Predictors of restenosis after carotid endarterectomy: 17-year experience in a tertiary referral vascular center.

INTRODUCTION: Carotid endarterectomy (CEA) is a well-established surgical technique in stroke prophylaxis. Long-term follow-up data on restenosis or recurrent neurological symptoms in Oriental patients are unclear. METHODS: Patients' notes from 1994 to 2011 were retrospectively reviewed and analyzed. A total of 301 cases of CEA were identified. RESULTS: A lower restenosis rate was associated with the use of patch and never smokers in both univariate and multivariate analysis. Use of patch and never smokers were also found to be significantly associated with longer restenosis-free survival. Use of patch and postoperative use of statin were associated with better overall survival in both univariate and multivariate analysis. CONCLUSION: Use of patch and lack of smoking history are associated with less restenosis and longer restenosis-free survival. Use of patch and use of postoperative statin improves overall survival. Although restenosis after CEA is relatively common, reintervention was rarely necessary.

Ten-year epidemiological review of in-hospital patients with Marfan syndrome.

Marfan syndrome is a connective tissue disorder with a worldwide prevalence of 1 in 5,000, without any racial predilection. Major cardiovascular manifestations of Marfan disease often require surgical intervention. The aim of this study was to examine the demographics of patients with Marfan syndrome admitted to Hong Kong hospitals over a 10-year period from 1997 to 2006. We retrospectively reviewed the prospectively collected Hong Kong Health Authority's Clinical Data Analysis and Reporting System and Clinical Medical System. Statistical analysis was performed using SPSS, version 15. A total of 525 patients with Marfan syndrome (310 male, 215 female) were included in this study. For males, mean age at first hospital admission was 19.8 years (range 0-78) and for females, 18.7 years (range 0-60). One hundred and twelve (21.3%) patients (56 male, 56 female) had documented aortoiliac aneurysms and/or dissection, with 74 (66.7%) cases involving the thoracic aorta. Forty-nine (9.3%) patients had major cardiac or aortoiliac operations, with an operative mortality of 5/49 (10.2%). Thirty-seven (7.0%) patients (23 male, 14 female) died during this period, with a mean age at death of 41.0 years (range 0-83) for males and 29.9 years (range 0-59) for females. The majority of these patients died of cardiovascular causes, with four aortic dissections, two ruptured aneurysms, seven with sudden collapse and cardiac arrest, and five with heart failure. In addition, there were other causes of mortality: five perioperative, one congenital, and four pulmonary causes, three with malignancy and one of stroke. The cause of death was unknown in five patients. Patients with aortoiliac diseases have a statistically significant higher mortality rate (p < 0.05). This population-based study shows that significant numbers of patients with Marfan syndrome are admitted to hospital per year, with a significant proportion requiring admissions at a young age. Life span in Marfan patients is markedly shortened, and aortoiliac disease is probably underdiagnosed. A standardized diagnostic and therapeutic follow-up program should be offered to these patients and their families.

X-ray diagnosis of acute scaphoid fractures.

In a retrospective review of the radiographs taken for 113 acute scaphoid fractures, each view was assessed for the clarity of demonstration of the fracture. The X-rays on which diagnosis of fracture were made, were taken between 0 and 16 days after injury (mean, 2 days). Whenever a lateral, supinated oblique or elongated view was taken, the fracture was always seen clearly on an alternative view. We recommend the use of four views at initial presentation of suspected scaphoid fracture: PA and lateral to assess carpal alignment, with pronated oblique and ulnar deviated PA to detect the fracture.

Epidemiology of venous thromboembolism in a Chinese population.

BACKGROUND: Deep vein thrombosis (DVT) is uncommon in Asians and routine thromboprophylaxis for surgery is controversial. Despite recent reports of higher incidences in some Asian countries, population-based data are lacking. METHODS: Information from 2000 to 2001 was retrieved from a centralized computer public healthcare database serving an ethnic Chinese population of 6.7 million. The incidence, demographics and hospital mortality rates of DVT and pulmonary embolism (PE) were obtained, and analysed for different surgical categories. RESULTS: The overall annual incidences of DVT and PE were 17.1 and 3.9 per 100000 population respectively. Venous thromboembolic disease was more common with increasing age in both sexes. The annual age-specific incidences of DVT and PE were 81.1 and 18.6 per 100000 for those aged 65 years and over. Hospital mortality rates associated with DVT and PE were 7.3 and 23.8 per cent respectively. Among 120940 surgical operations a year, the mean incidence of postoperative DVT and PE was only 0.13 and 0.04 per cent respectively. No high-risk surgical group was identified. CONCLUSION: Venous thromboembolism is not as common in Chinese as in Caucasians, but it is certainly not rare. The majority of DVTs and PEs, however, were not associated with surgery, so routine thromboprophylaxis may not be required.

Clinical outcomes and changes in venous hemodynamics after subfascial endoscopic perforating vein surgery.

BACKGROUND: We evaluated the clinical results of subfascial endoscopic perforating vein surgery (SEPS) in patients with severe chronic venous insufficiency (CVI) (clinical class 4-6) and assessed the hemodynamic changes associated with SEPS using air plethysmography (APG). METHODS: Forty-five patients with severe CVI who had undergone SEPS were evaluated. Clinical score and venous hemodynamics, as measured by APG before operation and at 1 month and 1 year after operation, were compared using the Wilcoxon signed rank test. Patient satisfaction (on a visual analogue scale of 0 to 100%) was also assessed. RESULTS: There were 29 men and 16 women; their mean age was 60 years (range, 37-83). Thirty-five patients (78%) had active venous ulcers; the ulcers' mean size was 7.8 +/- 11.9 cm2 and the mean duration of ulceration was 9 +/- 10 months. There were no hospital deaths. Postoperative complications were uncommon (one groin wound infection and one case of thrombophlebitis). At a mean follow-up of 15 +/- 9 months, 34 ulcers (97%) had healed. The cumulative ulcer healing was 82% at 3 months. There were five recurrent ulcers (15%). Significant improvement was seen in the clinical scores (10 +/- 3 before operation, 6 +/- 4 at 1 month, and 4 +/- 3 at 1 year after operation). The venous filling index was also significantly improved after operation; this improvement was maintained at 1-year follow-up (7.36 +/- 6.23 ml/sec before operation, 3.63 +/- 3.90 ml/sec at 1 month, and 3.14 +/- 2.06 ml/sec at 1 year). The degree of patient satisfaction was also remarkable, with 74 +/- 17% and 90 +/- 12% satisfaction at 1-month and 1-year follow-up, respectively. CONCLUSIONS: SEPS is a safe and effective treatment for patients with severe CVI. It leads to hemodynamic improvement, with rapid ulcer healing, and it is associated with a high degree of patient satisfaction.

Changes in venous hemodynamics after superficial vein surgery for mixed superficial and deep venous insufficiency.

The purpose of this study was to determine the hemodynamic changes after superficial vein surgery in patients with mixed superficial and deep venous insufficiency (MVI). Between July 1996 and June 1998, all patients with MVI together with saphenofemoral reflux were evaluated prospectively with air plethysmography (APG) and duplex scanning before and 1 month after superficial vein surgery. Saphenofemoral flush ligation without stripping was performed with multiple small incisions for avulsion of varicosities. Seventy-eight patients with 102 operated limbs were included for analysis. The venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) improved significantly after superficial vein surgery (mean VFI 5.99 +/- 3.39 vs. 1.82 +/- 1.21 ml/s, p < 0.001; mean EF 48.39% +/- 11.74% vs. 52.78% +/- 14.33%, p < 0.05; mean RVF 49.80% +/- 11.18% vs. 36.19% +/- 12.98%, p < 0.001, respectively, before and after operation). The proportion of limbs with deep venous incompetence on duplex scanning at more than one site decreased from 70% to 44% after operation. The mean number of sites with deep venous incompetence decreased from 2.14 +/- 0.96 to 1.52 +/- 1.21 after operation (p < 0.001). In conclusion, superficial vein surgery resulted in significant improvement in hemodynamic parameters in limbs with MVI. There was also abolition of deep venous reflux after superficial vein surgery alone. Superficial vein surgery should be the first line of treatment in limbs with MVI, with deep vein reconstructive surgery reserved for those not responding to superficial vein surgery.

Clinical and hemodynamic outcomes in patients with chronic venous insufficiency after oral micronized flavonoid therapy.

The aim of this study was to prospectively investigate the clinical efficacy of Daflon therapy in patients with mild to moderate chronic venous insufficiency (CVI) (clinical class 1-4) and to assess the changes in venous hemodynamics by using air plethysmography (APG). Fifty-six limbs in 28 patients were studied. They all had primary venous insufficiency with no venous obstruction, and mixed deep and superficial venous incompetence was found in 64% of the limbs. There was a significant decrease in symptom score for swelling and heaviness after 6 months of Daflon therapy. The symptom score for cramps also showed improvement though it did not reach statistical significance. Pain was significantly reduced with a mean pain score of 21.8 +/- 19.3% before comparing to 10.4 +/- 20.2% after 6 months of Daflon therapy (p < 0.01). This was also associated with a decrease in mean calf circumference from 37.0 +/- 4.3 to 36.4 +/- 4.3 cm (p < 0.001). There was no significant change in the venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) before and after 6 months of Daflon therapy (VFI: 3.7 +/- 3.5 vs 3.4 +/- 2.5 mL/s, EF: 54.5 +/- 15.9% vs 57.7 +/- 19.7%, RVF: 41.4 +/- 19.2% vs 39.4 +/- 24.2%). The clinical improvement without associated changes in venous hemodynamics as measured by APG suggests that Daflon mainly works by modifying the microcirculatory environment not detected by APG and this microcirculatory change is associated with clinical improvement. In this regard, Daflon would be especially useful for symptomatic relief in patients with functional venous insufficiency who do not have clinical evidence of varicose veins but suffer from symptoms of venous insufficiency.

Air plethysmography in chronic venous insufficiency: clinical diagnosis and quantitative assessment.

To define the role of air plethysmography (APG) in the clinical diagnosis and quantitative assessment of chronic venous insufficiency (CVI), APG studies were performed on 582 limbs in 291 patients with signs and symptoms of CVI. One hundred and thirty-one limbs were classified into group I (no evidence of CVI), 291 into group II (mild CVI), and 160 into group III (advanced CVI). On APG, the mean venous filling index (VFI) was 1.45 mL/s, 3.90 mL/s, and 5.25 mL/s in groups I, II, and III respectively (p<0.05). The mean ejection fraction (EF) and mean residual volume fraction (RVF) also showed significant differences between the limbs with CVI and the contralateral normal limbs, but the values were similar for the different severities of CVI limbs. The amount of overlap in VFI, EF, and RVF values among the clinical groups was considerable. Discrimination analysis derived a VFI value of 2.67 mL/s as a cutoff point between normal limbs and limbs with CVI, with a positive predictive value of 96%. In conclusion, APG is a simple and noninvasive test for quantitative assessment of the different components of CVI, valvular reflux, and calf muscle pump function. However, only VFI correlated significantly with the severity of CVI. VFI, with its high positive predictive value, may be useful in diagnosis of CVI, and it may serve as an objective quantitative measurement for monitoring the effect of treatment.

Nostril asymmetry: microform of cleft lip palate? An anthropometrical study of healthy North American caucasians.

Eight surface measurements of the nose and quality of nostril type and ala shape helped in the classification of 184 nostril asymmetries found in 1312 health North American Caucasians six to 18 years of age. Twenty-one of 1312 persons (1.6%) revealed severe degrees of nostril asymmetry characterized by uneven level of the alar base, asymmetries in the width of the nostril floor and length of the columella, and deviations in the columella and nasal bridge. This variation was most similar to the nasal disfigurement found in noncleft members of cleft families (Fukuhara and Saito, 1963; Tolarová et al., 1971). In order to accept this variation as a microform of the cleft anomaly, further anthropometrical study of the nose of noncleft members of cleft families will be required;