An observational study into the management of arteriomegaly: a call for a revised classification system.

INTRODUCTION: Arteriomegaly is the diffuse ectasia of arteries with or without aneurysmal disease. Patients with arteriomegaly have a higher incidence of morbidity including limb loss compared to patients with other arteriopathies. The aim of this observational study was to review the management of these patients in our institution. METHODS: Radiologists and surgeons prospectively reviewed aortofemoral angiography. Patients with arteriomegaly were identified. Data relating to demographics, mode of presentation, risk factors, type of arteriomegaly, management and progression of disease were analysed. RESULTS: Arteriomegaly was identified in 1.3% of patients (n = 69) undergoing lower limb angiography in the study period. Of these, the majority (n = 67) were men. The mean age was 74 years (range: 60-89 years) and 76% were smokers. Co-morbidities included coronary artery disease (55%), diabetes mellitus (20%), hypertension (45%) and cerebrovascular events (6%). Forty-nine patients presented with critical limb ischaemia and eighteen patients were seen electively in the outpatients department with symptoms of intermittent claudication. Data were incomplete for two male patients and were therefore not included. At presentation, 22 patients were classified as Hollier type I, 5 were type II and 9 were type III. Thirty-one patients had arteriomegalic vessels but no aneurysmal disease. After a median follow-up duration of 76 months (range: 6-146 months), 34 patients progressed to type I, 2 to type II and 18 to type III. Thirteen remained without aneurysmal disease. Twenty-nine patients required angioplasty and twenty-eight required bypass surgery during this time. In total, 102 procedures were required for complicated disease. The limb salvage rate was 92%. Although 8 patients in our series died, the remaining 59 are under regular follow up. CONCLUSIONS: This study illustrates the progressive nature of arteriomegaly. Results of the management of these patients in our institution are similar to those in the literature. We suggest an additional fourth category to Hollier's classification that describes arteriomegalic disease without aneurysmal degeneration as this, too, deserves special management. Regular follow-up visits and early intervention for patients with arteriomegaly is advocated to reduce the high incidence of morbidity.

Saphenofemoral junction ligation and disconnection for varicose veins-a longitudinal study of cosmesis and function.

BACKGROUND: Saphenofemoral junction ligation and disconnection (SFJLD) can be performed without exceeding the safe limits of local anesthetic if stripping of the long saphenous vein is not routine. We studied the early cosmetic and functional outcome of this procedure to identify the optimum time gap from SFJLD to multiple stab avulsions for varicose veins (VV). METHODS: A series of patients with primary VV underwent SFJLD under local anesthetic as day case procedures. The volume of VV was quantified with a cartograph wheel, whereas the extent and severity of VV was assessed with four validated questionnaires: (a) Clinical Etiology Anatomy Pathology Score, (b) Venous Clinical Severity Score, (c) Aberdeen Varicose Vein Severity Score, and (d) Short Form 36. Patients were assessed preoperatively, and at 1, 3, and 6 months postoperatively. The analysis of variance for repeated measures test was used; a p value <0.05 was found to be significant. RESULTS: There were 48 patients (15 men; mean age: 54 years; 95% CI: 29-79). In all, 91% (n = 44) of patients had cosmetic and symptomatic improvement. The volume of VV reduced significantly over the three postoperative time points when compared with preoperatively (112 [95% CI: 88-136] vs. 75 [95% CI: 55-97] vs. 65 [95% CI: 43-87] vs. 58 [95% CI: 31-86], p = 0.001). Using the Clinical Etiology Anatomy Pathology, Venous Clinical Severity Score, and Aberdeen Varicose Vein Severity Score questionnaires, severity of VV improved postoperatively when compared withpreoperatively (p = 0.001 respectively). Improvements in quality of life were also noted postoperatively with the Short Form 36 questionnaire (p = 0.032). At maximum follow-up of 3 years, 13% (n = 6) had recurrent VV. CONCLUSION: SFJLD confers cosmetic and symptomatic improvement at 1 month. Improvement is sustained on early follow-up, thereby allowing multiple stab avulsions to be performed as a staged procedure within 6 months. The rates of recurrent VV are acceptable on short-term follow-up.

Small bowel haemangioma with local lymph node involvement presenting as intussusception.

Gastrointestinal haemangiomas make up 0.05% of all intestinal neoplasms. They are sometimes multiple and usually present with pain, bleeding, and obstruction. An associated haemangiomatous change in regional lymph nodes has not been reported previously. A woman of 21 years presented with abdominal pain and vomiting. Abdominal ultrasound and computed tomography scan showed a lower abdominal mass. Laparotomy revealed a small bowel tumour causing an intussusception together with enlarged mesenteric lymph nodes. Pathological examination revealed a small bowel haemangioma with mesenteric node involvement. The pathogenesis of haemangiomatous involvement of lymph nodes is discussed. Hamartomatous change is the likely cause in this patient.

Bacterial translocation in patients undergoing abdominal aortic aneurysm repair.

BACKGROUND: Bacterial translocation occurs in humans and is associated with an increased incidence of septic morbidity. The aims of this study were to determine the prevalence of bacterial translocation in patients undergoing open abdominal aortic aneurysm (AAA) repair and to identify any association with postoperative septic complications. METHODS: This was a prospective observational study in which patients undergoing aneurysm repair were assessed for evidence of bacterial translocation by culture of a mesenteric lymph node (MLN), small bowel serosal exudate and thrombus within the aneurysm. All postoperative septic complications were recorded. RESULTS: A total of 51 patients was studied (40 men, 11 women; median age 72 years). Enteric bacteria were isolated from the MLNs of five patients (prevalence of bacterial translocation 10 per cent), one of whom also yielded growth from the serosal exudate. Septic morbidity occurred in four of five patients in whom bacterial translocation was identified, compared with nine of 46 in those without translocation (P = 0.013, Fisher's exact test, mid P). One patient in whom Escherichia coli was grown from the MLN developed an aortoenteric fistula, with a coliform species isolated from the graft. CONCLUSION: This study suggests that bacterial translocation occurs in patients undergoing AAA repair. It is associated with an increased incidence of postoperative septic morbidity and provides a possible mechanism for infection of prosthetic aortic grafts.

The ultrasonic evaluation of the carotid intima-media thickness and its relation to risk factors of atherosclerosis in normal and diabetic population.

High-resolution ultrasound provides an excellent tool for the non-invasive assessment of the severity of atherosclerosis. It allows the measurement of the common carotid artery (CCA) intima media thickness (IMT) which has been found to be a feasible and reliable method for the evaluation of the progression and regression of the disease. The aim of this study was to evaluate the influence of risk factors of atherosclerosis on the mean CCA IMT in both normal and non-insulin dependent diabetic (NIDDM) individuals and to determine the effect of diabetes as a major atherosclerotic risk factor on the CCA IMT. Four hundred and eighty-four subjects were studied, 244 normal individuals and 240 non insulin dependent diabetic patients. The right and left CCA IMT were measured using high resolution ultrasonography. Both in the normal and diabetic individuals, the mean CCA IMT was found to increase linearly with age (p < 0.01), was directly related to total serum cholesterol and triglyceride and inversely related to HDL-cholesterol (p < 0.01). Multiple linear regression analysis showed the most important risk factor influencing the CCA IMT and hence early athrosclerosis to be the presence of diabetes, followed by serum HDL-cholesterol (inverse relation), total cholesterol, age and serum triglyceride. This study has shown that high resolution ultrasonography can be used to evaluate the effect to risk factors on early atherosclerosis and could be used to monitor future clinical trails aiming to modify the progression of atherosclerosis in the population.

The relative effect of carotid plaque heterogeneity and echogenicity on ipsilateral cerebral infarction and symptoms of cerebrovascular disease.

OBJECTIVE: To determine the relative effect of carotid plaque heterogeneity and echogenicity as measured by computer on the incidence of ipsilateral cerebral infarction and symptoms of cerebrovascular disease. MATERIALS AND METHODS: 138 patients with 209 carotid plaques producing > 50% stenosis were studied. 110 plaques were from symptomatic sides. All patients had computer tomography (CT) brain scans. Images of the carotid plaques obtained by duplex scanner were transferred to a computer. Using an image analysis program plaque echogenicity, measured as the grey scale median (GSM) and heterogeneity, evaluated as the heterogeneity index (HI) was calculated. RESULTS: 42% of plaques were associated with cerebral infarction. Symptomatic plaques and those associated with cerebral infarction were more echolucent and less heterogeneous than asymptomatic plaques and those not associated with cerebral infarction. Plaques with GSMs below or equal to 32 were associated with a significantly higher incidence of cerebral infarction. Plaques with GSMs below or equal to 32 were associated with a significantly higher incidence of cerebral infarction and symptoms of cerebrovascular disease than those with GSMs above this level (p < 0.01). Plaques with HIs below or equal to 20 were associated with a significantly higher incidence of symptoms of cerebrovascular disease as compared to those with HIs above this level (p < 0.01). CONCLUSIONS: Computer analysis of carotid plaque morphology is an objective tool that can identify high risk plaques. The potential of such analysis in the identification of asymptomatic patients with advanced carotid stenosis at a high risk of stroke should be explored in a natural history study.