Meta-analysis of the use of surgical sealants for suture-hole bleeding in arterial anastomoses.

BACKGROUND: Suture-hole bleeding in arterial anastomoses prolongs operating time and increases blood loss, particularly with the use of prosthetic grafts. Surgical sealants (such as fibrin) may be used as haemostatic adjuncts in vascular surgery. This is a systematic review and meta-analysis of published studies that investigated the utility of surgical sealants in arterial-to-prosthetic graft anastomoses. METHODS: A systematic review was undertaken of papers published until January 2015 on Embase, MEDLINE, PubMed, PubMed Central and Cochrane databases that analysed the use of surgical sealants as haemostatic adjuncts after arterial anastomoses. RCTs were included, with study endpoints of time to haemostasis or haemostasis at 5 min. Secondary outcomes included treatment failure, mean difference in estimated blood loss and duration of surgery. Sensitivity and subgroup analyses were performed, as well as funnel plot analysis for publication bias. RESULTS: A total of 2513 citations were reviewed; 19 RCTs comprising 1560 patients were ultimately included in the analysis. The majority of studies compared fibrin sealant with control haemostatic measures. Pooled analysis suggested that surgical sealants reduced the time to haemostasis (mean difference 243·26 (95 per cent c.i. 183·99 to 302·53) s; P < 0·001), improved haemostasis at 5 min (odds ratio 4·50, 95 per cent c.i. 2·59 to 7·81; P < 0·001), and were associated with less treatment failure, blood loss and shorter duration of surgery. CONCLUSION: Surgical sealants appear to reduce suture-hole bleeding significantly in vascular prosthetic graft anastomoses compared with standard haemostatic measures.

Peripheral artery disease: a marked lack of awareness in Ireland.

OBJECTIVES: Patients with symptomatic peripheral artery disease (PAD) have a 30% risk of death within 5 years. However, public awareness of vascular disease has been shown to be low. The aim of this study was to assess awareness regarding risk factors, significance and potential sequelae of PAD in an Irish population. DESIGN: A cross-sectional, anonymous survey of patients and members of the public. MATERIALS: An anonymous questionnaire was developed to collect details on basic demographics, presence of and treatment for risk factors for cardiovascular disease, awareness of PAD and its risk factors and sequelae. The local ethics committee granted ethical approval. METHODS: Two investigators in face-to-face interviews administered the survey with patients and members of the general public, older than 40 years of age, attending a range of outpatient clinics, day care services and in patients. RESULTS: A total of 336 questionnaires were administered. A post-secondary school course had been completed by 32% of respondents. Only 19% of patients reported familiarity with PAD, a figure considerably lower than those reporting familiarity with stroke (94%), coronary artery disease (78%) or diabetes (98%) (Chi Squared p<0.001). The only independent predictor of awareness of PAD was having a post-secondary school course with an odds ratio or 4.2. CONCLUSIONS: This study demonstrates a disturbing lack of awareness of PAD and highlight the need for a meaningful targeted public health awareness campaign on PAD in order to close the gap of knowledge in Irish patients, prior to any prevention campaign.

Predicting acute appendicitis? A comparison of the Alvarado score, the Appendicitis Inflammatory Response Score and clinical assessment.

BACKGROUND: Patients presenting with suspected appendicitis pose a diagnostic challenge. The appendicitis inflammatory response (AIR) score has outperformed the Alvarado score in two retrospective studies. The aim of this study was to evaluate the AIR Score and compare its performance in predicting risk of appendicitis to both the Alvarado score and the clinical impression of a senior surgeon. METHODS: All parameters included in the AIR and Alvarado scores as well as the initial clinical impression of a senior surgeon were prospectively recorded on patients referred to the surgical on call team with acute right iliac fossa pain over a 6-month period. Predictions were correlated with the final diagnosis of appendicitis. RESULTS: Appendicitis was the final diagnosis in 67 of 182 patients (37 %). The three methods of assessment stratified similar proportions (~40 %) of patients to a low probability of appendicitis (p = 0.233) with a false negative rate of <8 % that did not differ between the AIR score, Alvarado score or clinical assessment. The AIR score assigned a smaller proportion of patients to the high probability zone than the Alvarado score (14 vs. 45 %) but it did so with a substantially higher specificity (97 %) and positive predictive value (88 %) than the Alvarado score (76 and 65 %, respectively). CONCLUSIONS: The AIR score is accurate at excluding appendicitis in those deemed low risk and more accurate at predicting appendicitis than the Alvarado score in those deemed high risk. Its use as the basis for selective CT imaging in those deemed medium risk should be considered.

Predicting carotid artery disease and plaque instability from cell-derived microparticles.

OBJECTIVES: Cell-derived microparticles (MPs) are small plasma membrane-derived vesicles shed from circulating blood cells and may act as novel biomarkers of vascular disease. We investigated the potential of circulating MPs to predict (a) carotid plaque instability and (b) the presence of advanced carotid disease. METHODS: This pilot study recruited carotid disease patients (aged 69.3 ± 1.2 years [mean ± SD], 69% male, 90% symptomatic) undergoing endarterectomy (n = 42) and age- and sex-matched controls (n = 73). Plaques were classified as stable (n = 25) or unstable (n = 16) post surgery using immunohistochemistry. Blood samples were analysed for MP subsets and molecular biomarkers. Odds ratios (OR) are expressed per standard deviation biomarker increase. RESULTS: Endothelial MP (EMP) subsets, but not any vascular, inflammatory, or proteolytic molecular biomarker, were higher (p < .05) in the unstable than the stable plaque patients. The area under the receiver operator characteristic curve for CD31(+)41(-) EMP in discriminating an unstable plaque was 0.73 (0.56-0.90, p < .05). CD31(+)41(-) EMP predicted plaque instability (OR = 2.19, 1.08-4.46, p < .05) and remained significant in a multivariable model that included transient ischaemic attack symptom status. Annexin V(+) MP, platelet MP (PMP) subsets, and C-reactive protein were higher (p < .05) in cases than controls. Annexin V(+) MP (OR = 3.15, 1.49-6.68), soluble vascular cell adhesion molecule-1 (OR = 1.64, 1.03-2.59), and previous smoking history (OR = 3.82, 1.38-10.60) independently (p < .05) predicted the presence of carotid disease in a multivariable model. CONCLUSIONS: EMP may have utility in predicting plaque instability in carotid patients and annexin V(+) MPs may predict the presence of advanced carotid disease in aging populations, independent of established biomarkers.

Endogenous endophthalmitis following ipsilateral carotid endarterectomy.

We report a case involving a 75-year-old lady who presented to our department of ophthalmology complaining of a 1 day history of ocular pain and reduced vision in the right eye, associated with rigors and diarrhoea. This patient, who had undergone a right carotid endarterectomy (CEA) 4 days previously, was subsequently confirmed to have developed endogenous endophthalmitis. To our knowledge, endogenous endopthalmitis has not previously been described as a postoperative complication of CEA, and should be considered in patients presenting with ocular complaints after this type of surgery.

Life-threatening gastrointestinal haemorrhage in Von Recklinghausen's disease.

Neurofibromatosis Type I (NF-1), also known as Von Recklinghausen's disease, is a common disorder, but gastrointestinal manifestations are rare and can be associated with severe complications and malignancy. We describe a case of multiple intestinal tumours, which presented as major per-rectal bleeding and was diagnosed by laparotomy. Presenting symptoms of this condition are usually non-specific, but the risk of malignancy and perforation should allow for a high index of suspicion in patients with NF-1 presenting with gastrointestinal symptoms. We present this case as a reminder that blood loss from the bowel in Von Recklinghausen's disease may be life-threatening, requiring immediate surgery to control haemorrhage.

Preoperative assessment of primary varicose veins: a duplex study of venous incompetence.

OBJECTIVES: we investigated the importance of preoperative duplex scanning in primary uncomplicated varicose vein surgery by evaluating the incidence of superficial venous imcompetence and significant anatomical variations that may be difficult to detect clinically and therefore might be expected to contribute to recurrence. DESIGN: a retrospective study of a prospectively collected database. MATERIALS: over 15 consecutive months, patients attending the non-invasive vascular laboratory for duplex scanning of their primary uncomplicated varicose veins were assessed. METHODS: vascular laboratory case notes were assessed and incidence of superficial venous incompetence and any significant anatomical variations that would have been difficult to detect clinically +/-HHD were documented. Any correlation with clinical findings was also evaluated. RESULTS: a total of 223 limbs (176 patients) were assessed. Sixty-seven limbs (30%) in fact had a competent sapheno-femoral junction. Sixty-one limbs (27%) had pure sapheno-femoral reflux and nil else. Fifty-three limbs (24%) had significant anatomical variations. Forty-two limbs (19%) had short saphenous vein incompetence, of which 67% were clinically unsuspected. CONCLUSIONS: preoperative duplex scanning is indicated in all patients with uncomplicated primary varicose veins if appropriate venous surgery is contemplated. There are obvious resource and recurrence rate implications. Further evaluation in the form of randomised trials are required.

Management of synchronous infrarenal aortic disease and large bowel cancer: a North-east of Scotland experience.

OBJECTIVES: to review our experience of combined aortic and colonic surgery. DESIGN: retrospective review. METHODS: synchronous aortic and colorectal procedures were identified from prospective computerised audit and archival vascular records. Clinical parameters were used as surrogates for measuring clinical outcome. RESULTS: six patients (F:M=2:1), median age 75.6 years (range 70-80 years) were identified with infrarenal aortic pathology (5 aneurysms, median AP diameter 6 cm, 1 occluded aortoiliac segment) and colonic carcinoma. All carcinomas were Dukes stage B and moderately well differentiated. Synchronous aortic and colonic resections were performed in five cases, bypass for aortoiliac occlusion was deferred in preference to colonic resection in one case. Operating time ranged between 3-6.5 hours (median 4 h), transfusion requirements 2-5 units (median 3 units). One anastomotic dehiscence was reported. With follow-up between 6 months to 6 years all patients remain alive; no patient has re-presented with graft sepsis or symptomatic tumour recurrence. CONCLUSION: synchronous resections of aortic and colonic lesion may be a treatment option in selected cases.

Inflammatory abdominal aortic aneurysms: diagnosis with gadolinium enhanced T1-weighted imaging.

AIM: Inflammatory abdominal aortic aneurysms (IAAA) are a variant of abdominal aortic aneurysms, which are associated with an increased morbidity. The diagnosis of IAAA has traditionally been established with a combination of clinical and laboratory findings together with contrast enhanced CT. There is a high incidence of renal impairment in this group, and therefore contrast enhanced CT may be harmful. PATIENTS AND METHODS: Five patients with IAAA underwent T1-weighted spin echo and gradient echo gadolinium enhanced abdominal MRI. A total of eight examinations were performed, including three patients who underwent repeat MRI following steroid therapy. RESULTS: The inflammatory cuff was clearly identified following gadolinium administration in all eight examinations. The cuff enhanced homogeneously in all patients with no alteration in appearance following steroid therapy. The intravenous administration of gadolinium DTPA enabled clearer definition of locally involved structures. CONCLUSION: Gadolinium enhanced MRI readily demonstrates features of IAAA. In view of potential renal impairment in this patient group, we recommend this technique in preference to contrast enhanced CT in the initial investigation of inflammatory abdominal aortic aneurysms.

Screening for diabetes on a vascular ward: lessons from an audit.

Owing to the high prevalence of diabetes mellitus in patients with peripheral arterial disease, screening for this disorder is necessary on a vascular ward. Our current practice of random plasma glucose (RPG) testing on every admission was reviewed. This test, although crude, excludes diabetes if the cutoff level is set as low as 6.0 mmol/L. A total of 36% of our patients had an abnormal result, but this was not further acted upon. A further 19% had no test result recorded at all. This practice is inadequate and has resulted in the following implementations: (1) every patient with clinical evidence of arterial disease should have their RPG level measured; (2) patients with a level > 6.0 mmol/L should have a fasting plasma glucose level estimated; and (3) patients with an abnormal fasting plasma glucose level should be referred to the diabetic clinic.

Long-term human vein graft contractility and morphology: a functional and histopathological study of retrieved coronary vein grafts.

Vasoreactivity of 11 coronary artery vein bypass grafts and 13 human saphenous veins was examined. Isometric tension studies were performed in response to potassium chloride (110 mmol/l), noradrenaline (10(-9)-10(-4) mol/l), serotonin (10(-9)-10(-4) mol/l) and histamine (10(-8)-10(-2) mol/l). After precontraction with noradrenaline (10(-5) mol/l), the response to acetylcholine (10(-8)-10(-4) mol/l) and the calcium ionophore A23187 (10(-8)-10(-4) mol/l) was also assessed. Results are given as mean(s.e.m.). Compared with saphenous veins, vein grafts showed decreased sensitivity to noradrenaline (1.7(0.5) versus 0.4(0.1) mumol/l, P = 0.01), no change in sensitivity to serotonin (55(18) versus 37(15) mumol/l, P > 0.05) and supersensitivity to histamine (3.2(0.9) versus 30.1(13.2) mumol/l, P = 0.01). Vein grafts had a decreased maximal contraction to potassium chloride (1.1(0.3) versus 5.5(0.8) g, P = 0.0001), noradrenaline (1.2(0.3) versus 4.1(0.8) g, P = 0.005), histamine (1.2(0.3) versus 4.5(0.8) g, P = 0.003) and serotonin (0.7(0.2) versus 5.7(0.6) g, P = 0.0002) compared with saphenous vein. Precontracted vein grafts did not relax in response to acetylcholine; in contrast, saphenous vein relaxed in a dose-dependent manner to a maximal relaxation of 22(3) per cent. Both saphenous vein and vein graft relaxed in response to A23187. Vein graft intimal thickness was approximately fourfold greater than that of saphenous vein (540(110) versus 136(30) microns). Scanning electron microscopy of vein and vein graft revealed an intact endothelium. Coronary artery vein grafts are capable of responding to various contractile agonists; these response are notably different from those of saphenous vein and there is a loss of endothelium-dependent relaxation. Even at a late stage vein grafts are not inert but are functional conduits with an abnormally responsive endothelium and a less potent, but significantly altered, smooth muscle contractile profile.

Improved limb salvage and mobility following peroneal artery bypass.

During the 10-year period August 1981 to 1991, 92 consecutive patients underwent revascularisation to the peroneal artery (40 to the upper third, 30 to the mid and 22 to the distal third). The male/female ratio was 1.6:1 and the mean age was 72 years. Thirteen patients had independent mobility preoperatively while 58 had limited mobility and the remaining 18 were bed/housebound. Following surgery the patients were prospectively evaluated and mean follow-up was 25 months. The 1 and 3 year patency rates were 67 and 59% respectively and cumulative limb salvage rates were 75 and 71%. Forty-four patients returned to independent mobility while 36 had limited mobility and 11 remained housebound. Reconstruction to the peroneal artery is a valuable adjuvant for limb salvage providing satisfactory cumulative patency and facilitating improved mobility.

Foreign body complications of central venous catheterisation in critically ill patients.

In three critically ill patients, central venous catheter--associated foreign bodies were identified while the patients were in the intensive care unit. Two patients had fragments of retained catheter; in the third patient a guide-wire was lost within the vascular tree. The catheter fragments were associated with clinical symptoms while side effects were not observed with loss of the guide-wire. All three foreign bodies were removed without complications.

Reduction of intimal hyperplasia and enhanced reactivity of experimental vein bypass grafts with verapamil treatment.

Recent studies have shown that calcium antagonists exert an antiatherogenic effect in animals fed cholesterol. Vein graft intimal hyperplasia is believed to be an early event in atherosclerotic lesion formation, which is a significant cause of graft failure. Altered vasoreactivity has also been postulated in the etiology of vein graft failure. Therefore this study examined the effect of verapamil treatment on the development of intimal hyperplasia and the vasoreactivity of experimental vein bypass grafts. The right external jugular vein was grafted into the right carotid artery of 30 male New Zealand white rabbits fed normal rabbit chow. The left external jugular vein was used as the control vein. Fifteen animals received verapamil (1.25 mg/day for 28 days) via the femoral vein by means of an osmotic pump. In 15 control animals the pump contained saline. Plasma verapamil concentration was 50.9 +/- 13.2 ng/mL (x +/- SEM), a dose that showed no effect on either blood pressure, total serum cholesterol, or in vitro platelet aggregation to ADP. Fourteen of fifteen grafts were patent in each group, for a patency rate of 93%. Histologic examination using computer morphometry showed significant reduction of intimal hyperplasia at the proximal, middle, and distal graft segments (p less than 0.05). In addition in vitro isometric tension studies of the vein grafts and control veins showed that verapamil causes enhanced reactivity of both vein grafts and control veins in response to norepinephrine and histamine (p less than 0.05). Reactivity of vein grafts to serotonin was unaltered. While none of the normal veins in the control group responded to serotonin, normal veins treated with verapamil contracted readily in response to serotonin. Endothelial-dependent relaxation to acetylcholine was absent in both control and verapamil-treated vein grafts, while normal veins from both groups responded to the same extent to acetylcholine. Because we could not demonstrate any difference in platelet or endothelium function between untreated and verapamil-treated animals, we examined the direct effect of verapamil on smooth muscle. Verapamil significantly inhibited [3H]-thymidine incorporation into DNA in vascular smooth muscle cells in culture in a dose-dependent manner. Verapamil treatment significantly reduces intimal hyperplasia in experimental vein grafts and inhibits smooth muscle cell proliferation in culture. Furthermore the enhanced reactivity to norepinephrine and histamine in the verapamil-treated vessels has no detrimental effect on the patency rate at 4 weeks. Thus by inhibiting intimal hyperplasia, calcium antagonists may improve the long-term patency of vein bypass grafts.

Normal endothelial function and decreased vasoreactivity of experimental arterial grafts.

During autogenous vascular grafting endothelial cell damage inevitably occurs. In this study we examined the functional and morphologic integrity of experimental arterial grafts. The right external iliac artery was grafted into the right carotid artery of 12 male New Zealand white rabbits. The left external iliac artery was used as the control artery. Four weeks after surgery, isometric tension studies were performed on rings of control artery and arterial graft. Control arteries and arterial grafts precontracted with norepinephrine demonstrated endothelium-dependent relaxation of 28.3% +/- 5.6% and 16.1% +/- 1.7%, respectively, in response to acetylcholine (5 x 10(-6) mol/L). Both control arteries and arterial grafts contracted in response to norepinephrine, histamine, and serotonin. The median effective dose (ED50) of norepinephrine was 4.1 +/- 1.3 x 10(-7) mol/L for control arteries and 62.1 +/- 17.9 x 10(-7) mol/L for arterial grafts (p less than 0.005). Similarly, arterial grafts were less sensitive to histamine; the ED50 of histamine for control arteries was 4.6 +/- 1.3 x 10(-7) mol/L and 51.4 +/- 13.0 x -7 mol/L for arterial grafts (p less than 0.005). In contrast, reactivity to serotonin was unaltered. The ED50 was 4.1 +/- 1.3 x 10(-7) mol/L for control arteries and 4.5 +/- 1.3 x 10(-7) mol/L for arterial grafts. Scanning and transmission electron microscopy revealed a largely intact endothelial surface. These data are markedly different from our previous findings with vein grafts in which serotonin supersensitivity was associated with an absence of endothelium-mediated relaxation to acetylcholine.(ABSTRACT TRUNCATED AT 250 WORDS)