Rapid Carotid Screening by Duplex: A Prospective Single Centre Assessment.

OBJECTIVE: A novel carotid quick scan (CQS) protocol was developed to rapidly screen for carotid atherosclerosis greater than 50% stenosis in a vascular outpatient setting. This study assessed accuracy and time saved. MATERIAL & METHODS: The CQS was developed by consensus agreement between vascular surgeons and accredited clinical vascular scientists through a modified Delphi technique. The protocol comprised a rapid B-mode then colour flow transverse sweep of the common and internal carotid arteries, with internal carotid artery velocity assessment. One hundred outpatients attending with peripheral artery disease or abdominal aortic aneurysm were recruited. CQS sensitivity, specificity and accuracy was assessed against a conventional full carotid duplex study, performed to UK and ESVS guidelines. RESULTS: Twenty four percent of patients (n = 100) had >50% carotid NASCET stenosis. CQS achieved an excellent accuracy of 96.5% in detecting >50% stenosis when compared to full duplex; Cohen's ƙ = .88, (95%CI .79-.97; P < .001), sensitivity 91.4%, specificity 97.6%, positive predictive value (PPV) 88.9% and negative predictive value (NPV) 98.2%. Median (IQR) time to complete the CQS was 13 sec (±12) per side, compared to 151 sec (±78) per side for the full carotid duplex. In the presence of >50% carotid disease, median CQS time was 25 sec (±31) per side compared to 214 (±104) by full scan. CONCLUSION: CQS as a carotid screening tool is rapid, accurate and acceptable to the population and workforce. It would be simple to roll out in all vascular laboratories to reduce the time and cost burden of excluding significant carotid disease in any group.

Pelvic vein incompetence and chronic pelvic pain: a case-control study.

OBJECTIVE: To investigate the association between chronic pelvic pain (CPP) and pelvic vein incompetence (PVI) or pelvic varices. DESIGN: Case-control study. SETTING: Gynaecology and vascular surgery services in two teaching hospitals in north-west England. SAMPLE: A total of 328 premenopausal women (aged 18-54 years), comprising 164 women with CPP and 164 matched controls with no history of CPP. METHODS: Symptom and quality-of-life questionnaires and transvaginal duplex ultrasound for PVI and pelvic varices. MAIN OUTCOME MEASURES: Venous reflux of >0.7 s in the ovarian or internal iliac veins (primary outcome) and presence of pelvic varices (secondary outcome). Statistical analysis compared the prevalence of PVI between women with and without CPP using the two-sided chi-square test. Logistic regression was used to compare the odds of having PVI and pelvic varices between women with and without CPP. RESULTS: Pelvic vein incompetence was found on transvaginal duplex ultrasound in 101/162 (62%) women with CPP, compared with 30/164 (19%) asymptomatic controls (OR 6.79, 95% CI 4.11-11.47, p < 0.001). Forty-three of 164 (27%) women with CPP had pelvic varices compared with three of 164 (2%) asymptomatic women (OR 18.9, 95% CI 5.73-62.7, p < 0.001). CONCLUSIONS: There was a significant association between PVI, as detected by transvaginal duplex imaging, and CPP. Pelvic varices were strongly associated with CPP and were infrequently seen in control patients. These results justify further evaluation of PVI and its treatment in well-designed research.

Transvenous occlusion of incompetent pelvic veins to treat chronic pelvic pain in women: A randomised controlled trial.

OBJECTIVE: To investigate the effectiveness of transvenous occlusion of incompetent pelvic veins in women presenting with chronic pelvic pain (CPP) in improving symptoms and quality of life. DESIGN: Patient-blinded randomised controlled trial with objective outcome measures. Results were analysed on an intention-to-treat basis. SETTING: Gynaecology and Vascular Surgery Services of two teaching hospitals in northwest England. POPULATION: Sixty women aged 18-54 years presenting with CPP after exclusion of other pathology, and who were found to have pelvic vein incompetence. METHODS: Participants were randomised and assigned to contrast venography alone or contrast venography plus transvenous occlusion of the incompetent pelvic veins. MAIN OUTCOME MEASURE: The primary outcome was change in pain score measured using the short-form McGill Pain Score (SF-MPQ) and the Visual Analogue Score (VAS) recorded at 12 months post-randomisation. Secondary outcomes included quality of life using the EQ-5D instrument, symptomatic improvement and procedure-related complications. RESULTS: Sixty participants were randomised to transvenous occlusion of incompetent pelvic veins or venography only. At 12 months, median pain scored 2 (3-10) in the intervention group versus 9 (5-22) in controls (p = 0.016). Pain on the VAS scored 15 (0-3) versus 53 (20-71), respectively (p = 0.002). Median EQ-5D improved after intervention from 0.79 (0.74-0.84) to 0.84 (0.79-1.00; p = 0.008) over 12 months. No major complications were reported. CONCLUSION: Transvenous occlusion of pelvic vein incompetence reduced pain scores, improved quality of life and diminished symptom burden with no major reported complications. TRIAL REGISTRATION: ISRCTN 15091500.

Resistance to Antiplatelet Therapy Is Associated With Symptoms of Cerebral Ischemia in Carotid Artery Disease.

BACKGROUND: Platelet inhibitory therapy is prescribed to prevent arterial thromboembolism in patients with atherosclerotic disease. Although taken by millions of people, around 30% are resistant to the treatment they are being prescribed. AIMS: To determine whether symptoms of cerebral ischemia, or pre-operative cerebral emboli, in patients admitted for a carotid endarterectomy were associated with resistance to aspirin or clopidogrel. METHODS: Venous blood from 133 patients immediately before carotid endarterectomy (CEA) was analyzed for resistance to aspirin and clopidogrel by multiplate impedance aggregometry. The number of emboli/hour entering the ipsilateral middle cerebral artery was counted by transcranial Doppler (TCD) on the day before surgery in 33 of these patients. RESULTS: Resistance was found in 21 (26.3%) of 100 patients taking aspirin and 14 (42%) of 33 taking clopidogrel. Mean (sd) residual platelet aggregation was significantly higher at 41.9(32) Au in patients who had suffered recent symptoms of cerebral ischemia compared with 30.8(16) Au in asymptomatic patients (p = 0.012). Residual platelet aggregation also correlated significantly with the number of emboli/hour counted by TCD in the ipsilateral middle cerebral artery (r = 0.45, p = 0.009). CONCLUSION: Antiplatelet resistance was associated with the frequency of cerebral emboli and recent symptoms of cerebral ischemia in patients with carotid disease. Definitive clinical studies are needed to explore whether testing for antiplatelet resistance should be undertaken routinely in patients starting platelet inhibitory therapy for cardiovascular disease.

Extracranial arterial wall volume is increased and shows relationships with vascular MRI measures in idiopathic Parkinson's disease.

OBJECTIVE: Idiopathic Parkinson's disease (IPD) is the second most common neurodegenerative disorder, often complicated by dementia. Cardiovascular risk factors and spontaneous cerebral emboli (SCE) are strongly associated with Alzheimer's (AD) and vascular dementia (VaD). We measured SCE in the middle cerebral artery and arterial wall volume in the extracranial arteries in patients with IPD and controls, and explored the relationships with structural and physiological MRI brain neurovascular measures. PATIENTS AND METHODS: Arterial wall volume over 2cm of the axillary and internal carotid arteries (ICA) bilaterally was measured by 3-D tomographic ultrasound in 15 IPD patients and 16 age/gender matched controls. SCE were counted by Transcranial Doppler (TCD) using international consensus criteria. Venous to arterial circulation shunting (v-aCS), usually through a patent foramen ovale (PFO), was measured using a TCD technique with intravenous microbubble contrast. Structural and physiological MRI brain neurovascular measures, acquired separately, comprised white matter lesion volume (WMLV), cerebral blood flow (CBF) and arterial arrival time (AAT). RESULTS: Mean (95% CI) axillary and ICA wall volume was higher in IPD patients at 523 mm3 (446, 600) and 455 mm3 (374, 536) respectively compared with 412 mm3 (342, 483) and 408 mm3 (362, 454) in controls being significant for the axillary artery (p = 0.04). Cerebral WMLV was related to mean arterial wall volume for both axillary (r = 0.555, p = 0.009) and ICA (r = 0.559, p = 0.026) in all participants. SCE were detected in four IPD patients and three controls (p = 1.00). Two IPD patients and three controls were positive for a v-aCS equivalent to PFO (p = 0.477). CONCLUSION: Although frequent in AD and VaD, neither SCE nor v-aCS were associated with IPD. This is the first study to demonstrate arterial wall volume is increased in IPD and relates to WMLV.

Diagnosing of pelvic vein incompetence using minimally invasive ultrasound techniques.

Background Pelvic vein incompetence is a cause for pelvic pain and recurrent varicose veins in women. The gold standard diagnostic method is reflux venography involving radiation, nephrotoxic contrast and jugular puncture. Trans-vaginal ultrasound (TVU) is increasingly being used as a diagnostic tool for pelvic vein incompetence. Methods Fifty women with clinical suspicion of pelvic vein incompetence and aged between 18 and 55 years were recruited prospectively over two years at a large UK University Teaching Hospital. Trans-vaginal ultrasound was performed using a standardised protocol which included assessment of the ovarian and internal iliac veins bilaterally in the supine and semi-standing position with provocative manoeuvres. Diagnostic readability and inter-observer variability was determined. Results Mean (range) age of 43 (23-51). Visibility of all four pelvic veins was better in the supine position compared with semi-standing position (76% vs 64%). Pelvic vein incompetence was identified in 34 of 50 (68%) women in the supine position compared with 38 of 50 (76%) women in the semi-standing position. Pelvic vein incompetence was demonstrated in 35 of 50 (70%) women with Valsalva manoeuvre. Inter-observer variability was 0.84 (kappa, very good agreement, p = 0.001). Conclusion Trans-vaginal ultrasound is effective at demonstrating pelvic vein incompetence. All trans-vaginal ultrasound protocols should include assessment of pelvic veins in the supine and semi-standing position with Valsalva manoeuvre.

Is pelvic vein incompetence associated with symptoms of chronic pelvic pain in women? A pilot study.

OBJECTIVE: Pelvic vein incompetence (PVI) affects 15-20% of all women, yet we know little about how it affects sufferers. The aim of this prospective pilot study was to explore symptoms experienced by women with PVI, and determine its impact on quality of life and NHS costs. STUDY DESIGN: Case-control study at a UK University teaching hospital conducted over an eight-month period. Cases were 40 premenopausal women aged 18-49 years with PVI and varicose veins (VV). There were two age-matched controls groups: (i) 40 healthy women with no PVI but with VV, and (ii) 40 healthy women with no PVI and no VV. Subjects were asked to complete a structured questionnaire on disease specific outcomes, health status and use of healthcare resources. RESULTS: Mean age (range) was 39.8 (24-47) years for cases, 39.1 (24-49) for VV controls and 38 (25-49) for healthy controls. Pelvic pain was reported by 38 of 40 (95%) PVI cases, compared with 25 of 40 (62%) VV controls, and 26 of 40 (65%) healthy controls (p=0.001). The median (range) EQ-5D utility score for PVI cases was 0.80 (0.29-1.0) compared with 0.80 (0.09-1.0) for VV controls and 1.0 (0.62-1.0) for healthy controls (p=0.002). Of the 40 PVI cases, 35 (88%) visited a consultant in the previous 12 months compared with 12 of 40 (30%) VV controls, and 14 of 40 (35%) healthy controls (p<0.001). CONCLUSIONS: Women with PVI report a greater frequency of pelvic pain with reduced health status and increased use of healthcare resources compared with matched controls.

Calculating when elective abdominal aortic aneurysm repair improves survival for individual patients: development of the Aneurysm Repair Decision Aid and economic evaluation.

BACKGROUND: Abdominal aortic aneurysm (AAA) repair aims to prevent premature death from AAA rupture. Elective repair is currently recommended when AAA diameter reaches 5.5 cm (men) and 5.0 cm (women). Applying population-based indications may not be appropriate for individual patient decisions, as the optimal indication is likely to differ between patients based on age and comorbidities. OBJECTIVE: To develop an Aneurysm Repair Decision Aid (ARDA) to indicate when elective AAA repair optimises survival for individual patients and to assess the cost-effectiveness and associated uncertainty of elective repair at the aneurysm diameter recommended by the ARDA compared with current practice. DATA SOURCES: The UK Vascular Governance North West and National Vascular Database provided individual patient data to develop predictive models for perioperative mortality and survival. Data from published literature were used to model AAA growth and risk of rupture. The cost-effectiveness analysis used data from published literature and from local and national databases. METHODS: A combination of systematic review methods and clinical registries were used to provide data to populate models and inform the structure of the ARDA. Discrete event simulation (DES) was used to model the patient journey from diagnosis to death and synthesised data were used to estimate patient outcomes and costs for elective repair at alternative aneurysm diameters. Eight patient clinical scenarios (vignettes) were used as exemplars. The DES structure was validated by clinical and statistical experts. The economic evaluation estimated costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) from the NHS, social care provider and patient perspective over a lifetime horizon. Cost-effectiveness acceptability analyses and probabilistic sensitivity analyses explored uncertainty in the data and the value for money of ARDA-based decisions. The ARDA outcome measures include perioperative mortality risk, annual risk of rupture, 1-, 5- and 10-year survival, postoperative long-term survival, median life expectancy and predicted time to current threshold for aneurysm repair. The primary economic measure was the ICER using the QALY as the measure of health benefit. RESULTS: The analysis demonstrated it is feasible to build and run a complex clinical decision aid using DES. The model results support current guidelines for most vignettes but suggest that earlier repair may be effective in younger, fitter patients and ongoing surveillance may be effective in elderly patients with comorbidities. The model adds information to support decisions for patients with aneurysms outside current indications. The economic evaluation suggests that using the ARDA compared with current guidelines could be cost-effective but there is a high level of uncertainty. LIMITATIONS: Lack of high-quality long-term data to populate all sections of the model meant that there is high uncertainty about the long-term clinical and economic consequences of repair. Modelling assumptions were necessary and the developed survival models require external validation. CONCLUSIONS: The ARDA provides detailed information on the potential consequences of AAA repair or a decision not to repair that may be helpful to vascular surgeons and their patients in reaching informed decisions. Further research is required to reduce uncertainty about key data, including reintervention following AAA repair, and assess the acceptability and feasibility of the ARDA for use in routine clinical practice. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

The role of compression in the management of soft tissue ankle injuries: a systematic review.

BACKGROUND: Ankle sprains are very common injuries which can lead to long-term pain, swelling and instability. Compression is often used in the treatment of these common injuries but is it effective and how best is it delivered? METHODS: MEDLINE (1966-current), EMBASE (1980-current), Cochrane Library (2011:1) and MEDION were included in our search. Studies evaluating compression in the treatment of ankle sprains were included. Two authors independently reviewed potential studies according to a set eligibility criteria. RESULTS: Twelve studies including 1,701 patients with ankle sprains were identified (level of evidence: four grade 1b; five grade 2b; three grade 4). Intermittent pneumatic compression (IPC), elastic tubular bandage and compression bandaging were all evaluated. Five of the 12 studies reported that compression therapy improves recovery after ankle injury, of which one evaluated IPC, and the remaining four elastic bandages (Elastoplast, class II elastic stockings, wool and crepe, focal compression with air stirrup). Five studies evaluating Tubigrip in ankle sprains concluded that Tubigrip has no positive effect on functional recovery and may increase the requirement for analgesia compared with no intervention. CONCLUSION: Compression may be an effective tool in the management of ankle injuries and has been shown to reduce swelling and improve quality of life in single studies. Definitive conclusions are hampered by the poor quality of evidence and the variety of treatments used. The most effective form of compression to treat ankle sprains or is yet to be determined. Adequately designed randomized control trials are clearly needed.

Trans-venous occlusion of incompetent pelvic veins for chronic pelvic pain in women: a systematic review.

Chronic pelvic pain (CPP) affects 24% of women worldwide; the cause cannot be identified in 40% despite invasive investigations. Dilated, refluxing pelvic veins may be a cause of CPP and treatment by trans-venous occlusion is increasingly performed when gynecological causes are excluded, but is it effective? A systematic review of the literature published between 1966 and July 2014 was conducted. Two authors independently reviewed potential studies according to a set of eligibility criteria, with a third assessor available as an arbiter. Thirteen studies including 866 women undergoing trans-venous occlusion of pelvic veins for CPP were identified (Level of evidence: one study grade 2b, 12 studies grade four). Statistical significant improvements in pelvic pain were reported in nine of the 13 studies. Technical success was reported in 865 of 866 (99.8%) with low complication rates: coil migration in 14 women (1.6%), abdominal pain in ten women (1.2%) and vein perforation in five (0.6%). In a study on varicose veins of the legs, recurrence was seen in 13% of 179 women 5-years following coil embolization. Subjective improvements in pain were seen in all 13 studies after treatment by trans-venous occlusion. All 13 studies were of poor methodological quality. Complication rates were low and no fatalities occurred. Well-designed studies are essential to determine whether pelvic vein incompetence (PVI) is associated with CPP, and to explore whether trans-venous occlusion of PVI improves quality of life for these women.

Use of three-dimensional contrast-enhanced duplex ultrasound imaging during endovascular aneurysm repair.

BACKGROUND: Iodinated contrast during endovascular aneurysm repair (EVAR) is used with caution in patients with chronic kidney disease. Contrast-enhanced ultrasound (CEUS) imaging using nonnephrotoxic sulphur hexafluoride microbubble contrast is a novel imaging modality that accurately identifies and characterizes endoleaks during EVAR follow-up. We report our initial experience of using three-dimensional (3D) CEUS imaging intraoperatively as completion imaging after endograft deployment. Our aim was to compare intraoperative 3D CEUS against uniplanar angiography in the detection of endoleak, stent deformity, and renal artery perfusion during EVAR. METHODS: The study enrolled 20 patients undergoing elective conventional infrarenal EVAR, after which a completion angiogram was performed and the presence of endoleak, renal artery perfusion, or device deformity were recorded. With the patient still under anesthetic, a vascular scientist blinded to angiographic findings performed 3D CEUS and reported on the same parameters. RESULTS: Three endoleaks, one type I and two type II, were detected on uniplanar angiography and 13 endoleaks, 11 type II and two type I, were found using 3D CEUS imaging. Of note, one of these type I endoleaks was not seen on angiography, and this patient underwent balloon moulding of the neck with resolution of the endoleak on repeat imaging. Of the 11 type II endoleaks seen with 3D CEUS imaging, the inflow vessel was identified in nine cases. No graft deformity or limb kinking was seen in any patient. Both renal arteries could be visualized in 10 patients, whereas the target renal artery was seen in 11 patients. In the remaining patients, the renal arteries could not be visualized, mainly due to intra-abdominal gas or patient body habitus. CONCLUSIONS: 3D CEUS imaging detected endoleaks not seen on uniplanar digital subtraction angiography, including a clinically important type I endoleak, and was also more sensitive than 2D CEUS imaging for the detection of the source of endoleak. This technology has the potential to supplement or replace digital subtraction angiography for completion imaging to reduce the use of x-ray contrast. Intraoperative 3D CEUS has been applied to allow safe EVAR with ultralow or no iodinated contrast usage in selected cases, without compromising completion imaging.

Elastic stockings or Tubigrip for ankle sprain: a randomised clinical trial.

BACKGROUND: Ankle sprains are common and generally believed to be benign and self-limiting. However, a significant proportion of patients with ankle sprains have persistent symptoms for months or even years. AIMS: The study aimed to evaluate whether elastic stockings improve recovery following ankle sprain. METHODOLOGY: All patients within 72 h of ankle sprain were identified in Accident & Emergency or the Fracture Clinic. Consenting patients, stratified for sex, were randomised to either: (i) Tubigrip or (ii) class II below knee elastic stockings (ESs, Medi UK Ltd.) which were fitted immediately and worn until the patient was pain-free and fully mobile. The deep veins of the injured legs were imaged by duplex Doppler for deep vein thrombosis (DVT) at 4 weeks. Outcome was compared using the American Orthopaedic Foot and Ankle Score (AOFAS) and SF12v2 for quality of life. RESULTS: In the 36 randomised patients, the mean (95% confidence interval (CI)) circumference of the injured ankle treated by ES was 23.5 (23-24)cm initially and 22 (22-23) and 22 (21-22.5)cm at 4 and 8 weeks (p<0.001) compared with 24 (23-25) cm initially and 24 (23-25) and 24 (23-24.5) cm using Tubigrip (p<0.001). By 8 weeks, the mean AOFAS and SF12v2 scores were significantly improved by ES at 99 (8.1) and 119 (118-121) compared with 88 (11) and 102 (99-107) with Tubigrip (p<0.001). Of the 34 duplex images at 4 weeks, none had a DVT. CONCLUSION: Elastic compression improves recovery following ankle sprain.

Incidence of venous thromboembolism during chemotherapy for breast cancer: impact on cancer outcome.

BACKGROUND: Evidence suggests that cancer patients who develop venous thromboembolism (VTE) have a poorer outcome than those who do not. The aim of this prospective study was to assess the incidence of the development of VTE in breast cancer patients commencing chemotherapy and the relationship between development of thrombosis and cancer progression and death. PATIENTS AND METHODS: One hundred and thirty-four breast cancer patients were recruited and followed up prior to chemotherapy and at 3, 6, 12 and 24 months. Duplex ultrasound imaging (DUI) was performed 1 month following commencement of chemotherapy or if patients became symptomatic. RESULTS: Thirteen patients developed VTE. Six patients with advanced breast cancer and seven with early breast cancer developed VTE. Three patients died from VTE; all had advanced breast cancer. In patients with VTE, the 28-day mortality rate was 15%, but in patients with symptomatic VTE, the 28-day mortality was 22%. Development of VTE did not predict for progression by three and six months in advanced breast cancer patients. VTE demonstrated a trend for predicting progression by two years. Using Cox regression survival analysis, there was no survival advantage in those with or without VTE. CONCLUSION: Although the body of evidence supports a worse prognosis when VTE and cancer coexist as compared to either diagnosis alone, a larger prospective study is required to confirm this and clarify whether any premature death is primarily due to VTE or to more aggressive cancer.

Chimney stent technique for treatment of severe abdominal aortic atherosclerotic stenosis.

Application of the "chimney" stent technique is described in a case of complex multilevel atherosclerotic disease involving the juxtarenal aorta. A patient with significant comorbidities was unsuitable for major open reconstructive surgery. He was treated with a combined procedure consisting of chimney stent placement in the juxtarenal aorta, iliac "kissing" stent placement, and right-sided common femoral artery (CFA) replacement. This case shows that the chimney stent technique can be a feasible alternative to leaving a safety wire in the renal arteries and observation during primary angioplasty in complex atherosclerotic lesions of the abdominal aorta.

High prevalence of right-to-left shunt in patients with symptomatic great saphenous incompetence and varicose veins.

BACKGROUND: Varicose veins are common and increasingly are being treated by less invasive endoscopic methods such as foam sclerotherapy. Patent foramen ovale (PFO) is also common, present in approximately one-quarter of adults. PFO allows bubbles introduced by foam sclerotherapy to cross into the general circulation, potentially causing cerebral artery gas embolization with unevaluated consequences. METHODS: Men and women aged 18 to 60 years with symptomatic varicose veins (CEAP C(3-5)) responded to an advertisement to recruit volunteers for a study on endovenous microfoam ablation (EMA). Participants' veins were screened by duplex ultrasound imaging, and those with isolated great saphenous vein (GSV) incompetence were tested for right-to-left (R-L) vascular shunt using transcranial Doppler (TCD) of the middle cerebral artery to detect the presence of bubble emboli after an injection of an agitated saline, blood, and air mixture as a contrast at rest and with the Valsalva maneuver. RESULTS: Of 221 participants tested for R-L shunt, 85 (38.5%) were positive at rest (95% confidence interval [CI], 32.5-45.2) and 114 (51.8%) were positive after the Valsalva maneuver (95% CI, 45.4-58.5). A total 130 patients (58.8%) were positive for R-L shunt at rest or after Valsalva (95% CI, 52.5%-65.1%). This is significantly higher than the reported 26% prevalence of PFO in the general population (95% CI, 24.4-30.1). CONCLUSIONS: The prevalence of R-L shunt in patients with GSV incompetence CEAP C(3-5) in this study was higher than expected in the general population. TCD does not differentiate between intracardiac shunts and intrapulmonary shunts, so this observation needs further investigation. This link between R-L shunt and varicose veins is novel and, whether etiologic or functional, may improve the understanding of both conditions. The findings have importance in the treatment of varicose veins with foam sclerotherapy and EMA.