, 8 and 12 weeks (p=0.001, paired t test). Patient satisfaction was 100% throughout. Subjective mean percentage reduction in sweat production was 98, 96 and 90 at 4, 8 and 12 weeks. Side effects were minimal. CONCLUSION: Neurobloc is an effective treatment for axillary hyperhidrosis.

Markers of coagulation activation, endothelial stimulation and inflammation in patients with peripheral arterial disease.

OBJECTIVES: Patients with peripheral arterial disease have a significantly increased risk of cardiovascular and cerebrovascular mortality. Studies have shown that some haemostatic and inflammatory markers are elevated in these patients but the effect of the severity of the disease has not been fully documented. The aim of this study was to assess the level of coagulation activation, endothelial stimulation and inflammation in patients with claudication and critical limb ischaemia (CLI) compared to healthy controls. DESIGN AND METHODS: A prospective observational study was conducted amongst 202 subjects: 132 claudicants, 30 patients with critical ischaemia, and 40 controls. D-dimer (DD) and thrombin-antithrombin III (TAT) levels measured using ELISA as markers of coagulation activation. von Willebrand factor (vWF) and high-sensitivity C-reactive protein (CRP) levels were measured as markers of endothelial and inflammatory stimulation. RESULTS: vWF and CRP levels were significantly higher in patients with intermittent claudication (1.9 U/ml, range 0.78-4.05; p < 0.001; 3.4 mg/l, range 0.15-24; p > 0.001, respectively) and critical ischaemia (2.36 U/ml; range 1.03-5.69; p < 0.001; 7.17 mg/ml, range 0.15-174; p < 0.001, respectively) compared to controls (1.28 U/ml, range 0.62-3.13; 1.04, range 0.15-7.59 mg/l). DD was also significantly higher in claudicants (48.6 microg/ml; range 2-1741; p < 0.001) and in patients with CLI (61.1 microg/ml, range 3.65-1963; p < 0.001) compared to controls (26.1 microg/ml, range 9.65-203.1). TAT levels were significantly higher in CLI (3.14 mg/l, range 2.09-58.11), compared to controls (2.36 mg/l, range 1.49-7.38; p = 0.004). Patients with CLI had significantly higher levels of CRP, vWF, and TAT than claudicants. CONCLUSIONS: Coagulation activation and endothelial stimulation are significantly increased in patients with peripheral arterial disease compared to healthy controls. Coagulation and endothelial activation increases with the severity of the arterial disease.

Randomized clinical trial of the antiplatelet effects of aspirin-clopidogrel combination versus aspirin alone after lower limb angioplasty.

BACKGROUND: There is a high risk of reocclusion after successful lower limb angioplasty. Platelets play a central role in this process. The aim of this study was to investigate the antiplatelet effect of a combination of aspirin and clopidogrel compared with aspirin alone in patients with claudication undergoing endovascular revascularization. METHODS: This was a double-blind randomized placebo-controlled trial. Some 132 patients were randomized to clopidogrel and aspirin or placebo and aspirin, with a loading dose 12 h before endovascular intervention. Flow cytometric measurements of platelet fibrinogen binding and P-selectin expression were taken as measures of platelet function at baseline, 12 h after the loading dose, and 1 h, 24 h and 30 days after intervention. RESULTS: Within 12 h of the loading dose, platelet activation in the clopidogrel group had decreased (P-selectin by 27.3 per cent, P = 0.017; fibrinogen binding by 34.7 per cent, P = 0.024; stimulated fibrinogen binding by 49.2 per cent, P < 0.001). No change was observed in the placebo group. Platelet function in the clopidogrel group was significantly suppressed compared with baseline at 1 h, 24 h and 30 days after endovascular intervention (stimulated fibrinogen binding by 53.9, 51.7 and 57.2 per cent respectively; all P < 0.001). CONCLUSION: A combination of clopidogrel and aspirin inhibited platelet function more than aspirin alone in patients with claudication before and after angioplasty.

An unusual presentation of a rare nerve cell tumour.

We present a rare case of a schwannoma in a pre/para-aortic position resembling a thrombosed saccular abdominal aortic aneurysm.

Management of secondary risk factors in patients with intermittent claudication.

OBJECTIVES: The first line management of patients with intermittent claudication is "best medical therapy" i.e., smoking cessation, exercise, antiplatelet therapy and risk factors modification. The aim of this study was to assess the current management of risk factors in primary care and to compare General Practitioner (GP) attitudes and actual management. DESIGN AND METHODS: Postal questionnaire of all 336 GPs in the referral area (Grampian, Scotland). Questionnaire and measurement of serum cholesterol, blood glucose and HbA1c of new clinic patients (n = 104) with claudication referred by general practitioners. RESULTS: A 73% GP response rate was obtained. Ninety-five percent of GPs would treat risk factors. The vast majority would prescribe aspirin, yet 28% of patients were on no anti-platelet therapy. Eighty-nine percent of GPs would advise an increase in exercise but only 14% of patients recalled being told to do so. One in seven of the GPs would not check serum cholesterol, 18% considered cholesterol lowering therapy to be primary prevention and 41% would only treat levels above 5.5 mmol/l. Eighty-five percent of patients were on a statin or had a cholesterol above 5 mmol/L. Seventy-seven percent of GPs would check glucose levels, and 14% of patients were found to be previously undiagnosed diabetics. CONCLUSIONS: Risk factors in claudicants are suboptimally managed. Urgent guidelines for the specific management of claudicants by general practitioners, as well as strategies to ensure their implementation, are required.

The effect of peripheral percutaneous transluminal angioplasty on quality of life in patients with intermittent claudication.

BACKGROUND AND OBJECTIVE: intermittent claudication is associated with a significant reduction in quality of life. Treatment of claudicants aims to reduce mortality from cardio- and cerebro-vascular events and to improve quality of life. Quality of life assessment should be used to guide and evaluate treatment in this group of patients. Peripheral percutaneous transluminal angioplasty (PTA) is now widely used in the treatment of intermittent claudication. The aim of this review is to examine the effect of PTA on quality of life (QOL) in patients with intermittent claudication. METHODS: a review was conducted of prospective clinical trials assessing the effect of peripheral PTA on QOL. Publications were retrieved by searching Medline and PreMedline, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of systematic reviews, AMED and CINAHL. The reference lists of the relevant publications were also searched. RESULTS: seven prospective studies (10 publications) on the effect of PTA on QOL in claudicants were identified. Several different questionnaires were used to measure quality of life (Nottingham Health Profiile, SF-36, EuroQol) none of which were disease specific. All the studies showed some improvement in QOL after PTA at follow-up periods of between 6 weeks and 24 months, except for one which showed some improvement at 6 months but not at 24 months. CONCLUSIONS: despite the fact that studies on the effect of PTA on QOL in claudicants have used generic QOL questionnaires which are relatively insensitive, the findings suggest that PTA may result in some improvement in QOL in these patients, although level I evidence to support this is lacking. The availability of disease-specific questionnaires should enable a more accurate assessment of PTA on QOL in these patients.