Cycling related common femoral artery disease: an unusual case in an otherwise healthy male.

A cyclist reported gradual onset, bilateral leg claudication without any atherosclerotic risk factors and with a normal vascular examination. Duplex ultrasound and magnetic resonance angiography revealed bilateral focal stenoses due to coralline plaques of the common femoral arteries (CFAs) but normal proximal and distal vasculature. A surgical endarterectomy with vein patch angioplasty resolved all symptoms. Cyclist's iliac syndrome (whereby mechanical and anatomical factors in competitive cyclists and runners lead to arterial kinking and subsequent intimal hyperplasia, endofibrosis and, ultimately, stenoses of the external iliac arteries) is well documented. This is the first report to our knowledge of a similar process isolated to the CFA.

Short series of emergency stent-graft repair of symptomatic penetrating thoracic aortic ulcers (PTAU).

Acute penetrating thoracic aortic ulcers (PTAU) are associated with vessel rupture, particularly when intramural haematoma (IMH) is present. Although surgical repair is the treatment of choice for PTAU in the aortic arch, definitive treatment of PTAU in other locations of the thoracic aorta remains controversial, particularly in this frail cohort of patients. Recent series of elective and semi-elective endovascular stent-graft repair of PTAU of the descending thoracic aorta show comparable results with the previously advocated best medical management. We report our results from a retrospective, observational study of acute stent-graft repair of symptomatic PTAU. Between 2000 and 2005, 11 patients (seven male, four female; median age 71 years) presented with acute PTAU. CT scans demonstrated an associated IMH in six, a contained leak in three or rupture in four unstable patients. All were covered by a single endovascular stent [Gore (5), Talent (5), Zenith (1); 10 inserted via the groin and one via iliac conduit within 1 week of presentation (five < 24 h). Technical success was 90.90% (10/11) and 3/11 (27%) died within 30 days (two ARDS, one a persistent leak and rupture at 48 h). One patient developed transient paraplegia; three haemothoraces required chest drains, one of which subsequently required empyema drainage. In survivors, CT scans were satisfactory, with no further intervention required at 32.5 (6-66) months of median follow-up. In conclusion, endovascular management of acute PTAU appears effective and durable with mortality rates that are likely to be better than for open surgery. However, haemodynamic compromise at presentation remains a robust denominator of over-all survival.

The clinical significance of below-knee great saphenous vein reflux following endovenous laser ablation of above-knee great saphenous vein.

AIMS: The standard technique for endovenous laser ablation (EVLA) for varicose veins due to great saphenous vein (GSV) reflux involves obliteration of the above-knee (AK) GSV. This study assesses the significance of persistent below-knee (BK) GSV reflux following such therapy. METHODS: Sixty-nine limbs (64 patients) with varicosities and GSV reflux underwent AK-EVLA. Post treatment, GSV reflux (ultrasound: six, 12 weeks) and Aberdeen varicose vein severity scores (AVVSS, 12 weeks) were assessed, and residual varicosities treated with foam sclerotherapy (six weeks). RESULTS: The untreated BK-GSV remained patent in all limbs. Ultrasound showed normal antegrade flow in 34/69 (49%, Group A), flash reflux<1 s in 7/69 (10%, Group B) and >1 s reflux in 28/69 (41%, Group C). Although AVVSS improved in all groups (P<0.001): A: 14.6 (8.4-19.3) versus 2.8 (0.5-4.4), B: 13.9 (7.5-20.1) versus 3.7 (2.1-6.8), C: 15.1 (8.9-22.5) versus 8.1 (5.3-12.6) the improvement was less in Group C (P<0.001 versus A and B) and was associated with a greater requirement (A: 4/34 [12%]; B: 1/7 [14%]; C: 25/28 [89%]) for sclerotherapy (persisting varicosities) (P<0.001). CONCLUSION: Although AK-GSV EVLA improves symptoms regardless of persisting BK reflux, the latter appears responsible for residual symptoms and a greater need for sclerotherapy for residual varicosities.

Fate of the great saphenous vein following endovenous laser ablation: does re-canalisation mean recurrence?

OBJECTIVE: To assess changes in great saphenous vein (GSV) diameter and the significance of re-canalisation following endovenous laser ablation (EVLA). DESIGN: Prospective cohort study. METHODS: Two groups were studied. Group A: 73 consecutive patients (84 GSVs) underwent EVLA followed by duplex ultrasound at 6, 12 and 52 weeks. Vein diameter and patency were recorded. Group B: From a prospectively maintained database 27 patients with a GSV that was found to have recanalised 6-12 weeks post-EVLA were identified and rescanned at 52 weeks. Pre- and post-treatment Aberdeen varicose vein severity scores (AVVSS) were measured. RESULTS: Group A: 81/84 (96%) GSVs were ablated and 3/84 (4%) had re-canalised (flash reflux <1s). GSV diameter diminished with time: pre-EVLA: mean diameter 7.7 S.D .2.0mm; 6 weeks: 5.1 S.D. 1.3mm; 12 weeks: 3.2 S.D. 1.2; 52 weeks: 85% non-visible (p<0.001). Group B: 3/27 (11%) with reflux >1s underwent repeat EVLA. 16/27 (59%) remained competent at 52 weeks and 8/27 (30%) showed trickle reflux. Vein diameter decreased in both subgroups (mean diameter 7.3 S.D. 2.5mm to 3.1 S.D. 0.8mm (p=0.006) and 7.2 S.D. 2.3mm to 3.0 S.D. 0.7mm (p=0.009) respectively) as did the AVVSS (p<0.001). CONCLUSIONS: Successful EVLA causes GSV shrinkage with transition from a non-compressible "thrombosed" vein to a non-visible vein by 1 year. A re-canalised GSV usually remains small with no/minimal reflux and persisting clinical benefit.

Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins.

BACKGROUND: Endovenous laser ablation (EVLA) is a minimally invasive technique for treating varicose veins due to truncal vein incompetence. This randomized trial compared EVLA with conventional surgery in patients with primary saphenofemoral and great saphenous vein (GSV) reflux. METHODS: Consecutive consenting patients with symptomatic varicose veins were randomized to EVLA 1 (stepwise laser withdrawal), EVLA 2 (continuous laser withdrawal) or surgery (saphenofemoral ligation, GSV stripping, multiple phlebectomies). Principal outcome measures were abolition of GSV reflux and improvement in Aberdeen Varicose Vein Symptom Score (AVVSS) 3 months after treatment. RESULTS: GSV reflux was abolished in 41 of 42 legs treated with EVLA 1, 26 of 29 following EVLA 2 and 28 of 32 after surgery (P = 0.227). The median (interquartile range, i.q.r.) AVVSS improvement was similar: 9.38 (4.54-14.93) with EVLA 1, 10.26 (5.03-15.03) after EVLA 2 and 8.36 (4.54-13.21) following surgery (P = 0.694). Return to normal activity (median (i.q.r.) 2 (0-7) versus 7 (2-26) days; P = 0.001) and work (4 (2-7) versus 17 (7.25-33.25) days; P = 0.005) was quicker after EVLA by either method. CONCLUSION: 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. REGISTRATION NUMBER: ISRCTN99270116 (http://www.controlled-trials.com).

Factors influencing the effectiveness of endovenous laser ablation (EVLA) in the treatment of great saphenous vein reflux.

OBJECTIVE: Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and great saphenous vein (GSV) reflux. This study assesses factors that might influence its effectiveness. DESIGN: Prospective, observational study. METHOD: EVLA was used to treat the great saphenous vein in 644 limbs as part of the management of varicose veins. Body mass index (BMI), maximum GSV diameter, length of vein treated, total laser energy (TLE) and energy density (ED: Joules/cm) delivered were recorded prospectively. Data from limbs with ultrasound confirmed GSV occlusion at 3-months were compared with those where the GSV was partially occluded or patent. Complications were recorded prospectively. RESULTS: GSV occlusion was achieved in 599/644 (93%) limbs (group A). In 45 limbs (group B) the vein was partially occluded (n=19) or patent (n=26). Neither BMI [group A: 25.2 (23.0-28.5); group B: 25.1 (24.3-26.2)], nor GSV diameter [A: 7.2mm (5.6-9.2); B: 6.9 mm (5.5-7.7)] influenced success. TLE and ED were greater p<0.01) in group A (median [inter-quartile range]: 1877J (997-2350), 48 (37-59)J/cm) compared to group B (1191J (1032-1406), 37 (30-46)J/cm). Although TLE reflects the greater length of GSV ablated in Group A (33 cm v 29 cm, p=0.06) this does not influence ED. GSV occlusion always occurred when ED>/=60 J/cm with no increase in complications. CONCLUSIONS: ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.

Risk factor awareness in patients with peripheral arterial disease.

AIM: This study was designed to determine how aware patients with peripheral arterial disease (PAD) were with regard to the risk factors (RF) associated with atherosclerosis. METHODS: Seventy patients (49 men; median age 72 years, range 42-89 years) with PAD admitted as inpatients to the department of vascular surgery over a three-month period were asked to complete a single-paged questionnaire. Data were also obtained from the hospital notes with regard to gender, age, actual RFs that each patient suffered from, admission route (elective or acute), drug history and diagnosis. RESULTS: Diabetes mellitus (DM): 16 patients (23%) had DM, 15 (94%) of whom were aware of their condition, but only 5 (31%) believed DM to be a vascular RF. Smoking: 53 patients (76%) were either current smokers or had recently stopped smoking, only 31 (58%) of which knew smoking to be a cardiovascular RF. Hypercholestero-laemia: 41patients (59%) had been diagnosed with hypercholesterolaemia, 29 (71%) of which actually knew their cholesterol level was elevated, but only 10 (25%) believed it to be a RF for vascular disease. Hypertension: 40 patients (57%) were known hypertensives, 75% of which knew that they had hypertension but only 10% knew that it was a RF for vascular disease. CONCLUSION: RF awareness amongst patients with PAD is suboptimal. Intensive efforts need to be undertaken to educate this patient cohort in order to improve consciousness for best medical therapy.

Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein.

BACKGROUND: Unlike surgery, endovenous laser ablation (EVLA) abolishes great saphenous vein (GSV) reflux but does not specifically interrupt the GSV tributaries at the groin. The fate and clinical significance of these tributaries were assessed in a prospective study. METHODS: Eight-one legs (70 patients) underwent colour flow duplex ultrasonography 12 months after GSV ablation for primary varicose veins. Saphenofemoral junction (SFJ) reflux, tributary patency, and recurrent or residual varicosities were recorded, and Aberdeen Varicose Vein Severity Scores (AVVSS) were compared with pretreatment values. RESULTS: The GSV had recanalized without evidence of reflux in two patients. None of the 81 legs showed SFJ reflux although one or more patent tributaries were visible in 48 (59 per cent); all were competent. In 32 legs (40 per cent) there was flush GSV occlusion with the SFJ and no tributaries were detectable. One leg showed evidence of neovascularization in the groin. AVVSS values were similar in groups with or without visible tributaries, both before and after EVLA: median (interquartile range) 13.9 (7.6-19.2) before EVLA and 2.9 (0.6-4.8) at follow-up in patients with visible tributaries, and 14.9 (9.2-20.2) and 3.1 (0.8-5.1) respectively in those without. Recurrent varicosities were present in one leg only, due to an incompetent mid-thigh perforating vein. CONCLUSION: Persistent non-refluxing GSV tributaries at the SFJ did not appear to have an adverse impact on clinical outcome 1 year after successful EVLA of the GSV.

Endovenous laser ablation (EVLA) of great saphenous vein to abolish "paradoxical reflux" in the Giacomini vein: a short report.

INTRODUCTION: Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) reflux in the Giacomini vein is a rare but well described pattern of reflux. Treatment of this type of reflux is controversial and only surgical treatment has been described. REPORT: We describe 2 patients in whom this type of reflux was successfully abolished following endovenous laser ablation (EVLA) of the GSV with the SPJ and Giacomini vein regaining competency. DISCUSSION: Paradoxical reflux in the Giacomini vein and SPJ is secondary to GSV incompetence which exerts a syphon effect. EVLA of the refluxing segment of GSV interrupts this effect and prevents the paradoxical reflux at the SPJ.

Initial experience in endovenous laser ablation (EVLA) of varicose veins due to small saphenous vein reflux.

OBJECTIVE: Conventional surgery for varicose veins due to small saphenous reflux is associated with high recurrence rates (up to 50%), many resulting from inadequate surgery. This prospective audit examines the safety and efficacy of EVLA in the treatment of this. METHOD: 65 patients (68 limbs) with varicosities due to primary or recurrent sapheno-popliteal junction (SPJ) and small saphenous vein (SSV) reflux underwent out-patient EVLA (810 nm diode laser). The SSV was ablated from mid-calf to the SPJ. Symptomatic improvement (Aberdeen Varicose Vein Severity Score [AVVSS]), time to return to normal activity, post-EVLA analgesic requirements, and complications were recorded. RESULTS: Duplex ultrasound follow-up (median 6-months) confirmed abolition of SPJ/SSV reflux in all limbs following a median total laser energy delivery of 1131J (IQR 928-1364) at an energy density of 66.3 Joules/cm (IQR 54.2-71.6). AVVSS improved from 15.4 (IQR 11.8-19.7) to 4.6 (IQR 3.2-6.7) at three months (p<0.001). Median analgesia requirement was 3 days (23% [15/65] patients required none) and the median time to normal activity was 0 (0-4) days (65% [42/65] returning to normal daily activity immediately). There were no instances of skin burns or DVT but 3 patients (4.4%) developed transient cutaneous numbness (sural nerve). 98% (64/65) patients would undergo EVLT again. CONCLUSIONS: EVLA abolished SPJ/SSV reflux in all limbs. This is likely to be more effective than conventional surgery, although long-term follow up is required. Data from a randomised control trial would be desirable.

Arterial consequences of recreational drug use.

BACKGROUND: Recreational drug use is becoming an increasing problem throughout the world. Many of the drugs used and their routes of administration have the potential to cause damage to the vascular system. Intravenous drug administration with the risk of arterial puncture predisposes to the formation of infected pseudoaneurysms. Inadvertent intra-arterial injection predisposes to distal limb ischaemia. Cocaine has numerous effects not only on the heart, but also potentially on any vascular bed. METHODS: A systematic review of published literature with regard to the arterial consequences of recreational drug abuse was undertaken by undergoing an electronic search. RESULTS: Most of the available literature is in the form of case reports and case series. Pseudoaneurysm formation is a serious consequence for intravenous drug users. For femoral aneurysms vessel ligation is the safest option with a low amputation risk. A high proportion of patients do have symptoms of claudication in the long term. Intra-arterial injections can result in limb threatening ischaemia. Systemic anticoagulation forms the mainstay of treatment. Cocaine has significant effects upon both the myocardium and the arterial tree in general. Arterial problems must always be considered in cocaine users who present acutely. CONCLUSION: The consequences of recreational drug use will result in an increased exposure of vascular surgeons to its associated complications posing unique and challenging problems.

Treatment of venous leg ulcers with Dermagraft.

BACKGROUND: A number of different treatment approaches have been recommended for the treatment of venous ulceration, including local ulcer treatment, compression and drug therapy. Recent advances in tissue engineering have resulted in living tissues being developed for cutaneous wound repair and skin replacement. The aim of this pilot study was to compare the rate of healing of venous ulcers in patients treated with Dermagraft (a human fibroblast-derived dermal replacement) and compression therapy or compression therapy alone. METHODS: A total of 18 patients with venous ulceration of the leg were recruited into the pilot study. Ten patients were treated with Dermagraft and compression therapy, and eight patients were treated with compression therapy alone. Healing was assessed by ulcer tracing and computerised planimetry. Skin perfusion was measured by laser Doppler. RESULTS: Five (50%) of the patients treated with Dermagraft and one (12.5%) control patient had healed by the end of the 12-week study period (NS). The total ulcer area rate of healing and linear rate of healing was significantly improved in patients treated with Dermagraft (P=0.001 and P=0.006, respectively, Mann-Whitney U-test). The number of capillaries increased in both the treatment and control group. Peri-ulcer skin perfusion increased by 20% in patients treated with Dermagraft, compared with 4.9% in the control group. CONCLUSION: The data from this small pilot study suggests that Dermagraft is associated with improved healing of venous ulceration. Following this pilot study, further clinical studies are needed to confirm the validity of these results in 'hard to heal' venous leg ulcers.

Bacterial colonisation of Doppler probes on vascular surgical wards.

AIM: hospital acquired infections cost the NHS 1 pound sterling billion each year and medical equipment may act both as source and vector of nosocomial infection. This study examined bacterial contamination of Doppler ultrasound probes (USP) in routine use on vascular surgical wards in six hospitals and the knowledge of staff about the potential for cross infection from contaminated probes. METHODS: probe head impressions and swab cultures of probe holders were plated on mannitol salt agar before and after cleaning with a paper towel. Putative S. aureus isolates were identified to species level and susceptibility to selected antimicrobials tested. Concurrently, junior medical staff were surveyed about probe cleaning protocols. RESULTS: methicillin susceptible S. aureus was isolated from 2/21 (10%) with near confluent bacterial growth from six others (28%). The latter may have obscured low numbers of S. aureus. Further since swabs were plated without prior enrichment culture, it is likely that contamination with S. aureus might have been underestimated. No positive cultures were obtained after wiping the USP with a paper towel. 22/23 (95%) junior doctors failed to clean the USP prior to use. CONCLUSION: USP contamination with pathogenic bacteria occurs under "in-use" conditions and junior medical staff are unaware of simple measures to prevent this. Strict guidelines for USP cleaning between patient use should, therefore, be adopted particularly when monitoring postoperative graft patency.