The clinical significance of below-knee great saphenous vein reflux following endovenous laser ablation of above-knee great saphenous vein, by NS Theivacumar, RJ Darwood, D Dellagrammaticas, AID Mavor, MJ Gough, Phlebology DOI:10.1258/phleb.2008.008004, published February 2009; 24 (1): 17-20. The authors would like to note the following correction to their article: One of the co-authors' names was misspelled; it appears as Dellegrammaticas; however, it should be spelt Dellagrammaticas.

BACKGROUNDNitrous oxide has been associated with increased vascular risk in the perioperative period. Here, we conducted a secondary analysis of the GALA trial to ascertain the impact of nitrous oxide on outcomes after carotid surgery under general anaesthesia (GA).METHODSOne thousand seven hundred and seventy-three patients underwent GA, but 158 patients were excluded from this analysis as nitrous oxide use was unknown. The decision to use nitrous oxide was at the discretion of the anaesthetist and was not randomized. Six hundred and seventy-one patients received nitrous oxide and 944 patients did not. Logistic regression was used to analyse the same primary outcome as the original trial (risk of death, stroke, or myocardial infarction within 30 days of the operation).RESULTSPatients who received nitrous oxide were more likely to have had coronary artery disease, peripheral vascular disease, and atrial fibrillation (all P<0.05). Overall, there were 35 (5.2%) primary outcome events in patients receiving nitrous oxide compared with 44 (4.7%) in those who did not [relative risk 1.12, 95% confidence interval (CI: 0.73, 1.73); P=0.63]. The adjustment for the imbalanced baseline variables using logistic regression reduced the point estimate of harm for nitrous oxide [adjusted odds ratio 1.09, 95% CI (0.68, 1.74); P=0.73].CONCLUSIONSGiven the greater prevalence of vascular risk factors in the nitrous oxide group and the lack of any definite effect on the primary outcome measure, these data do not support a clinically meaningful adverse effect of nitrous oxide on our composite outcome in patients undergoing carotid surgery.

Several treatment options are available for primary hyperhidrosis. Selection for individual patients is influenced by symptom severity, success rates and the relative risk of compensatory hyperhidrosis. A 24-year-old female presented with a 10-year history of palmar, pedal and axillary hyperhidrosis. Following recurrent relapse after botulinum toxin (BOTOX®) injections for axillary hyperhidrosis bilateral axillary sweat gland curettage was performed with immediate procedural success. At 6 month follow-up recurrent hyperhidrosis was reported affecting both axillae. A starch-iodine test showed a rim of persisting sweating at the periphery of both axillae. Curettage is generally performed without specific identification of sweat gland distribution, perhaps explaining the recurrence in this patient. In contrast, a starch–iodine test is used to guide administration of BOTOX® for hyperhidrosis. We propose pre-operative use of this technique before axillary curettage.

Objectives: To compare the half-life of STD and Polidocanol air-based foams and the damage they inflict upon human great saphenous vein in an in-vitro model.Methods: The time for the volume of 3% STD and polidocanol foams to reduce by 10% (T-90) and 50% (T-50) was recorded in an incubator at 37 C. Segments of proximal GSV harvested during varicose vein surgery were filled with foam for 5 or 15 min. Histological analysis determined percentage endothelial cell loss and depth of media injury.Results: Median (+/-IQR) T-90 and T-50 for polidocanol were 123.3 s(111.7-165.6) and 266.3 s(245.6-383.1) versus 102.03 s (91.1-112) and 213.13 s (201-231.6) for STD (T-90 p = 0.008, T-50 p = 0.004). Median endothelial loss with polidocanol was; 63.5% (62.2-82.8) and 85.9% (83.8-92.5) versus 86.3% (84.8-93.7) and 97.64% (97.3-97.8) for STD after 5 and 15 min (p = 0.076 and p = 0.009). The median depth and % media thickness injured were 0 mu m (0-0 mu m) and 0% for both assessments with polidocanol versus 37.4 mu m (35.3-45.8 and 43.4 mu m (42.1-46.7) and 3.5% (3.1-3.6) and 5.3% (3.7-6.0) after 5 and 15 min for STD (p < 0.01 for all comparisons).Conclusion: Although polidocanol foam shows greater stability than STD foam perhaps remaining in the vein for longer, endothelial cell loss and damage to the media were significantly greater with STD. (C) 2012 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery.

Professor Naylor and his team should be congratulated on both the thoroughness of this audit and the excellent results that they have achieved. The principle ethos for all surgeons who perform carotid endarterectomy (CEA) should be an on-going commitment to increase the safety of surgery. For these authors quality control, both intra- and post-operatively has been the focus of improved outcomes during an extensive experience. So why haven’t we all adopted the methods that Professor Naylor proposes? Is it laziness, overconfidence, lack of resources or a belief that the problem is not as great as the authors lead us to believe? Like most vascular surgeons I consider myself neurotic about the ability of CEA to end in devastating outcomes for both the patient and surgeon so this rules out the first two reasons for not adopting angioscopy. I also believe that neurosis, together with the use of intra-operative magnification eliminates the need to further examine the distal limit of the endarterectomy, a view that is essentially supported by the findings of Professor Naylor’s report. What remains is the issue of residual thrombus at the endarterectomy site as a cause of intra-operative stroke. This will not be prevented by completion duplex ultrasonography performed once flow has been restored, a technique proposed by other authors who also report excellent outcomes for surgery.1Padayachee T.S. Brooks M.D. Modaresi K.B. Arnold A.J. Self G.W. Taylor P.R. Intraoperative high resolution duplex imaging during carotid endarterectomy: which abnormalities require surgical correction?.Eur J Vasc Endovas Surg. 1998; 15: 387-393Google Scholar, 2Walker R.A. Fox A.D. Magee T.R. Horrocks M. Intraoperative duplex scanning as a means of quality control during carotid endarterectomy.Eur J Vasc Endovas Surg. 1996; 11: 364-367Google Scholar Of course, nobody would dispute that large thrombi that embolise following clamp release will probably cause a stroke and that they should be removed. Given that nearly all CEAs are performed under loco-regional anaesthesia in our unit I can be confident that we are not leaving large thrombi in situ. Thus it seems logical to assume that a policy of more limited inspection prior to patch closure and a very careful protocol for flushing the endarterectomy site can achieve the same results. The principle steps in this protocol are:1.Back-bleed the internal (ICA) and external (ECA) carotid arteries and then re-clamp.2.Flush arteriotomy with heparinised saline and then blood at arterial pressure by releasing the proximal clamp temporarily (flushes both the distal common carotid artery and the endarterectomy site) and then re-clamp.3.A further forceful flush with heparinised saline followed by aspiration of the endarterectomy site with an American pattern sucker.4.Completion of patch closure during ICA back-bleeding followed by initial perfusion of the ECA. Thus I believe that the same benefit arises from continuous paranoia and the use of suction rather than angioscopy. Small thrombi that “blind” suction may miss are likely to be unstable following the administration of pre-operative clopidogrel and intra-operative heparin and thus even if embolisation occurs spontaneous lysis is likely. In conclusion, Professor Naylor views are correct because he pays obsessional attention to detail and he has confidence in this technique. However I would suggest that a fine suction device might be a simple alternative to angioscopy. There is no place for laziness or overconfidence but I’m not going to buy an angioscope either! The War Against Error: A 15 Year Experience of Completion Angioscopy Following Carotid EndarterectomyEuropean Journal of Vascular and Endovascular SurgeryVol. 43Issue 2PreviewA policy of intra-operative transcranial Doppler (TCD) and completion angioscopy was previously associated with virtual abolition of intra-operative stroke (apparent upon recovery from anaesthesia) following carotid endarterectomy (CEA). The aims of this study were to determine whether the prevalence of technical error has diminished with experience and whether our monitoring/quality control policy was still associated with low rates of intra-operative stroke 20 years after its introduction. Full-Text PDF Open Archive

Carotid endarterectomy (CEA) within two weeks of the index neurological event (INE) achieves maximum stroke prevention. This study assesses the impact of institution-wide policy changes on CEA performance in symptomatic patients. Between two study periods (1 January 2007 and 31 December 2007; 1 August 2008 and 31 July 2009) transient ischaemic attack (TIA) clinics, an acute stroke protocol and utilisation of vascular operating lists, were adopted. Following the changes, the interval between the INE and CEA fell from 23 (n = 65; interquartile range (IQR) 9-66) to 6.5 (n = 52; IQR 2-13.5) days (p < 0.001) with 32.3% v 82.7% performed within two weeks (p < 0.001). Significant improvements were seen in the time taken from onset of symptoms to presentation, and presentation to a carotid duplex and surgical review. Univariate analyses suggest this improvement is associated with the type of INE, point of presentation and the need for further imaging. Implementation of these policies has produced a significant improvement in service provision largely meeting the two-week target.

ObjectivesThis cohort study assesses the effectiveness and safety of endovenous laser ablation (EVLA) in the management of recurrent varicose veins (RVVS).Method104 limbs (95 patients) undergoing EVLA for RVVS were grouped according to pattern of reflux. For patients with recurrent SFJ/great saphenous vein (GSV) (Group GR) and SPJ/small saphenous vein (SSV) (Group SR) varicosities ablation rates and QoL (Aberdeen Varicose Vein Severity Scores (AVVSS)) were compared with those for age/sex matched patients undergoing EVLA for primary GSV/SSV dependent varicose veins (Groups GP and SP).ResultsIn patients with RVVS the axial vein was ablated in 102/104 (98%) limbs whilst 2 GSVs (group GR) partially recanalised by 3 months (GSV ablated in 49/51 (96%) limbs versus 50/51 (98%) limbs in GP [p = 0.2]). Improvements in AVVSS at 3 months (median GR: 14.2 (inter-quartile range (IQR) 10.2–18.9) to 3.2(1.2–6.4), p < 0.001; GP: median 15.9(IQR 11.4–22.7) to 3.8(1.1–5.6), p < 0.001, Mann–Whitney u-test) were similar (78% versus 76%, p = 0.23). The SSV was ablated in 24/24 limbs in groups SR and SP and the % improvement in AVVSS was 83% (median 14.4 (IQR 8.2–19.4) to 2.4 (1.9–4.6), p < 0.001, Mann–Whitney u-test) and 84% (median 13.8 (IQR 6.3–17.5) to 2.2 (1.2–5.1), p < 0.001) respectively (p = 0.33). These improvements persisted at 1 year follow-up. A further 29 limbs with isolated anterior accessory great saphenous vein (AAGSV) or segmental GSV/SSV reflux were successfully ablated. Complication rates for primary and RVVS were similar.ConclusionsEVLA is a safe and effective option for the treatment of RVVS and could be a preferred option for suitable patients.

INTRODUCTION:Recanalisation rates (20-32%) 1-3 years after truncal vein foam sclerotherapy (FS) suggest thrombotic occlusion rather than irreversible vein wall injury. This study examines the injury inflicted by sodium tetradecyl sulphate (STD) foam before and after balloon endothelial denudation (BD). METHODS:In 20 patients undergoing great saphenous vein (GSV) stripping 1.5 cm proximal GSV were harvested (controls). The next 1.5 cm were harvested after in situ BD (n = 10) or no denudation (n = 10). These test segments were filled with 1% or 3% STD foam (5 min), flushed and fixed in formalin. Percentage endothelial cell loss (ECL) and tunica media injury were determined (H&E staining) and collagen structure assessed (transmission electron microscopy, TEM). RESULTS:Controls showed no injury. 1% and 3% STD foam caused 86.3% and 92.2% ECL (p < 0.001 versus controls; 1% versus 3%, p = 0.55). Endothelial cells persisted in all sections. BD increased ECL (1%: 96.9%, 3%: 98.1%, p = 0.01) Tunica media injury (smooth muscle vacuolation) was minimal (8.9% (1% STD) and 12% (3% STD) of its depth) and not enhanced by BD (1%: 8.7%, p = 0.93; 3%: 11.3%; p = 0.86). No collagen disruption occurred (TEM). CONCLUSIONS:Balloon denudation increased ECL but did not facilitate tunica media injury. Equivalent injury was inflicted by 1% and 3% STD.

We read with interest this article regarding improving the provision of carotid endarterectomy (CEA). As noted, achieving a 2-week target requires a change in practice as well as ‘motivated’ surgeons. Historically, CEA was performed more frequently by some surgeons in our unit (7 in total) than others, reflecting referral practices and ‘special’ interests. In order to meet the 2-week target, we developed a policy that all symptomatic patients requiring CEA would be accommodated on the next available consultant operating list. Over the last 6 months, we have achieved 97% compliance with the 2-week target. With increasing centralisation, many centres now have ‘vascular’ lists most days. We would, therefore, recommend our unit's policy to others particularly since a recent national audit suggests little improvement in CEA provision since the 2-week time limit was published.1 In addition, the greatest risk of stroke is within the first few days following the index neurological event2 and awareness amongst the public and GPs regarding the significance of transient ischaemic attacks is poor;3 greater steps are required to identify ‘brain attacks’ early through public awareness campaigns and physician education. We believe that this and the suggested changes in service provision are required to improve overall outcomes.

Background: Patency and limb salvage after synthetic bypass to the arteries below-knee are inferior to that which can be achieved with autologous vein. Use of a vein collar at the distal anastomosis has been suggested to improve patency and limb salvage, a problem that is analysed in this randomised clinical study.Methods: Patients with critical limb ischaennia undergoing polytetrafluoroethylene (PTFE) bypass to below-knee arteries were randomly either assigned a vein collar or not in two groups bypass to the popliteal artery below-knee (femoro-popliteal below-knee (FemPopBK)) and more distal bypass (femoro-distal bypass (FemDist)). Follow-up was scheduled until amputation, death or at most 5 years, whichever event occurred first.Results: In the FemPopBK and in the FemDist groups, 115/202 and 72/150 were randomised to have a vein collar, respectively. Information was available for 345 of 352 randomised patients (98%).At 3 years, primary patency was 26% (95% confidence interval (CI) 18-38) with a vein collar and 43 (33-58) without a vein collar for femoro-popliteal bypass and 20 (11-38), and 17 (9-33) for femoro-distal bypass, respectively. The corresponding figures for limb salvage were 64 (54-75) and 61(50-74) for femoro-popliteal bypass, and 59 (46-76) and 44 (32-61) for femoro-distal bypass with and without a vein collar, respectively. Log-rank-test for the whole Kaplan-Meier life table curve showed no statistically significant differences with or without vein collar primary patency: p = 0.0853, p = 0.228; secondary patency: p = 0.317, p = 0.280; limb salvage: p = 0.757, p = 0.187 for FemPopBK and FemDist, respectively. The use of a vein collar did not influence patency or limb salvage.Conclusion: This study failed to show any benefit for vein collar with PTFE bypass to a below-knee artery. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Health outcomes and costs are both important when deciding whether general (GA) or local (LA) anaesthesia should be used during carotid endarterectomy. The aim of this study was to assess the cost‐effectiveness of carotid endarterectomy under LA or GA in patients with symptomatic or asymptomatic carotid stenosis for whom surgery was advised.

Background: Attempts to stratify carotid plaques according to clinical risk using single longitudinal view (SLV) echomorphology have not been uniformly successful. We compared SLV grey scale median measurements (SLV-GSM) with a newer technique of multiple cross-sectional view echomorphology (MCSV-GSM) in carotid plaques from 3 patient groups (asymptomatic, ocular, and hemispheric symptoms).Methods: SLV and MCSV images were obtained from 109 carotid stenoses (70-99%; 41 hemispheric, 17 ocular, 51 asymptomatic). SLV-GSM and MCSV-GSM(min) (lowest plaque MCSV image GSM) were determined to assess echolucency whilst MCSV-GSM(max-min) (highest minus lowest MCSV-GSM) assessed heterogeneity.Results: Echolucency was greater (lower GSM) in plaques causing hemispheric symptoms versus asymptomatic plaques (MCSV-GSMmin, P = .002; SLV-GSM, P = .002). Only MCSV imaging detected differences in echolucency between asymptomatic plaques and those causing ocular symptoms (SLV-GSM, p = 0.84; MCSV-GSM(min), p = .003). Symptomatic plaques showed greater heterogeneity versus asymptomatic plaques, significantly in those causing ocular symptoms (hemispheric P = .126; AF P = .011).Conclusions: Both SLV and MCSV echomorphology confirm increased echolucency in plaques causing hemispheric symptoms. Plaques causing ocular symptoms could only be distinguished from asymptomatic plaques with MCSV assessment (increased echolucency and heterogeneity). This suggests that amaurosis fugax may be associated with a more focal plaque instability that is best detected with MCSV imaging. (C) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Aim: During surgery for sapheno-femoral junction (SFJ) and anterior accessory great saphenous vein (AAGSV) reflux, many surgeons also strip the great saphenous vein (GSV). This study assesses the short-term efficacy (abolition of reflux on Duplex ultrasound) of endovenous laser ablation (EVLA) of the AAGSV with preservation of a competent GSV in the treatment of varicose veins occurring due to isolated AAGSV incompetence.Method: Thirty-three patients (21 women and 12 men) undergoing AAGSV EVLA alone (group A) and 33 age/sex-matched controls undergoing GSV EVLA (Group B) were studied. Comparisons included ultrasound assessment of SFJ competence, successful axial vein ablation, Aberdeen Varicose Vein Symptom Severity Scores (AVVSS) and a visual analogue patient-satisfaction scale.Results: At the 1-year follow-up, EVLA had successfully abolished the target vein reflux (AAGSV: median length 19 cm (inter-quartile range, IQR: 14-24 cm) vs. GSV: 32 cm (IQR 2442 cm)) and had restored SFJ competence in all. patients. Twenty of the 33 patients (61%) in group A and 14 of the 33 (42%) in group B (p = 0.218) required post-ablation sclerotherapy at 6 weeks post-procedure for residual varicosities. The AVVSS at 12 months follow-up had improved from the pre-treatment scores in both the groups (group A: median score 4.1 (IQR 2.1-5.2) vs. 11.6 (IQR: 6.9-15.1) p<0.001; group B: median score 3.3 (IQR 1.1-4.5) vs. 14.5 (IQR 7.6-20.2), p < 0.001), with no significant difference between the groups. Patient-satisfaction scores were similar (group A: 84% and group B: 90%).Previous intervention in group A included GSV EVLA (n = 3) or stripping (n = 9). Thus, the GSV was preserved in 21 patients. The AVVSS also improved in this subgroup (4.4 (2.0-5.4) vs. 11.4 (6.0-14.1), p < 0.001) and SFJ/GSV competence was found to be restored at the 1 year follow-up.Conclusions: AAGSV EVLA abolishes SFJ reflux, improves symptom scores and is, therefore, suitable for treating varicose veins associated with AAGSV reflux. (C) 2008 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objective: Neovascularisation is a major cause of recurrent varicosities following surgery. This prospective cohort study compares recurrence rates and the occurrence of neovascularisation following surgery or endovenous laser ablation (EVLA) for great saphenous vein reflux.Method: 118 consecutive patients (72 female, 46 mate, median age 48 [range 32-68 years]), 129 limbs were reviewed at a median of 24 months (range 18-30) after surgery (n = 60 Limbs) or EVLA (n = 69 limbs) for primary sapheno-femoral and GSV reflux. Varicose vein recurrence, ultrasound detected groin neovascularisation and patient satisfaction (visual analogue scale) were recorded.Results: Recurrence rates at 2 years were: surgery group 4/60 (6.6%; mid-thigh perforator n = 2, residual GSV with neovascularisation n = 2), EVLA group 5/69 (7%; GSV recanalisation n = 3 (all received < 50 J/cm laser energy), mid-thigh perforator n = 1, new anterior saphenous vein reflux n = 1) p = 0.631. Neovascularisation was detected in 11/60 (18%) of the surgery group and 1/69 (1%) of the EVLA group, p = 0.001. Patient satisfaction rates were 90% and 88% respectively (p = 0.37).Conclusions: Although the frequency of recurrent varicosities 2 years after surgery and EVLA was similar, neovascularisation, a predictor of future recurrence, was less common following EVLA. Further, current recommendations on delivering > 70 J/cm laser energy should reduce recanalisation rates and recurrence after EVLA. (c) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background: Although warfarin is routinely stopped prior to varicose vein surgery the absence of incisions may make this unnecessary prior to EVLA. Nevertheless continuing therapy may compromise ablation rates resulting in treatment failure. Since EVLA is particularly suitable for older patients with co-morbidities this study investigates whether warfarin influences outcome.Method: A prospective observational cohort study was designed to assess ablation rates (1 year, duplex ultrasound), Aberdeen varicose vein symptom severity scores (AVVSS) and patient satisfaction following GSV EVLA in 22 patients ("warfarin group": 12 female, 10 mate; 24 limbs) taking warfarin and 24 age/sex and disease-severity matched controls who were not taking anticoagulants ("no-warfarin group").Results: Complete ablation of the treated-length of GSV was achieved in 20/24 (83%) limbs in the "warfarin group" versus 23/24 (96%) in the "no-warfarin" group (p = 0.347, chi squared). Suboptimal energy densities were delivered to 3/4 failures in the "warfarin group". A similar, significant (p < 0.001, Wilcoxon) improvement in AVVSS occurred in both groups [warfarin: median 14.6 (inter-quartile range 8.9-19.1) to 3.8 (1.9-6.2), no-warfarin: median 13.9 (IQR 7.6-20.1) to 3.5 (2.2-6.4)]. Patients were equally satisfied with outcomes (warfarin = 92%, no-warfarin = 90%; p = 0.391, Mann-Whitney). No major complications occurred.Conclusions: EVLA in patients taking warfarin is safe and effective. Since cessation of therapy is unnecessary it should provide a valuable alternative to surgery in these patients. (c) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.