The perigenicula lower limb amputations performed for peripheral vascular disease in Nottingham between April 1987 and September 1992 were reviewed. Of the 434 amputations, 173 were below-knee amputations (BKA), 144 Gritti-Stokes amputations (GSA) and 117 above-knee amputations (AKA). The 30-day mortality was significantly greater for AKA patients than either GSA or BKA patients. There was no difference in mortality within 30 days of amputation between GSA and BKA. Re-amputation rate to a more proximal level was significantly higher in BKA compared with GSA. Mobility after prosthetic rehabilitation was assessed using the Stanmore grading. A greater number of patients achieved mobility grade III and above in the GSA and BKA groups when compared with the AKA group, but there was no significant difference between GSA and BKA groups. At follow-up, a median of 23 months after amputation, there was a tendency for more patients to have given up using their limb prosthesis in the GSA group than either the BKA or AKA groups. However, there remained no significant difference between the BKA and GSA groups in the numbers of patients who remained successfully rehabilitated to Stanmore grade III or above.

OBJECTIVES:To compare collagen, elastin and smooth muscle contents of varicose and control long saphenous veins.DESIGN:Collagen, elastin and muscle were estimated stereologically using random sampling and histological staining.MATERIALS:Varicose vein samples were collected from nine patients (mean age 52 years, range 34-64 years) undergoing vein stripping, sample sites being saphenofemoral junction and knee. Control samples were taken from five patients (mean age 58 years, range 38-76 years) presenting for femoral-popliteal bypass at equivalent levels.METHODS:Veins were fixed, sectioned transversely, and stained with Picric Acid Sirius Red. Analysis of samples was performed using point and intersection counting on vertically projected images.RESULTS:Using two way analysis of variance tests, varicose saphenous veins had significantly larger wall areas (p < 0.01) and higher amounts of collagen (p < 0.01). Collagen content and wall area were significantly larger proximally compared to distally in both control and varicose veins (p < 0.05) with a higher content of smooth muscle and elastin in varicose veins proximally compared to distally (p < 0.05). There was no difference in wall thickness or elastin content between the two groups.CONCLUSIONS:This suggests that varicose veins are a dynamic response to venous hypertension and are not thin walled structures as previously thought.

Objectives: To assess the effect of varicose vein surgery on the venous function of the lower limb and to determine the ability of strain-gauge and photoplethysmography in discriminating between normal and abnormal venous function.Design: Prospective randomized trial with follow-up to 1 month postoperatively.Study group: Fifteen patients presenting for varicose vein surgery and 10 controls with no evidence of venous insufficiency. Interventions: Venous investigations were carried out preoperatively and at 1 month postoperative appointments. Main outcome measures: The effect of varicose vein surgery on lower limb venous function and the ability of plethysmography to distinguish normal from abnormal venous function. Results: Significant differences were found between pre- and postoperative venous refilling times (VRT) in patients attending for varicose vein surgery (p<0.01). Significant differences were also found between control and case preoperative VRTs. No significant differences were found between pre- and postoperative, and case/control venous outflow (VO) and venous capacitance (VC) values.Conclusion: Varicose vein surgery improved the venous function in all of the lower limbs investigated. Photoplethysmographic venous refilling times were found to be a useful, reproducible measure, able to distinguish normal from abnormal venous function.

Pulse spray thrombolysis is a technique of accelerated peripheral thrombolysis which has been evaluated in 38 patients, 29 with threatened limb viability and nine with a viable but critically ischaemic limb. The median length of occlusion was 26.5 (range 3-65) cm. The lytic agent used was recombinant tissue plasminogen activator (rtPA), injected manually via a pulse spray catheter at a concentration of 0.33 mg/ml and a bolus size of 0.2 ml. The median total dose of rtPA was 18 (range 5-35) mg. Patency and flow were completely restored in 34 of 38 patients and clinical success at 30 days was maintained in 27 of 38. The median lysis time was 120 (range 35-1125) min, compared with a median duration of 1545 (range 42-5760) min in 120 consecutive patients previously treated with conventional low-dose infusion thrombolysis using rtPA. This represents a 12-fold reduction in lysis time (P < 0.001). The overall estimated cumulative limb salvage rate for the 38 patients who entered the study was 84 per cent and the cumulative patency rate for the 34 patients in whom patency was restored was 74 per cent at 18 months follow-up. Pulse spray thrombolysis rapidly restores patency with good limb salvage at 30 days; the benefit is sustained even in patients with limbs at immediate risk of irreversible ischaemic injury who are not considered suitable for conventional thrombolysis.

Objectives: To compare the rime required to achieve lysis with the pulse spray technique and the conventional slow continuous infusion technique.Design: Prospective randomised open Study.Methods: Eighteen patients suitable for intra-arterial thrombolytic therapy with conventional and pulse spray technique were randomised 1:1 to receive either pulse spray thrombolysis with 0.33 mg/ml rt-PA injected as a bolus of 0.2 ml or conventional thrombolysis with 0.05 mg/ml rt-PA infused at a rate of 10 ml/h.Results: The age, duration of symptoms, length of occlusion and prethrombolysis ankle brachial pressure index were comparable in the two groups. The median duration of thrombolytic therapy in the pulse spray group was 195 min (range 90-1260) compared to 1390 min (range 300 - 2400) in the Conventional group. The difference between the two groups was significant, p<0.002 (Mann-Whitney test).Conclusions: Significantly shorter lime is required to achieve local thrombolysis with pulse spray compared to the conventional infusion method.

Objectives: To study the use of carbon dioxide as a contrast medium for arteriMethods: Carbon dioxide was used as a contrast medium for intra-arterial digital subtraction lower limb angiography in 12 examinations on 11 patients.Results: No complication was encountered and no significant changes occurred in the arterial pH, PaCO2 and PaO2. The quality of images as assessed by an independent observer was adequate for the majority of the vessels (77%).Conclusions: Carbon dioxide is a safe alternative in patients at an increased risk of adverse reaction to iodinated ionic or non-ionic contrast medium and is very cheap.

Objective: Assessment of outcome after varicose vein surgeryDesign: Prospective study using the Health Assessment Questionnaire (SF36) which considers different aspects of overall health.Setting: University Hospital and Community.Materials: 150 patients undergoing varicose vein surgery.Chief outcome measures: SF36 questionnaires were sent pre-operatively and at 1 and 6 months post surgery.Main results: Eighty-nine (59%) patients answered all three questionnaires. Pre-operatively their overall health was similar to that of the general population. The ''cost'' to the patient of the operation was demonstrated by an increased pain and reduced role function at 1 month post-operation (p<0.01). By 6 months post-operation, when compared with preoperative values, all dimensions except social function and health perception were improved (p<0.01). Overall symptoms improved (p<0.01) by 1 month and were further improved at 6 months.Conclusions: The general good health of varicose vein patients may justify the low priority given to their treatment, but the improvement in symptoms and general health that relatively simple surgery provides should ensure its continued provision as a health care service.

Objectives: To assess the ability of compression stockings to reduce the postoperative recurrence of varicose veins after surgery and to assess patient compliance.Design: Prospective randomized trial with follow-up to 1 year after surgery.Patients: Sixty-nine patients presenting for varicose vein surgery.Interventions: Interview for stocking compliance post-operatively with clinical and Doppler assessment of recurrence at 3, 6, 9 and 12 months postoperatively.Main outcome measures: Recurrence of varicosities and patient compliance.Results: 39% of patients allocated stockings were either lost to follow-up or abandoned their use after 3 months; 11% declined the stockings on presentation. By 1 year postoperatively, only 6% in the stocking group had recurrent varicose veins compared with 71% in the control group (no stockings).Conclusion: Despite an early, relatively high noncompliance rate, external compression hosiery significantly reduced postoperative recurrence of varicose veins.

Pulse-spray thrombolysis (PST) is a new technique of accelerated peripheral arterial thrombolysis. This technique has been evaluated on 24 patients with limb ischaemia. Severe acute limb-threatening ischaemia with sensory and motor deficit was present in 11/24 (45.8%) patients. The median dose of recombinant tissue plasminogen activator (rt-PA) used was 18 mg (10-35 mg) injected in a concentration of 0.33 mg/ml and bolus size of 0.2 ml. The median length of occlusions treated was 23 cm (range 4-55 cm). Complete initial lysis was achieved in 23/24 (95.8%) and limb salvage at 30 days was achieved in 18/24 (75%) of the cases. The overall 30-days mortality was 4/24 (16.6%) and 2/4 (50%) in those who required surgical intervention. The median duration of thrombolytic treatment was 137.5 minutes (range 35-1125 minutes) which is an 11-fold and significant reduction (p < 0.001, Mann-Whitney) in lysis time compared with the results of conventional low dose infusion of rt-PA at a rate of 0.5 mg/h in 120 consecutive patients in our unit. PST rapidly restores vascular patency and may become the treatment of choice for acute limb ischaemia including those at immediate risk of irreversible ischaemic injury which would not be considered suitable for conventional thrombolysis.

Pulse spray thrombolysis (PST) is a new technique of accelerated intra-arterial thrombolysis. The systemic fibrinolytic effect of PST with tissue-type plasminogen activator (t-PA) has been studied on 10 patients after they received 10 mg t-PA. A moderate systemic fibrinolytic effect was observed but this was not significantly different from the effect seen in another group of 32 patients treated with continuous slow infusion of 10 mg t-PA intra-arterially over 20 hours.

In a prospective analysis of 150 consecutive major vascular reconstructions, 104 patients were of normal weight (NW), 33 were overweight (OW) and 13 were obese (OB), as defined by body mass index calculations (BMI = kg/m2). Wound infections were more common in OW than NW patients (10/33 versus 10/104, p < 0.01) and in the OB compared to the NW group (4/13 versus 10/104, p < 0.05). Wound dehiscence was more common in the combined OW and OB groups than the NW patients (3/46 versus 0/104, p < 0.01). Chest infections were more common in OB (4/13) than NW (9/104) patients (p < 0.02). Median (interquartile range) in-patient stay was longer in OB patients [34 (15-41) days] compared to OW [14 (10-19) days, p < 0.001] and NW [11 (8-15) days; p < 0.001] patients. Nonetheless, there were no significant differences in the rates of more major complications or operative mortality between the three groups and early infrainguinal graft patency and limb salvage rates were not different. Only one prosthetic graft infection occurred in this series. In conclusion, despite the higher risk of infective complications, major vascular reconstruction can be performed safely in overweight and obese patients.

To determine the intermediate-term results of intra-arterial thrombolysis, 127 consecutive patients receiving 129 courses of treatment were reviewed at a median follow-up of 3 years. At initial review, 30 days after treatment, thrombolysis was successful in 63 cases (49 per cent). Of these patients, 16 were lost to follow-up: 15 died without further vascular symptoms and one moved from the area. Some 35 patients were alive and asymptomatic, of whom 33 had either angiographic or clinical evidence of continued arterial patency. Symptomatic reocclusion occurred in 12 cases; a further two patients remained asymptomatic and reocclusion was detected at follow-up. Two of the 12 symptomatic patients required amputation. Estimated patency rates were 80 per cent at 1 year, 72 per cent at 2 years and 70 per cent at 3 years. The intermediate-term results in the 66 cases in which lysis was unsuccessful were worse, only 16 patients (24 per cent) surviving to follow-up with the treated limb intact. It is concluded that, if thrombolysis is successful at 30 days, the intermediate-term results are good.

SummaryIn peripheral thrombolysis adjuvant anti-platelet therapy may help to lyse otherwise resistant thrombus, thereby increasing the number of patients successfully treated and reducing the “time to lysis”. If continued after lysis it may help to prevent early rethrombosis. In this pilot study 21 patients undergoing peripheral thrombolysis with streptokinase were randomised to receive the thromboxane receptor antagonist sulotroban or placebo. The dose of sulotroban given was 2 mg/min (four patients), 4 mg/min (five patients) or 8 mg/min (four patients), eight patients received placebo. The clinical and laboratory effects of the treatment were monitored.Thrombolysis was achieved more quickly in patients receiving sulotroban, however, there was no difference between groups in the number of patients in whom recanalisation was achieved (six of eight receiving placebo and eight of 13 receiving sulotroban) or in the number of cases of early rethrombosis. During lysis there was an increase in plasma beta-thromboglobulin with similar levels being found in patients receiving sulotroban and streptokinase and those receiving streptokinase alone. No other major changes in platelet function during lysis were seen in patients receiving streptokinase alone. Sulotroban significantly reduced platelet aggregtion and 14C-5HT release in response to several platelet agonists. With the thromboxane mimetic U46619 the degree of inhibition of aggregation and 14C-5HT release depended on the dose of sulotroban used. High levels of inhibition were associated with an excess of haemorrhagic complications especially in combination with a low plasma fibrinogen level.We conclude that the use of low dose sulotroban in combination with streptokinase merits further study and may have a role in accelerating lysis. However, the combination of high dose sulotroban with streptokinase causes an increased incidence of bleeding. Monitoring platelet function during such therapy may identify patients likely to bleed.

Objective: Determination of the ratio of collagen and elastin to protein content of varicose/non-varicose veins from calf and determination of collagen, elastin and smooth muscle density of varicose/non-varicose vein walls.Design: Prospective study; control vein samples obtained from amputees for ischaemic vascular disease and varicose vein samples obtained from an equivalent position following surgical stripping.Setting: Departments of Human Morphology and Vascular Surgery, Queen's Medical Centre, University of Nottingham, UK.Patients: Seven patients with no evidence of venous disease treated by amputation of the lower limb for vascular disease and 12 patients treated for varicose veins by ligation and stripping of the long saphenous vein.Interventions: Vein sections were examined biochemically and histologically using stereological techniques.Main outcome measures: Biochemical quanitfication of collagen, elastin and protein and stereological analysis of collagen, elastin and smooth muscle density of varicose and non-varicose veins.Results: There was no difference between the collagen/protein or elastin/protein ratio in varicose and normal veins but there was a significant increase in muscle density with corresponding decrease in collagen and elastin density in the walls of varicose veins compared with non-varicose vein controls.Conclusions: There were no differences in the collagen or elastin content of varicose veins when compared with non-varicose veins. Smooth muscle hypertrophy occurs in varicose veins, which appears to disrupt the collagen/elastin lattice of the vein wall.

Earlier workers have suggested a possible fibrinolytic effect using prostaglandin or prostaglandin analogues. Despite using maximum tolerated doses of the prostaglandin analogue Iloprost, we have been unable to demonstrate any significant effect on fibrinolysis in patients with stage IV peripheral vascular disease (Fontaine classification).