Randomised controlled trial to evaluate the efficacy of TachoComb H patches in controlling PTFE suture-hole bleeding.

OBJECTIVE: Suture-hole bleeding is a considerable problem in vascular procedures using polytetrafluoroethylene (PTFE) grafts. This study aimed to study the efficacy of TachoComb H patches in controlling suture-hole bleeding. DESIGN: Prospective randomised controlled trial. Materials and methods. Patients undergoing femoral anastomosis and femoral or carotid patch angioplasty with PTFE grafts were prospectively randomised to TachoComb H patches or standard compression with surgical swabs. RESULTS: Twenty four patients were randomised (12 patients in each treatment group). The median time to haemostasis was 300 (range 180-600)s in patients treated with TachoComb H and 660 (range 180-1200)s in the control group. The log rank test of equality over treatments based on the 22 patients with assessment of time to haemostasis showed statistical significance (p=0.0134). There were no serious complications associated with use of TachoComb H patches. CONCLUSION: TachoComb H patches were found to be safe and effective for the control of suture-hole bleeding in patients undergoing vascular reconstruction with PTFE grafts.

Pseudomyxoma peritonei.

Pseudomyxoma peritonei is a relatively rare and poorly understood condition in which mucus accumulates within the peritoneal cavity. The presence of cells in the mucin, either inflammatory or neoplastic, distinguishes it from simple acellular mucus ascites caused by mucinous spillage. There is widespread seeding of the peritoneal and omental surfaces with a heavy cancerous glaze. This is principally a complication of borderline or malignant neoplasm of the ovary and/or appendix. This paper describes two cases of previously healthy women who both presented with an acute abdomen, and were diagnosed postoperatively with pseudomyxoma peritonei. In addition, literature on the clinical presentation, diagnostic procedures, and treatment options has been briefly reviewed.

The identification of the high risk carotid plaque.

OBJECTIVE: To determine the influence of carotid plaque morphology and severity of stenosis on symptoms of cerebrovascular disease and cerebral infarction. PATIENTS AND METHODS: One hundred and ninety patients with 329 carotid plaques producing 50-99% stenosis were studied. Carotid plaque echogenicity on ultrasonography was evaluated using computerised measurement of the median of the overall grey scale content (GSM). Heterogeneity was evaluated as the difference between the GSMs of the most echogenic and the most echolucent areas within each plaque and expressed as the heterogeneity index (HI). All patients had a CT brain scan and the presence of ipsilateral cerebral infarction noted. RESULTS: Cerebral infarction was more common in symptomatic than asymptomatic plaques (42% vs. 29%, p<0.02) and in echolucent than echogenic plaques (mean GSM of 37.8 vs. 29.7, p<0.01). Plaques with GSM below or equal to 32 were associated with a higher incidence of cerebral infarction as compared to those above this level, this was significant in both symptomatic and asymptomatic plaques. Symptomatic carotid plaque were less heterogenous than asymptomatic plaques. Plaques associated with cerebral infarction were less heterogenous than those not associated with infarction. CONCLUSION: This study has shown that the identification of the high risk carotid plaques, i.e. those associated with a high incidence of cerebral infarction is possible both in symptomatic and asymptomatic patients. The potential of such analysis in the identification of patients with asymptomatic carotid stenosis with high and low risk of stroke should be explored in a natural history study.

Computer-assisted carotid plaque characterisation.

OBJECTIVE: To determine the relationship between plaque echogenicity as measured by computer and the incidence of cerebral brain infarction. PATIENTS AND METHODS: Eighty-seven patients with 148 plaques producing more than 50% internal carotid artery stenosis were studied. Sixty-nine plaques were in asymptomatic patients, 35 were associated with amaurosis fugax, 19 with transient ischaemic attacks and 25 with stroke. All patients had a CT brain scan and the presence of ipsilateral cerebral infarction was noted. Images of the plaques obtained with an ATL Ultramark-4 Duplex scanner (7.5 MHz high resolution probe) were transferred to a computer. Using an image analysis program a histogram for each plaque was obtained with the number of pixels plotted against the grey scale (0-225). The median of the grey scale was used as a measure of echogenicity. RESULTS: Fifty-three (36%) of the 148 plaques were associated with ipsilateral CT brain infarction. Plaques with a grey scale median more than 32 (echogenic) were associated with an incidence of 11% (7/64) CT infarction. In contrast, plaques with grey scale median below or equal to 32 (echolucent) were associated with 55% (46/84) incidence of CT infarction (chi 2 = 30.35, p < 0.001, relative risk = 22, 95% confidence interval from 4.7 to 108). CONCLUSION: This study indicates that computer analysis of carotid plaque can identify high-risk carotid plaques. The potential of such analysis in the identification of asymptomatic high-risk patients should be explored in further studies.

The case for formal stratification analysis when prescribing deep vein thrombosis prophylaxis.

Postoperative deep vein thrombosis (DVT) is common following general and orthopaedic surgery. Certain factors are known to increase the risk of DVT. To ascertain how surgeons use these factors to assess DVT risk and modify their DVT prophylaxis for individual cases, we circulated a questionnaire to 100 general and 200 orthopaedic surgeons. We inquired about whether DVT prophylaxis was used, and what risk factors were recognized, and we asked the surgeons to ascribe a level of DVT risk for five imaginary cases. All surgeons claimed to use prophylaxis. Most surgeons were largely aware of the accepted risk factors. There was, however, no consensus in allocating level of risk to individual imaginary cases. In conclusion, in spite of being aware of risk factors, similar patients are being dealt with in widely different ways by different clinicians. Therefore, we feel it is important to formally assess each individual patient's DVT risk and prescribe prophylaxis accordingly.