Background: Peripheral artery disease is a common condition caused by narrowing/blockage of the arteries, resulting in reduced blood supply. Peripheral artery disease is associated with an increased risk of vascular complications, but early treatment reduces mortality and morbidity. Leg ulcers are long-lasting wounds, usually treated by compression therapy. Compression therapy is not suitable for people with peripheral artery disease, as it can affect the arterial blood supply. In clinical practice, people with peripheral artery disease are identified by measurement of the ankle-brachial pressure index using a sphygmomanometer and manual Doppler device. However, this method can be uncomfortable for people with leg ulcers and automated devices have been proposed as a more acceptable alternative. The objective of this appraisal was to summarise the clinical and cost-effectiveness evidence on the use of automated devices to detect peripheral artery disease in people with leg ulcers. Methods: Clinical effectiveness: To identify reports of relevant studies, we searched major electronic databases and scrutinised the information supplied by the manufacturers of the automated devices under investigation. Due to the lack of evidence on people with leg ulcers, we considered evidence from studies of any design assessing automated devices versus an acceptable reference device in any population receiving ankle-brachial pressure index assessment. We summarised information on diagnostic accuracy of the automated devices and level of agreement with the reference device. For each device, when data permit, we pooled data across studies by conducting random-effects meta-analyses using a Hierarchical Summary Receiving Operating Characteristics model. Cost-effectiveness: An economic model comprising a decision tree (24 weeks) and Markov models to capture lifetime costs and quality-adjusted life-years associated with venous, arterial and mixed aetiology disease in leg ulcer patients. Analyses were conducted from a United Kingdom National Health Service and Personal Social Services perspective. Costs and quality-adjusted life-years were discounted at 3.5% per year. Deterministic and several probabilistic analyses were used to capture uncertainty surrounding a range of optimistic and pessimistic assumptions about the impact of automated tests on health outcomes (ulcer healing and requirement for invasive management of arterial disease). Results: Clinical effectiveness: From the 116 records retrieved by the electronic searches, we included 24 studies evaluating five devices (BlueDop Vascular Expert, BOSO ABI-System 100, Dopplex Ability, MESI ankle-brachial pressure index MD and WatchBP Office ABI). Two studies assessing people with leg ulcers found that automated devices often gave higher ankle-brachial pressure index readings than manual Doppler (underestimation of arterial disease). In the 22 studies involving people without leg ulcers, automated devices generally demonstrated good specificity and moderate specificity. Meta-analysis of 12 studies showed a pooled sensitivity of 64% (95% confidence interval 57% to 71%) and a pooled specificity of 96% (95% confidence interval 92% to 98%) for detection of peripheral artery disease.Cost-effectiveness: Automated devices cost less than manual Doppler to deliver. However, increased risks of invasive treatment requirements for inappropriately compressed arterial/mixed ulcers due to false-negative results, and increased healing times due to delayed compression of false-positive test results mean that in most scenarios manual Doppler was less costly and had slightly higher quality-adjusted life-years than automated devices. Results are highly uncertain, dependent on many assumptions and should be interpreted cautiously. Limitations and conclusions: The limited evidence identified for each automated device, especially in people with leg ulcers, and its clinical heterogeneity precludes any firm conclusions on the diagnostic performance and cost-effectiveness of these devices in clinical practice

IntroductionLeg ulcers are usually treated with compression therapy unless there is evidence of peripheral arterial disease (PAD). Compression may lead to vascular complications in people with PAD. Timely diagnosis and appropriate treatment are important to ensure the best patient outcomes. PAD is usually assessed using a manual ankle brachial pressure index (ABPI). Automated devices may reduce time to diagnosis and treatment of leg ulcers. This study investigated the diagnostic accuracy, clinical effectiveness, and cost effectiveness of automated ABPI measurement, compared with manual doppler testing, to detect PAD in people with leg ulcers.MethodsWe conducted a systematic review of studies of any design assessing automated devices in any population. Meta-analyses were conducted where possible. A decision tree and Markov model was used to capture lifetime costs, quality-adjusted life-years (QALYs), and cost effectiveness from a UK National Health Service perspective. Sensitivity analyses captured the uncertainty surrounding model assumptions and probabilistic sensitivity analyses described parameter uncertainty. Value of information analysis was conducted to identify future research priorities.ResultsA total of 22 studies provided diagnostic accuracy data for five automated devices, but there were no studies in people with leg ulcers. Meta-analysis of 12 studies demonstrated a pooled sensitivity of 64 percent (95% confidence interval [CI]: 57, 71) and a specificity of 96 percent (95% CI: 92, 98) for detecting PAD. Automated devices were cheaper to complete due to shorter test times, but the increased risk of inappropriate or delayed treatment due to inaccurate test results offset the cost savings and reduced the QALYs for automated devices.ConclusionsGiven the current limited evidence base, automated devices would only be cost effective if they can demonstrate substantial reductions in time to diagnosis in clinical practice. Value of information analysis identified the following research priorities: (i) to determine diagnostic accuracy in a population with leg ulcers; (ii) to determine the impact of test results on ulcer healing times, and (iii) to determine the risk of providing inappropriate treatment based on inaccurate test results.

Objectives Periodontal disease and tooth loss were found to be associated with several peripheral vascular disorders. Nonetheless, an evaluation of the literature on the broader domains of oral health in individuals with peripheral vascular disorders is lacking. This systematic review aims to collate the current evidence on the oral health status of individuals with peripheral vascular disorders. Methods Five electronic databases were searched for studies assessing oral health parameters in individuals with peripheral vascular disorders. Outcome measures considered were periodontal health, dentition status, caries indices, oral prostheses, oral pathologies and oral hygiene behaviours. The Newcastle-Ottawa scale was used to appraise the quality of the studies. Results From 3025 records identified, 24 studies involving 1232 participants with peripheral vascular disorders were included in this review. In nine studies, periodontitis was significantly more prevalent in peripheral vascular disorders compared to non-peripheral vascular disorders participants. A further six studies reported individuals with peripheral vascular disorders also had significantly fewer teeth and increased rates of edentulism. Only one study reported a higher incidence of dental caries in peripheral vascular disorders participants. Other aspects of oral health such as oral prosthesis, oral pathology and oral hygiene behaviours were seldom assessed. Conclusions The scarcity of studies reporting on broader domains limited our ability to arrive at a conclusion regarding the oral health status of individuals with peripheral vascular disorders. Future studies ought to assess these domains in individuals with peripheral vascular disorders and controls to gain a more complete understanding of oral health and its potential association with peripheral vascular disorders.

Background: The utilisation rate of endovascular aortic aneurysm repair has increased continuously over the past 2 decades. Endovascular aortic aneurysm repair is still performed frequently in patients with an unfavourable proximal seal zone, despite the associated late complications. Purpose: We aimed to evaluate the mid-term durability of the GORE (R) EXCLUDER (R) AAA Endoprosthesis, featuring the C3 delivery system, in patients with a proximal neck anatomy outside the instructions for use (IFU). Methods: A retrospective sub-analysis of the Global Registry for Endovascular Aortic Treatment including patients treated for abdominal aortic aneurysms with the GORE EXCLUDER AAA Endoprosthesis (W.L. Gore & Associates, Inc, Flagstaff, Arizona) was performed. A "challenging neck" was defined as those treated outside the IFU with an aortic neck length < 15 mm and/or aortic neck angle > 60 degrees. Cox proportional analyses were used to test for time-to-event differences between those treated within and outside the IFU while accounting for covariates, specifically proximal neck length and neck angle. The main outcomes assessed were 5-year all-cause mortality, 5-year endoleak development (type I or III), and 5-year device-related reinterventions. Findings: Of the 3,324 patients included in the analysis, 411 (12.4%) had a challenging neck and 2,913 (87.6%) did not. The patients in the challenging neck group were significantly older (74.9 years vs. 73.2 years, p <= 0.0001) and had a significantly larger aortic aneurysm diameter at the time of the intervention than those treated within the IFU (61.2 mm vs. 56.4 mm, P < 0.0001), shorter proximal neck length (18 mm vs. 30 mm, P < 0.0001) and larger infrarenal neck angle (60.8 degrees vs. 25.8 degrees, P < 0.0001). In the multivariate analysis, brachial access site and challenging neck were not independent risk factors; increased age was associated with a shorter time to mortality (hazard ratio 1.051, 95% confidence interval 1.039-1.062, P < 0.0001), as was the use of tobacco (hazard ratio 1.329, 95% confidence interval 1.124-1.571, P = 0.0009). The 5-year all-cause mortality (36.2% vs. 27.5%, P = 0.002) and aorta-related mortality (3.8% vs. 1.1%, P = 0.002) were significantly higher in the challenging neck group. The risk of death within 5 years also increased significantly at 1.1% per millimetre increase in the abdominal aortic aneurysm diameter ( P = 0.0005). Furthermore, the rates of type Ia endoleak development (7% vs. 1.2%, P < 0.001) and requirement for reintervention (13.3% vs. 9.7%, P < 0.001) were higher in those treated outside the IFU (challenging neck group). Conclusions: Treatment with the Excluder AAA Endograft outside the IFU was associated with higher 5-year mortality values, increased type Ia endoleak development rates, and a greater need for reintervention compared with treatment within the IFU. This reiterates that fenestrated and open treatments should be strongly considered in cases with aortic neck anatomies outside the IFU. Infrarenal endovascular intervention outside the IFU should only be used when there is no alternative, with meticulous procedural planning and intervention to promote satisfactory outcomes.

Anatomical variation may result in unexpected complications after fenestrated endovascular aneurysm repair (FEVAR). We report a 78-year-old gentleman who was admitted for elective FEVAR procedure for a juxtarenal abdominal aortic aneurysm. Three days post-operatively, he deteriorated clinically. Computed tomography (CT) angiogram showed small bowel ischaemia and a replaced right hepatic artery originating from superior mesenteric artery. A necrotic gallbladder found during laparotomy required cholecystectomy following small bowel resection that required a relook for anastomosis and drainage of bile collection. He had prolonged ICU stay requiring treatment for multiple organ dysfunction then spent 4 weeks in hospital. Following multidisciplinary team approach in management of his complications during post-operative phase, he recovered well enough for rehabilitation and discharge home. Surveillance CT aorta at 1 month and 6 months post FEVAR showed satisfactory FEVAR appearance with no endoleak.

Background Endovenous laser ablation and ultrasound-guided foam sclerotherapy are recommended alternatives to surgery for the treatment of primary varicose veins, but their long-term comparative effectiveness remains uncertain. Methods In a randomized, controlled trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of laser ablation, foam sclerotherapy, and surgery. Primary outcomes at 5 years were disease-specific quality of life and generic quality of life, as well as cost-effectiveness based on models of expected costs and quality-adjusted life-years (QALYs) gained that used data on participants' treatment costs and scores on the EuroQol EQ-5D questionnaire. Results Quality-of-life questionnaires were completed by 595 (75%) of the 798 trial participants. After adjustment for baseline scores and other covariates, scores on the Aberdeen Varicose Vein Questionnaire (on which scores range from 0 to 100, with lower scores indicating a better quality of life) were lower among patients who underwent laser ablation or surgery than among those who underwent foam sclerotherapy (effect size [adjusted differences between groups] for laser ablation vs. foam sclerotherapy, -2.86; 95% confidence interval [CI], -4.49 to -1.22; P<0.001; and for surgery vs. foam sclerotherapy, -2.60; 95% CI, -3.99 to -1.22; P<0.001). Generic quality-of-life measures did not differ among treatment groups. At a threshold willingness-to-pay ratio of 20,000 pound ($28,433 in U.S. dollars) per QALY, 77.2% of the cost-effectiveness model iterations favored laser ablation. In a two-way comparison between foam sclerotherapy and surgery, 54.5% of the model iterations favored surgery. Conclusions In a randomized trial of treatments for varicose veins, disease-specific quality of life 5 years after treatment was better after laser ablation or surgery than after foam sclerotherapy. The majority of the probabilistic cost-effectiveness model iterations favored laser ablation at a willingness-to-pay ratio of 20,000 pound ($28,433) per QALY.

BACKGROUND:The European C3 module of the Global Registry for Endovascular Aortic Treatment (GREAT) evaluates the outcome and deployment mechanism of the C3 Gore Excluder stent-graft. We aimed to assess the mid- to long-term durability of the C3 Gore Excluder stent-graft in the management of challenging aortic neck morphology, outside the instruction of use (IFU). METHODS:The prospectively collected data from GREAT were retrospectively analyzed. For each subject demographic, pre/intra- and postoperative variables were collected. The main outcomes measured were serious adverse events (device-related, cerebrovascular, cardiac, pulmonary, pulmonary embolism, limb ischemia, and renal complications) and re-intervention at the 6-year follow-up. In this study, outside IFU was defined as aortic neck length <15 mm and/or aortic neck angle >60°. RESULTS:A total of 399 subjects (86.7% male, mean age 73.9 years) were identified. Sixty-eight subjects (17%) from 11 recruiting sites underwent endovascular aneurysm repair (EVAR) outside IFU, and 399 devices were implanted. Of these, 47% had neck length <15 mm, 72.3% had neck angulation > 60°, and 21% had both. Mean follow-up duration was 53.5 months (SD=22.3). At the 6-year follow-up, the group with challenging anatomy required significantly more re-interventions (23.5% vs. 13.3%, P<0.05) and reported more serious adverse events (42.6% vs. 30.6%, P<0.005) than those within IFU. CONCLUSIONS:Midterm outcomes of the C3 Gore Excluder stent-graft are safe and effective within IFU. Outside IFU patients required significantly more all or device related re-interventions; however, they did not sustain significantly more serious adverse events.

EVAR has revolutionized the care of patients with aortic abdominal aneurysms and efforts to evolve the technique continue, with aim of improving patient experience and outcomes.We aimed to collect objective data related to using percutaneous access in EVAR operations in our unit in Aberdeen Royal Infirmary, with particular focus on post-operative complications.We found that nearly all patients (11 out of 12) who underwent percutaneous EVAR or FEVAR in Aberdeen Royal Infirmary since the introduction of the technique did so without experiencing any post-operative wound complications.This case series reflects the success and benefits of the use of percutaneous EVAR in our unit and also contributes to current evidence base for the use of the technique in selected patient groups.

BACKGROUNDLeg ulcers are chronic wounds of the lower leg, caused by poor blood flow, that can take a long time to heal. The pooling of blood in the veins can damage the skin and surrounding tissues, causing an ulcer to form. Venous leg ulcers are associated with impaired quality of life, reduced mobility, pain, stress and loss of dignity. The standard treatment for venous leg ulcers is compression bandages or stockings. Shock wave therapy may aid the healing of these wounds through the promotion of angiogenesis (the formation and development of blood vessels) and reduction of inflammation, though this process is poorly understood at present.OBJECTIVESTo assess the effects of extracorporeal shock wave therapy on the healing and management of venous leg ulceration.SEARCH METHODSIn April 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. We applied no restrictions with respect to language, date of publication or study setting.SELECTION CRITERIAWe considered all published and unpublished randomised controlled trials (RCTs) assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration.DATA COLLECTION AND ANALYSISTwo review authors independently performed study selection. We planned that two review authors would also assess the risk of bias of included studies, extract study data and rate the certainty of the evidence using GRADE.MAIN RESULTSWe found no RCTs that met the inclusion criteria for this review.AUTHORS' CONCLUSIONSWe found no RCTs assessing the effectiveness of extracorporeal shock wave therapy in the healing and management of venous leg ulceration. The lack of high-quality evidence in this area highlights a gap in research and may serve to justify the need for further research and evidence to provide guidance concerning the use of this treatment option for this condition. Future trials should be of clear design and include concomitant use of the current best practice treatment, multilayer compression therapy. Recruitment should aspire to best represent patients seen in clinical practice and patient-related outcome measures should be included in study design.

Background and Aims: Thoracic Endovascular Repair (TEVAR) is the preferred option for managing aneurysm disease of the Descending Thoracic Aorta (DTAA) and complications of acute Thoracic Aortic Dissection (TAD).We describe our early Northeast Scotland 5-year experience of TEVAR.Methods: Retrospective analysis of all emergency and elective TEVAR from January 2012 -July 2017 was performed.Patient demographics, presentation, imaging, operative details, survival status and surveillance CTA status were recorded.Technical success was defined as exclusion of the DTAA without Type 1 endoleak or conversion to open repair or sealing of the proximal entry in acute dissection.Results: We identified 10 (M: F ratio of 4:1, mean age of 67 years old; standard deviation 17 years) with a technical success of 100%.7(70%) cases were performed as emergency (3 symptomatic dissection, 1 rupture dissection, 1 rupture aneurysm, 1 aortic transection, 1 rupture penetrating aortic ulcer).Postoperative SCI was not observed.1 (10%) patient had prophylactic spinal cerebrovascular fluid (CSF) drainage.3 (30%) patient had coverage of the left subclavian artery (LSA).Mean follow-up was 12 months.30-daymortality was zero, mortality at follow up was 10% (n=1).In hospital, post-operative morbidity was 30%.Endoleak was noted in 2 (20%) patients at follow up. Conclusion:This study demonstrates the relatively high incidence of unscheduled admission and treatment for this pathology and encouraging early results.Prophylactic measure for SCI remains a topic for debate.

BACKGROUND:Accurate measurement is central to abdominal aortic aneurysm screening, but information concerning differences between observers using modern ultrasound devices is lacking. Our aim was to assess clinical agreement among nurses within a national screening programme. METHODS:Between-observer repeatability was assessed among 2 pairs of nurses (A & B and C & D) screening a consecutive series of men at a single-community clinic in Grampian, Scotland. All 4 nurses used the same ultrasound device (GE-LOGIQe 1.5-4.6 MHz curvilinear probe) to measure maximal infrarenal inner-to-inner (ITI) anteroposterior diameter in longitudinal and transverse planes. Nurses alternated in their measurements and were blinded to their partners' measurements. Participants remained supine while "double-scanned." Clinical agreement was assessed as twice the standard deviation (2 SD) of mean differences. Analysis was undertaken using IBM-SPSS-Statistics (version 22) using the Bland-Altman "limits of agreement" (95% LoA) approach (mean difference ±2 SD) and related plots. RESULTS:A total of 63 consecutive men underwent assessment (30 men by nurses A & B; 33 men by nurses C & D). Mean age 65.5 years, brachial blood pressure 145/88 mm Hg, current smokers 14%, never smoked 41%, diabetic 18%, arterial disease 11%, daily aspirin 16%, antihypertensives 35%, and statin therapy 44%. Mean aortic diameter (ITI) was 1.81 centimeters (cm; range 1.28-2.45; SD 0.18). Pooled mean differences between nurses was 0.05 cm (95% confidence interval 0.02-0.08); 2 SD ± 0.23 with 95% LoA -0.18 to 0.28 cm. Repeatability was similar in both planes and for both pairs of nurses. CONCLUSIONS:Nurses can achieve a high level of agreement in the measurement of aortic diameter in a routine clinical setting.

Background: Foam sclerotherapy (foam) and endovenous laser ablation (EVLA) have emerged as alternative treatments to surgery for patients with varicose veins, but uncertainty exists regarding their effectiveness in the medium to longer term. Objectives: To assess the clinical effectiveness and cost-effectiveness of foam, EVLA and surgery for the treatment of varicose veins. Design: A parallel-group randomised controlled trial (RCT) without blinding, and economic modelling evaluation. Setting: Eleven UK specialist vascular centres. Participants: Seven hundred and ninety-eight patients with primary varicose veins (foam, n = 292; surgery, n = 294; EVLA, n = 212). Interventions: Patients were randomised between all three treatment options (eight centres) or between foam and surgery (three centres). Primary outcome measures: Disease-specific [Aberdeen Varicose Vein Questionnaire (AVVQ)] and generic [European Quality of Life-5 Dimensions (EQ-5D), Short Form questionnaire-36 items (SF-36) physical and mental component scores] quality of life (QoL) at 6 months. Cost-effectiveness as cost per quality-adjusted life-year (QALY) gained. Secondary outcome measures: Quality of life at 6 weeks; residual varicose veins; Venous Clinical Severity Score (VCSS); complication rates; return to normal activity; truncal vein ablation rates; and costs. Results: The results appear generalisable in that participants’ baseline characteristics (apart from a lower-than-expected proportion of females) and post-treatment improvement in outcomes were comparable with those in other RCTs. The health gain achieved in the AVVQ with foam was significantly lower than with surgery at 6 months [effect size −1.74, 95% confidence interval (CI) −2.97 to −0.50; p = 0.006], but was similar to that achieved with EVLA. The health gain in SF-36 mental component score for foam was worse than that for EVLA (effect size 1.54, 95% CI 0.01 to 3.06; p = 0.048) but similar to that for surgery. There were no differences in EQ-5D or SF-36 component scores in the surgery versus foam or surgery versus EVLA comparisons at 6 months.: The trial-based cost-effectiveness analysis showed that, at 6 months, foam had the highest probability of being considered cost-effective at a ceiling willingness-to-pay ratio of £20,000 per QALY. EVLA was found to cost £26,107 per QALY gained versus foam, and was less costly and generated slightly more QALYs than surgery. Markov modelling using trial costs and the limited recurrence data available suggested that, at 5 years, EVLA had the highest probability (≈ 79%) of being cost-effective at conventional thresholds, followed by foam (≈ 17%) and surgery (≈ 5%).: With regard to secondary outcomes, health gains at 6 weeks (p < 0.005) were greater for EVLA than for foam (EQ-5D, p = 0.004). There were fewer procedural complications in the EVLA group (1%) than after foam (7%) and surgery (8%) (p < 0.001). Participants returned to a wide range of behaviours more quickly following foam or EVLA than following surgery (p < 0.05). There were no differences in VCSS between the three treatments. Truncal ablation rates were higher for surgery (p < 0.001) and EVLA (p < 0.001) than for foam, and were similar for surgery and EVLA. Conclusions: Considerations of both the 6-month clinical outcomes and the estimated 5-year cost-effectiveness suggest that EVLA should be considered as the treatment of choice for suitable patients. Future work: Five-year trial results are currently being evaluated to compare the cost-effectiveness of foam, surgery and EVLA, and to determine the recurrence rates following each treatment. This trial has highlighted the need for long-term outcome data from RCTs on QoL, recurrence rates and costs for foam sclerotherapy and other endovenous techniques compared against each other and against surgery. Trial registration: Current Controlled Trials ISRCTN51995477. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 27. See the NIHR Journals Library website for further project information.

BACKGROUND Blunt traumatic thoracic aortic injury (BTAI) is a life-threatening surgical emergency associated with mortality up to 8000 per year, most commonly caused by rapid acceleration/deceleration injury sustained through motor vehicle accident and/or blunt thoracic trauma. BTAI has high pre-hospital mortality following the primary injury, with only 10% to 15% of patients surviving long enough to reach the hospital. Open surgical repair had remained the standard treatment option for BTAI since successfully introduced in 1959. However, with technological advances, thoracic endovascular repair (TEVAR) offers an alternative treatment option for BTAI. TEVAR is a less invasive surgical approach for management of these already critical patients; many reports have described favourable early outcomes.Thoracic endovascular repair may appear to be superior to open repair for treatment of BTAI. However, its long-term results and efficacy remain unknown. No randomised controlled trials (RCTs) have provided evidence to support the superiority of the endovascular approach versus open repair in the treatment of BTAI. This review aims to address this matter. This is an update of a review first published in 2015. OBJECTIVES To determine whether use of thoracic endovascular repair (TEVAR) for treatment of blunt traumatic thoracic aortic injury (BTAI) is associated with reduced mortality and morbidity when compared with conventional open surgery. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 20 August 2018. SELECTION CRITERIA We considered all published and unpublished randomised controlled trials (RCTs) comparing TEVAR and open surgery for BTAI. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all RCTs identified by the Cochrane Vascular Information Specialist. MAIN RESULTS We found no RCTs that met the inclusion criteria for this review. AUTHORS' CONCLUSIONS We found no RCTs conducted to determine whether use of TEVAR for the treatment of BTAI is associated with reduced mortality and morbidity when compared to conventional open repair. Hence, we are unable to provide any evidence to guide the treatment option for this life-threatening condition. To perform a randomised controlled trial to clarify the optimal management of BTAI would be highly challenging due to the natural history of the condition. Despite the lack of RCT evidence, clinicians are moving forward with endovascular treatment of BTAI on the basis of meta-analyses of cohort studies and large clinical series.

Introduction: Percutaneous transluminal angioplasty (PTA) is a common therapeutic option for the treatment of peripheral vascular disease. Pseudoaneurysm at the puncture site is a well-documented complication in patients.Case presentation: This case report describes a patient who presented to hospital several days following a left superficial femoral and popliteal artery PTA with lower limb pain and swelling. The working diagnosis included a deep vein thrombosis based on the Wells criteria. However, a combination of a duplex scan and computed tomography angiography confirmed a clinically rare occurrence of pseudoaneurysm of the sural artery, a branch of the popliteal artery. This was managed successfully with a thrombin injection, leading to complete resolution of the patient's symptoms.Conclusion: This case highlights the importance of the technical aspects of performing a PTA. We believe that the guide-wire position was not confirmed to be completely in the popliteal artery upon inflation of the balloon.

BACKGROUND Ultrasound-guided foam sclerotherapy and endovenous laser ablation are widely used alternatives to surgery for the treatment of varicose veins, but their comparative effectiveness and safety remain uncertain. METHODS In a randomized trial involving 798 participants with primary varicose veins at 11 centers in the United Kingdom, we compared the outcomes of foam, laser, and surgical treatments. Primary outcomes at 6 months were disease-specific quality of life and generic quality of life, as measured on several scales. Secondary outcomes included complications and measures of clinical success. RESULTS After adjustment for baseline scores and other covariates, the mean disease-specific quality of life was slightly worse after treatment with foam than after surgery (P=0.006) but was similar in the laser and surgery groups. There were no significant differences between the surgery group and the foam or the laser group in measures of generic quality of life. The frequency of procedural complications was similar in the foam group (6%) and the surgery group (7%) but was lower in the laser group (1%) than in the surgery group (P<0.001); the frequency of serious adverse events (approximately 3%) was similar among the groups. Measures of clinical success were similar among the groups, but successful ablation of the main trunks of the saphenous vein was less common in the foam group than in the surgery group (P<0.001). CONCLUSIONS Quality-of-life measures were generally similar among the study groups, with the exception of a slightly worse disease-specific quality of life in the foam group than in the surgery group. All treatments had similar clinical efficacy, but complications were less frequent after laser treatment and ablation rates were lower after foam treatment. (Funded by the Health Technology Assessment Programme of the National Institute for Health Research; Current Controlled Trials number, ISRCTN51995477.).

A 26-year-old man, who was previously fit and well was referred to the vascular surgical team with a painful right forearm 1 week after an aortic valve replacement for infective endocarditis (IE). He was an in-patient recovering from his cardiac surgery. He was on appropriate antibiotics for the IE. He had no systemic signs but had marked leucocytosis. Physical examination revealed a warm swollen painful right forearm with a more discrete pulsatile painful swelling in the mid-forearm measuring about 3×3 …

Objective: Omega-3 fatty acids have been shown to reduce platelet and endothelial activation in patients with or at risk of cardiac disease. We aimed to determine if Omega-3 fatty acid supplementation in addition to best medical therapy can reduce the increased platelet and endothelial activity that is present in patients with intermittent claudication.Methods: One hundred and fifty patients who were receiving aspirin and statin therapy were recruited into a randomised cross-over double blind study involving 6 week supplementation with OMACOR fish oil (850-882 mg eicosapentaenoic and docosahexaenoic acid) versus placebo. A 12 week washout period occurred between treatments. Patients with diabetes were excluded. For each outcome a random effects model was fitted in which treatment and period were fixed effects and patients were random effects.Results: Omega-3 supplementation had no effect on the primary outcome measure von Willebrand factor. Similarly Omega-3 supplementation resulted in no change in unstimulated or stimulated P-selectin expression and fibrinogen binding, or platelet aggregation (ultegra point of care). Pulse wave velocity was also unchanged. High-sensitivity C-reactive protein, s-ICAM and IL-6 were also unchanged.Conclusion: Supplementation with Omega-3 fatty acids had no affect on platelet and endothelial activation or markers of inflammation in patients with peripheral arterial disease. (C) 2012 Elsevier Ireland Ltd. All rights reserved.