Patients with Small Abdominal Aortic Aneurysm are at Significant Risk of Cardiovascular Events and this Risk is not Addressed Sufficiently.

BACKGROUND: Patients with abdominal aortic aneurysm (AAA) are at significant risk of cardiovascular (CV) events. Recent implementation of AAA-screening means thousands of patients are now diagnosed with small-AAA; however, CV risk factors are not always addressed. This study aimed at assessing and quantifying the CV characteristics of patients with small AAA following the introduction of screening programmes. METHODS: CV profiles of 384 men with a small AAA (<55 mm diameter) were assessed through the United Kingdom Aneurysm Growth Study (UKAGS), a nationwide prospective cohort study of men with small AAA. A prospective local cohort of an additional 142 patients with small AAA with available blood pressure (BP) and lipid profiles was also included and followed-up for 1 year. RESULTS: In the UKAGS population, 54% were current and 30% ex-smokers; 58% were hypertensive and 54% hypercholesterolaemic. In the local group, 54% were current and 40% were ex-smokers, and 94% were hypertensive. Patients were not more likely to receive CV medication after entering AAA surveillance in either group. All local patients were clustered "high-risk" for future CV events based on the Framingham score (mean 21.8%, 95% CI 20.0-23.6), JBS-2 (16.3%, 14.7-17.9) and ASSIGN (25.2%, 22.7-27.7). No change was seen in systolic BP levels between baseline and 1 year (140.9 mmHg vs. 142.5 mmHg, p=.435). A rise was seen in cholesterol (4.0 mmol-4.2 mmol, p<.0001) values at 1 year. CONCLUSIONS: This study suggests that patients with small AAA are at significant risk for developing CV events and this is not currently addressed, which is evident by the "high-risk" CV risk profiles of these patients despite being in AAA surveillance. Design and implementation of a CV risk reduction programme tailored for this population is necessary.

Outcome of open versus endovascular abdominal aortic aneurysm repair in obese patients: a systemic review and meta-analysis.

AIM: Obesity is increasingly common among patients diagnosed with vascular disease. This article aims to perform systemic review and meta-analysis on 30-day postoperative mortality and complication rate between open (OAR) and endovascular (EVAR) abdominal aortic aneurysm repair in obese patients. METHODS: A systematic search was performed using the PubMed, Embase and Cochrane databases to identify original articles on obese (BMI ≥30) patients undergoing abdominal aortic aneurysm (AAA) repair. Outcomes considered were 30-day mortality and postoperative complication rate following OAR or EVAR. Random-effects Poisson regressions were fitted for each outcome to estimate the risk ratios comparing EVAR to OAR. RESULTS: Four studies were included in the final analyses, all of which were observational in nature. There was no evidence of publication bias as suggested by funnel plots of the outcomes. Meta-analysis showed statistically significant fewer 30-day postoperative mortality in favour of EVAR (risk ratio 0.34 [95% confidence interval 0.25, 0.48], 4 studies, 2440 patients) and early postoperative complications: myocardial infarction (0.29 [0.13, 0.64]), chest infection (0.21 [0.12, 0.38]), renal failure (0.24 [0.11, 0.51]), wound infection (0.59 [0.48, 0.74]). Risk of postoperative bowel ischemia (0.26 [0.06, 1.13]) and stroke (0.32 [0.07, 1.55]) were equivocal between EVAR and OAR. CONCLUSION: The current study strongly suggests EVAR is superior to OAR with regards to 30-day mortality and early postoperative outcome in obese patients.

Prospective validation study of transorbital Doppler ultrasound imaging for the detection of transient cerebral microemboli.

BACKGROUND: Transient cerebral microemboli are independent biomarkers of early risk of ischaemic stroke in acute carotid syndromes. Transcranial Doppler imaging (TCD) through the temporal bone is the standard method for detection of cerebral microemboli, but an acoustic temporal bone window for TCD is not available in around one in seven patients. Transorbital Doppler imaging (TOD) has been used when TCD is not possible. The aim of this study was to validate the use of TOD against TCD for detecting cerebral microemboli. METHODS: The study included patients undergoing elective carotid endarterectomy; all had confirmed temporal and orbital acoustic windows. Subjects gave written informed consent to postoperative TCD and TOD monitoring, which was performed simultaneously for 30 min by two vascular scientists. RESULTS: The study included 100 patients (mean(s.e.m.) age 72(1) years; 65 men). Microemboli were detected by one or both methods in 40·0 per cent of patients: by TOD and TCD in 24 patients, by TOD alone in ten and by TCD alone in six. For detecting microemboli, TOD had a sensitivity of 80·0 per cent, specificity of 86·1 per cent, positive predictive value of 71·6 per cent and negative predictive value of 91·2 per cent. Bland-Altman analysis revealed no significant bias (bias 0·11 (95 per cent c.i. -0·52 to 0·74) microemboli; P = 0·810) with upper and lower limits of agreement of +6 and -6 microemboli. CONCLUSION: TOD appears a valid alternative to TCD for detecting microembolic signals in patients with no suitable temporal acoustic window.

Post-thrombotic syndrome: prevention is better than cure.

Post-thrombotic syndrome (PTS) can be debilitating to patients and have a major economic impact on health-care services. It arises after deep venous thrombosis (DVT) due to residual venous obstruction or valvular reflux, leading to increased venous pressure in the microcirculation. While the inflammatory process at the time of DVT may aid thrombus resolution, it may also promote destruction of venous valves. The diagnosis of PTS is principally clinical and patients typically complain of leg heaviness, swelling, pain, itching, cramps, ulcer and signs of lipodermatosclerosis. Several clinical scales or classifications have been used but it is recommended that Villalta scale is the most suitable. Risk factors for PTS include a proximal DVT and recurrent thrombosis as well as obesity and prior varicose veins. Poor quality of anticoagulation control may also be a factor. Established PTS is usually managed along the same lines as chronic venous hypertension with compression therapy and leg elevation. Surgery has only a limited role but may benefit some patients. Further trials are desperately needed to define the role of acute thrombolysis and mechanical thrombectomy, which seem to be promising treatments in the studies to date. For patients who have had a DVT more attention should be given to prescribing and using compression hosiery.