Previous Magnetic Resonance (MR) studies of carotid endarterectomy (CEA) specimens have been dire... more Previous Magnetic Resonance (MR) studies of carotid endarterectomy (CEA) specimens have been directed at interpreting image contrast to determine plaque composition and stability. Such studies may give misleading results since it is believed that the acquired MR data is affected by the conditions used to store the excised tissue. This has been investigated in a high-resolution imaging study of the changes in contrast occurring with a change in specimen temperature. MR images were acquired from 20 CEA specimens. The initial MR examination was made within four hours of excision in tissue maintained and imaged at body temperature. Specimens were subsequently cooled and then re-examined at different times. The MR data was interpreted by comparison with histology obtained from equivalent sections. With the exception of signals arising from blood, changes in MR image contrast occurring in the 24-hour period after the CEA were relatively slight. Plaque lipid T2-weighted image intensity was...
Results: Principal reflux sites were thigh perforators alone (6/153 [4%]), and the saphenofemoral... more Results: Principal reflux sites were thigh perforators alone (6/153 [4%]), and the saphenofemoral (106/153 [69%]) or saphenopopliteal (41/153 [27%]) junctions. A total of 10/153 (7%) had calf perforator incompetence (CPI). Four patterns of reflux were identified (I: isolated SV reflux ...
We have addressed the issue of validation in a different way,3 in which we used a modified standa... more We have addressed the issue of validation in a different way,3 in which we used a modified standard endarterectomy technique that provides an intact carotid plaque.3 The preservation of plaque morphology, in particular the luminal surface, allows accurate measurement ...
Carotid angioplasty and stenting is gaining in popularity as an alternative to carotid endarterec... more Carotid angioplasty and stenting is gaining in popularity as an alternative to carotid endarterectomy for the treatment of symptomatic critical stenoses of the internal carotid artery. However, the durability of this technique and the incidence of recurrent stenoses has not yet been fully evaluated. It has been reported that mechanical factors may cause deformity of a Palmaz stent, negating the initial benefits of the procedure. We describe successful carotid endarterectomy after distortion of a Strecker balloon-expandable stent.
Purpose: Symptomatic carotid plaques are characterized by reduced fibrous tissue content, increas... more Purpose: Symptomatic carotid plaques are characterized by reduced fibrous tissue content, increased lipid content, intraplaque hemorrhage, and cap rupture. This confers an increased stroke risk. Plaque remodelling reduces this risk, however, and this study has evaluated differences in echomorphology at varying times after a neurologic event.
Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% ... more Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% patients have residual varicosities. This randomized controlled trial (RCT) assesses whether more extensive GSV ablation enhances their resolution and influences symptom improvement. Sixty-eight limbs (65 patients) with varicosities and above and below-knee GSV reflux were randomized to Group A: AK-EVLA (n = 23); Group B: EVLA mid-calf to groin (n = 23); and Group C: AK-EVLA, concomitant below-knee GSV foam sclerotherapy (n = 22). Primary outcomes were residual varicosities requiring sclerotherapy (6 weeks), improvement in Aberdeen varicose vein severity scores (AVVSS, 12 weeks), patient satisfaction, and complication rates. EVLA ablated the treated GSV in all limbs. Sclerotherapy requirements were Group A: 14/23 (61%); Group B: 4/23 (17%); and Group C: 8/22 (36%); chi2 = 9.3 (2 df) P = .01 with P(A-B) = 0.006; P(B-C) = 0.19; P(A-C) = 0.14. AVVSS scores improved in all groups as follows: A: 14.8 (9.3-22.6) to 6.4 (3.2-9.1), (P < .001); B: 15.8 (10.2-24.5) to 2.5 (1.1-3.7), (P < .001); and C: 15.1 (9.0-23.1) to 4.1 (2.3-6.8), (P < .001) and P(A-B) = 0.011, P(A -C) = 0.042. Patient satisfaction was highest in Group B. BK-EVLA was not associated with saphenous nerve injury. Extended EVLA is safe, increases spontaneous resolution of varicosities, and has a greater impact on symptom reduction. Similar benefits occurred after concomitant BK-GSV foam sclerotherapy.
The International Journal of Lower Extremity Wounds, 2004
Varicose veins are a common problem, conventionally treated by an operation. Within the last few ... more Varicose veins are a common problem, conventionally treated by an operation. Within the last few years, minimally invasive techniques have been developed as alternatives to surgery in an attempt to reduce morbidity and improve recovery time. Radiofrequency ablation and endovenous laser ablation are the most promising of these new techniques. This review article looks at the evidence for these techniques and the clinical experience to date and discusses their role in the future treatment of varicose veins.
The use of contrast-enhanced magnetic resonance angiography (CE-MRA) in screening for suspected r... more The use of contrast-enhanced magnetic resonance angiography (CE-MRA) in screening for suspected renovascular disease may result in increased detection of renal artery aneurysms. We report the CE-MRA findings at diagnosis and follow-up in nine hypertensive patients with unsuspected renal artery aneurysms. A search of renal CE-MRAs of suspected renal artery stenosis at two tertiary referral institutions over 5 1/2 years was performed. All patients underwent CE-MRA using a fast spoiled gradient echo technique (TR/TE/flip 5.1-6 ms/1.6 ms/40 degrees), scan matrix 512 x 196-224, 1 excitation, FOV 400-450 mm x 266-360 mm, 32-50 mm x 1.5-2 mm interpolated slices. Gadolinium-enhanced 3D images were obtained during breath holding. Images were evaluated and post-processed on a workstation by a single operator. Nine patients with renal artery aneurysms out of a total of 912 cases were found, all involving the main artery or divisions proximal to the renal hilum. Renal arteries distal to the hilum were not consistently visualized. The aneurysm was bilobed in one patient, multilocular in another and unilocular in all others. Severe stenosis of the renal artery proximal to the aneurysm was present in two. Four patients underwent follow-up showing no change in aneurysm size. CE-MRA reliably identifies aneurysms involving the main renal arteries and proximal branches. Once diagnosed, CE-MRA offers a safe, non-invasive modality for surveillance of aneurysm if active intervention is not planned.
European Journal of Vascular and Endovascular Surgery, 2004
To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage fo... more To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage following carotid endarterectomy and formulate potential protocols for prevention. MEDLINE database search of the English language literature (1966-2002) was performed using the words 'cerebral haemorrhage', 'intracranial haemorrhage' and 'carotid endarterectomy'. Other articles were cross-referenced by hand. There are no data from randomised trials confirming the significance of any single risk factor. The evidence suggests that the following may have a role: pre-operative hypertension, recent ipsilateral non-haemorrhagic stroke, previous ischaemic cerebral infarction, surgery for a > 90% ipsilateral internal carotid artery (ICA) stenosis, impaired cerebrovascular reserve, intra-operative haemodynamic or embolic ischaemia, post-operative hypertension, an ipsilateral increase of > or =175% in peak middle cerebral artery velocity (MCAV) and/or a > or =100% increase in pulsatility index. A critical ICA stenosis with impaired cerebrovascular reserve resulting in maximal intracerebral vasodilatation and post-operative hyperperfusion (impaired autoregulation) appear to be central to the development of ICH. Appropriate pre-operative screening and post-operative monitoring in high risk patients might identify those who would benefit from manipulation of the haemodynamic events that appear to promote ICH.
European Journal of Vascular and Endovascular Surgery, 2008
The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains u... more The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains unclear. The aim of this study was to analyze the frequency and predictors of HD during CAS in a single centre experience.
European Journal of Vascular and Endovascular Surgery, 2007
Conventional surgery for varicose veins due to small saphenous reflux is associated with high rec... more 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. 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. 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. 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.
European Journal of Vascular and Endovascular Surgery, 2007
Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) r... more 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. 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. 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.
European Journal of Vascular and Endovascular Surgery, 2008
Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and gr... more 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. Prospective, observational study. 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. 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. ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.
European Journal of Vascular and Endovascular Surgery, 2008
On behalf of the GALA Trial Collaborators. Eur J Vasc Endovasc Surg 2008;36:385-9. Objective: Rec... more On behalf of the GALA Trial Collaborators. Eur J Vasc Endovasc Surg 2008;36:385-9. Objective: Recent meta-analyses confirm an advantage to patch angioplasty during carotid endarterectomy (CEA) and suggest a benefit from routine shunting. GALA Trial (RCT: general [GA] versus local [LA] anaesthesia for CEA) collaborators (non-UK [European] and UK) were surveyed to assess current practice techniques. Materials and Methods: Postal questionnaires determined: shunt usage, monitoring techniques dictating shunt deployment, criteria for patching and the influence of anaesthetic technique upon these decisions. Results: 157/216 surgeons (73%) replied. For UK surgeons (n ϭ 76) performing GA CEA a shunt was always, never, or selectively used by 73.6%, 4.2% and 22.2% respectively. Figures for non-UK surgeons (n ϭ 77) were 20.8% (p Ͻ 0.0001), 26% (p Ͻ 0.0002) and 53.2% (p Ͻ 0.0001). When shunting selectively, fewer UK surgeons relied on stump pressure (26.4% v 48.1%; p Ͻ 0.0064) with TCD more widely used (38.9% v 11.7%; p Ͻ 0.0001). Shunting criteria during LA CEA were the same for both groups (impaired awake-testing). Routine patching was commoner amongst UK surgeons (GA: 76.4% v 34.2%, p Ͻ 0.0001; LA: 70.1% v 31.9%, p Ͻ 0.0001).
ABSTRACT Gluteal compartment syndrome following aortic surgery is a rare, often unrecognised comp... more ABSTRACT Gluteal compartment syndrome following aortic surgery is a rare, often unrecognised complication. This report presents a case of unilateral gluteal compartment syndrome following an elective aortobifemoral bypass graft for an aortic aneurysm in a 58-year old male. Vascular surgeons and intensive care physicians should be aware of this potentially serious complication following aortic surgery and maintain a high index of suscpicion.
Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe caroti... more Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe carotid stenosis, provided surgical morbidity and mortality are acceptably low. To assess the current performance of CEA in the UK, an interim analysis of 30-day postoperative outcome data, blinded to anaesthetic allocation, from the first 1,001 UK patients randomised in the GALA Trial (multicentre randomised trial of general versus local anaesthesia for CEA) took place and the time from last symptomatic event to surgery was recorded. The 30-day risk of stroke was 5.3%, myocardial infarction (MI) 0.4%, death 1.7%, and stroke, MI or death 6.4%. Median delay between symptoms and surgery was 82 days. These risks are similar to those reported in the large randomised trials of CEA, but current delays to surgery are excessive and must have substantially reduced the benefit of endarterectomy.
15´6 pg ml ±1 respectively; P = 0´047, Kruskal±Wallis test). The AAA growth rate for patients of ... more 15´6 pg ml ±1 respectively; P = 0´047, Kruskal±Wallis test). The AAA growth rate for patients of GG, GC and CC genotypes was 0´38, 0´36 and 0´36 cm per year respectively (P = 0´37). Mortality was lower for patients of GG genotype than for those with GC or CC genotype: hazard ratio 0´51 (95 per cent con®dence interval (c.i.) 0´25±1´00), P = 0´05; and 0´32 (95 per cent c.i. 0´12±0´93), P = 0´036, for all-cause and cardiovascular mortality respectively. Conclusion: Genetic polymorphism is associated with clinical events in patients with an AAA. The G to C IL-6 polymorphism at position ±174 predicts future cardiovascular mortality. Neither plasma IL-6 concentration nor IL-6 genotype predicts AAA growth.
Previous Magnetic Resonance (MR) studies of carotid endarterectomy (CEA) specimens have been dire... more Previous Magnetic Resonance (MR) studies of carotid endarterectomy (CEA) specimens have been directed at interpreting image contrast to determine plaque composition and stability. Such studies may give misleading results since it is believed that the acquired MR data is affected by the conditions used to store the excised tissue. This has been investigated in a high-resolution imaging study of the changes in contrast occurring with a change in specimen temperature. MR images were acquired from 20 CEA specimens. The initial MR examination was made within four hours of excision in tissue maintained and imaged at body temperature. Specimens were subsequently cooled and then re-examined at different times. The MR data was interpreted by comparison with histology obtained from equivalent sections. With the exception of signals arising from blood, changes in MR image contrast occurring in the 24-hour period after the CEA were relatively slight. Plaque lipid T2-weighted image intensity was...
Results: Principal reflux sites were thigh perforators alone (6/153 [4%]), and the saphenofemoral... more Results: Principal reflux sites were thigh perforators alone (6/153 [4%]), and the saphenofemoral (106/153 [69%]) or saphenopopliteal (41/153 [27%]) junctions. A total of 10/153 (7%) had calf perforator incompetence (CPI). Four patterns of reflux were identified (I: isolated SV reflux ...
We have addressed the issue of validation in a different way,3 in which we used a modified standa... more We have addressed the issue of validation in a different way,3 in which we used a modified standard endarterectomy technique that provides an intact carotid plaque.3 The preservation of plaque morphology, in particular the luminal surface, allows accurate measurement ...
Carotid angioplasty and stenting is gaining in popularity as an alternative to carotid endarterec... more Carotid angioplasty and stenting is gaining in popularity as an alternative to carotid endarterectomy for the treatment of symptomatic critical stenoses of the internal carotid artery. However, the durability of this technique and the incidence of recurrent stenoses has not yet been fully evaluated. It has been reported that mechanical factors may cause deformity of a Palmaz stent, negating the initial benefits of the procedure. We describe successful carotid endarterectomy after distortion of a Strecker balloon-expandable stent.
Purpose: Symptomatic carotid plaques are characterized by reduced fibrous tissue content, increas... more Purpose: Symptomatic carotid plaques are characterized by reduced fibrous tissue content, increased lipid content, intraplaque hemorrhage, and cap rupture. This confers an increased stroke risk. Plaque remodelling reduces this risk, however, and this study has evaluated differences in echomorphology at varying times after a neurologic event.
Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% ... more Following above-knee (AK) great saphenous vein (GSV) endovenous laser ablation (EVLA) 40% to 50% patients have residual varicosities. This randomized controlled trial (RCT) assesses whether more extensive GSV ablation enhances their resolution and influences symptom improvement. Sixty-eight limbs (65 patients) with varicosities and above and below-knee GSV reflux were randomized to Group A: AK-EVLA (n = 23); Group B: EVLA mid-calf to groin (n = 23); and Group C: AK-EVLA, concomitant below-knee GSV foam sclerotherapy (n = 22). Primary outcomes were residual varicosities requiring sclerotherapy (6 weeks), improvement in Aberdeen varicose vein severity scores (AVVSS, 12 weeks), patient satisfaction, and complication rates. EVLA ablated the treated GSV in all limbs. Sclerotherapy requirements were Group A: 14/23 (61%); Group B: 4/23 (17%); and Group C: 8/22 (36%); chi2 = 9.3 (2 df) P = .01 with P(A-B) = 0.006; P(B-C) = 0.19; P(A-C) = 0.14. AVVSS scores improved in all groups as follows: A: 14.8 (9.3-22.6) to 6.4 (3.2-9.1), (P < .001); B: 15.8 (10.2-24.5) to 2.5 (1.1-3.7), (P < .001); and C: 15.1 (9.0-23.1) to 4.1 (2.3-6.8), (P < .001) and P(A-B) = 0.011, P(A -C) = 0.042. Patient satisfaction was highest in Group B. BK-EVLA was not associated with saphenous nerve injury. Extended EVLA is safe, increases spontaneous resolution of varicosities, and has a greater impact on symptom reduction. Similar benefits occurred after concomitant BK-GSV foam sclerotherapy.
The International Journal of Lower Extremity Wounds, 2004
Varicose veins are a common problem, conventionally treated by an operation. Within the last few ... more Varicose veins are a common problem, conventionally treated by an operation. Within the last few years, minimally invasive techniques have been developed as alternatives to surgery in an attempt to reduce morbidity and improve recovery time. Radiofrequency ablation and endovenous laser ablation are the most promising of these new techniques. This review article looks at the evidence for these techniques and the clinical experience to date and discusses their role in the future treatment of varicose veins.
The use of contrast-enhanced magnetic resonance angiography (CE-MRA) in screening for suspected r... more The use of contrast-enhanced magnetic resonance angiography (CE-MRA) in screening for suspected renovascular disease may result in increased detection of renal artery aneurysms. We report the CE-MRA findings at diagnosis and follow-up in nine hypertensive patients with unsuspected renal artery aneurysms. A search of renal CE-MRAs of suspected renal artery stenosis at two tertiary referral institutions over 5 1/2 years was performed. All patients underwent CE-MRA using a fast spoiled gradient echo technique (TR/TE/flip 5.1-6 ms/1.6 ms/40 degrees), scan matrix 512 x 196-224, 1 excitation, FOV 400-450 mm x 266-360 mm, 32-50 mm x 1.5-2 mm interpolated slices. Gadolinium-enhanced 3D images were obtained during breath holding. Images were evaluated and post-processed on a workstation by a single operator. Nine patients with renal artery aneurysms out of a total of 912 cases were found, all involving the main artery or divisions proximal to the renal hilum. Renal arteries distal to the hilum were not consistently visualized. The aneurysm was bilobed in one patient, multilocular in another and unilocular in all others. Severe stenosis of the renal artery proximal to the aneurysm was present in two. Four patients underwent follow-up showing no change in aneurysm size. CE-MRA reliably identifies aneurysms involving the main renal arteries and proximal branches. Once diagnosed, CE-MRA offers a safe, non-invasive modality for surveillance of aneurysm if active intervention is not planned.
European Journal of Vascular and Endovascular Surgery, 2004
To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage fo... more To determine risk factors for the development of hyperperfusion and intra-cerebral haemorrhage following carotid endarterectomy and formulate potential protocols for prevention. MEDLINE database search of the English language literature (1966-2002) was performed using the words 'cerebral haemorrhage', 'intracranial haemorrhage' and 'carotid endarterectomy'. Other articles were cross-referenced by hand. There are no data from randomised trials confirming the significance of any single risk factor. The evidence suggests that the following may have a role: pre-operative hypertension, recent ipsilateral non-haemorrhagic stroke, previous ischaemic cerebral infarction, surgery for a > 90% ipsilateral internal carotid artery (ICA) stenosis, impaired cerebrovascular reserve, intra-operative haemodynamic or embolic ischaemia, post-operative hypertension, an ipsilateral increase of > or =175% in peak middle cerebral artery velocity (MCAV) and/or a > or =100% increase in pulsatility index. A critical ICA stenosis with impaired cerebrovascular reserve resulting in maximal intracerebral vasodilatation and post-operative hyperperfusion (impaired autoregulation) appear to be central to the development of ICH. Appropriate pre-operative screening and post-operative monitoring in high risk patients might identify those who would benefit from manipulation of the haemodynamic events that appear to promote ICH.
European Journal of Vascular and Endovascular Surgery, 2008
The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains u... more The clinical significance of Haemodynamic Depression (HD) during carotid stenting (CAS) remains unclear. The aim of this study was to analyze the frequency and predictors of HD during CAS in a single centre experience.
European Journal of Vascular and Endovascular Surgery, 2007
Conventional surgery for varicose veins due to small saphenous reflux is associated with high rec... more 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. 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. 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. 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.
European Journal of Vascular and Endovascular Surgery, 2007
Reflux in the GSV due to sapheno-popliteal incompetence associated with ascending (paradoxical) r... more 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. 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. 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.
European Journal of Vascular and Endovascular Surgery, 2008
Endovenous laser ablation (EVLA) is an alternative to surgery for treating sapheno-femoral and gr... more 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. Prospective, observational study. 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. 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. ED (J/cm) of laser delivery is the main determinant of successful GSV ablation following EVLA.
European Journal of Vascular and Endovascular Surgery, 2008
On behalf of the GALA Trial Collaborators. Eur J Vasc Endovasc Surg 2008;36:385-9. Objective: Rec... more On behalf of the GALA Trial Collaborators. Eur J Vasc Endovasc Surg 2008;36:385-9. Objective: Recent meta-analyses confirm an advantage to patch angioplasty during carotid endarterectomy (CEA) and suggest a benefit from routine shunting. GALA Trial (RCT: general [GA] versus local [LA] anaesthesia for CEA) collaborators (non-UK [European] and UK) were surveyed to assess current practice techniques. Materials and Methods: Postal questionnaires determined: shunt usage, monitoring techniques dictating shunt deployment, criteria for patching and the influence of anaesthetic technique upon these decisions. Results: 157/216 surgeons (73%) replied. For UK surgeons (n ϭ 76) performing GA CEA a shunt was always, never, or selectively used by 73.6%, 4.2% and 22.2% respectively. Figures for non-UK surgeons (n ϭ 77) were 20.8% (p Ͻ 0.0001), 26% (p Ͻ 0.0002) and 53.2% (p Ͻ 0.0001). When shunting selectively, fewer UK surgeons relied on stump pressure (26.4% v 48.1%; p Ͻ 0.0064) with TCD more widely used (38.9% v 11.7%; p Ͻ 0.0001). Shunting criteria during LA CEA were the same for both groups (impaired awake-testing). Routine patching was commoner amongst UK surgeons (GA: 76.4% v 34.2%, p Ͻ 0.0001; LA: 70.1% v 31.9%, p Ͻ 0.0001).
ABSTRACT Gluteal compartment syndrome following aortic surgery is a rare, often unrecognised comp... more ABSTRACT Gluteal compartment syndrome following aortic surgery is a rare, often unrecognised complication. This report presents a case of unilateral gluteal compartment syndrome following an elective aortobifemoral bypass graft for an aortic aneurysm in a 58-year old male. Vascular surgeons and intensive care physicians should be aware of this potentially serious complication following aortic surgery and maintain a high index of suscpicion.
Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe caroti... more Carotid endarterectomy (CEA) is of benefit for stroke prevention in the presence of severe carotid stenosis, provided surgical morbidity and mortality are acceptably low. To assess the current performance of CEA in the UK, an interim analysis of 30-day postoperative outcome data, blinded to anaesthetic allocation, from the first 1,001 UK patients randomised in the GALA Trial (multicentre randomised trial of general versus local anaesthesia for CEA) took place and the time from last symptomatic event to surgery was recorded. The 30-day risk of stroke was 5.3%, myocardial infarction (MI) 0.4%, death 1.7%, and stroke, MI or death 6.4%. Median delay between symptoms and surgery was 82 days. These risks are similar to those reported in the large randomised trials of CEA, but current delays to surgery are excessive and must have substantially reduced the benefit of endarterectomy.
15´6 pg ml ±1 respectively; P = 0´047, Kruskal±Wallis test). The AAA growth rate for patients of ... more 15´6 pg ml ±1 respectively; P = 0´047, Kruskal±Wallis test). The AAA growth rate for patients of GG, GC and CC genotypes was 0´38, 0´36 and 0´36 cm per year respectively (P = 0´37). Mortality was lower for patients of GG genotype than for those with GC or CC genotype: hazard ratio 0´51 (95 per cent con®dence interval (c.i.) 0´25±1´00), P = 0´05; and 0´32 (95 per cent c.i. 0´12±0´93), P = 0´036, for all-cause and cardiovascular mortality respectively. Conclusion: Genetic polymorphism is associated with clinical events in patients with an AAA. The G to C IL-6 polymorphism at position ±174 predicts future cardiovascular mortality. Neither plasma IL-6 concentration nor IL-6 genotype predicts AAA growth.
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Papers by Michael Gough