Clinical and hemodynamical findings in legs with previous surgery of the great saphenous vein: role of the small saphenous vein

AIM

To assess the role of small saphenous vein (SSV) reflux in patients with a long history of varicose disease and previous stripping of the great saphenous vein (GSV).

METHODS

Consecutive patients with a history of GSV stripping 5-19 years earlier were enrolled in this prospective clinical study. A total of 101 legs of 75 consecutive patients fulfilled the study criteria: previous stripping of GSV from ankle to groin at least 5 years earlier, no history of thromboembolism and no previous surgery of deep veins or SSV. All patients were studied clinically using standardized classifications: clinical class, clinical disability score (CDS) and venous clinical scoring system (VCSS). Colour flow duplex imaging (CFDI) was used to assess reflux in deep and superficial veins. Details of prior surgery were evaluated.

RESULTS

Overall, SSV reflux was noted in 28 (28%) of the legs, recurrent GSV (rGSV) in the thigh in 41 (41%), reflux in tributaries alone in 28 (28%) and a combination of SSV and rGSV reflux in 4 (3%). Segmental deep reflux was measured in 23 (23%) of the legs; the prevalence of deep reflux was significantly higher in complicated than in uncomplicated legs (12% versus 47%; P<0.05). Deep reflux was more frequently associated with SSV reflux than with rGSV reflux (50% versus 22%; P<0.05). The prevalence of SSV with or without deep reflux increased from 17% to 50% (P<0.05) when uncomplicated (C2-3) and complicated (C4-6) legs were compared. A similar increase was not seen in the legs with rGSV (39% versus 44%; P>0.05). SSV reflux without deep reflux was observed in 25% of the legs with complicated (C4-6) disease, whereas the prevalence of SSV reflux was low (9%) in uncomplicated (C2-3) legs. VCSS was higher in the legs with SSV reflux than in those with rGSV reflux. CDS scores tended to be higher in the SSV reflux group than in the legs with rGSV reflux or tributary reflux alone. After exclusion of deep reflux, the results remained at the same level.

CONCLUSION

Small saphenous vein (SSV) reflux is common in legs with recurrent varicose veins and previous stripping of the GSV. SSV reflux alone is frequent in complicated legs, and SSV reflux is typically associated with segmental deep reflux. Clinical and hemodynamical findings stress the role of SSV reflux in this selected venous population.

The profile of leg symptoms, clinical disability and reflux in legs with previously operated varicose disease

PURPOSE

It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease.

METHODS

A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed.

RESULTS

The site of superficial reflux was at the groin in 58% (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11% (unoperated short saphenous vein). In 58% of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74% of the legs, sensation of oedema in 64%, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2-3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2-3) were significantly more frequent among complicated legs (CEAP clinical class C2-3: 22% versus CEAP clinical class C4-6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7% versus severe reflux: 48%; p < 0.005).

CONCLUSIONS

Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

Carotid artery surgery--critical analysis of indications in a regional Finnish vascular center

BACKGROUND

The purpose of this study was to analyze retrospectively the treatment of patients referred for carotid artery stenosis to a vascular surgical unit in the 1990's. Main attention was paid to the appropriateness of the indications for CEA.

MATERIAL AND METHODS

In the Pirkanmaa region (population of 440 000), all carotid surgery is performed in the regional University Hospital. All new referrals for vascular surgery because of carotid stenosis or bruit in 1990, 1992, 1994, 1996 and 1998 were included and case records reviewed.

RESULTS

Four hundred patients were referred. Indication for referral was a neurologic event in 46.2%, indefinite symptom in 27.9% and asymptomatic stenosis or carotid bruit in 25.9%. Most patients underwent carotid ultrasound as first imaging (93.7%). Almost half of the patients were operated (n=176). The 30-day combined stroke and death rate was 6.5%. Appropriate indication for CEA was found in 31.6%. Over half (57.0%) of the indications were considered uncertain and 11.4% inappropriate, most of these patients having asymptomatic stenosis.

CONCLUSION

Patients with asymptomatic stenosis underwent CEA relatively often and the proportion of inappropriate indications was too high. Evaluation of indications and perioperative complications is highly important in carotid surgery.

Revascularization decreases 8-isoprostaglandin F2alpha excretion in chronic lower limb ischemia

8-Isoprostaglandin F2alpha is one of a series of isoprostanes formed by free radical catalysed peroxidation of arachidonic acid. Urinary 8-isoprostaglandin F2alpha is a new marker which reflects oxidative stress in vivo and can be utilized as a diagnostic tool to assess the extent of oxidative stress in various disease states associated with lipid peroxidation. Increased levels of 8-isoprostaglandin F2alpha in cardiac ischemia/reperfusion provide evidence for oxidative stress during coronary perfusion. In animal studies, the restoration of blood flow after lower limb ischemia is followed by reperfusion syndrome. In this study we investigated whether lower limb ischemia/reperfusion is associated with oxidative stress, as reflected by urinary levels of 8-isoprostaglandin F2alpha. Ten patients (mean age 72 years, range 61-82 years) suffering from chronic lower limb ischemia and 10 healthy volunteers (mean age 69 years, range 60-79 years) participated in the study. In all patients, diagnostic angiography had revealed stenosis or occlusion either in the aortoiliac or femoropopliteal region. Surgical revascularization consisted of femoropopliteal reconstruction, femorofemoral reconstruction, aortobifemorial reconstruction, or femoral endartectomy. Urine samples from patients were collected a day before surgery and in the second postoperative day. Urinary 8-isoprostaglandin F2alpha was extracted on a C2 silica cartridge and determinated by radioimmunoassay. After revascularization, 8-isoprostaglandin F2alpha excretion (pg/micromol creatinine, mean +/- SD) was decreased by 2.5-fold (preoperative 48.9 +/- 8.9, postoperative 19.1 +/- 9.5, P < 0.001). The postoperative values were similar to the concentrations measured in healthy volunteers (18.0 +/- 11.0). All revascularizations were successful, and the increase in ankle-brachial index (preoperative 0-0.6, postoperative 0.4-0.8) revealed improved blood flow in the ischemic lower limb. We suggest that, as assessed by the quantitation of urinary 8-isoprostaglandin F2alpha, chronic lower limb ischemia is associated with increased oxidative stress, which is decreased by revascularization.

Endovascular treatment of venous malformations in extremities: results of sclerotherapy and the quality of life after treatment

PURPOSE

To evaluate the long-term results of endovascular sclerotherapy in treating venous extremity malformations and to assess the quality of life after treatment.

MATERIAL AND METHODS

Twenty-four patients were included who had completed treatment with ethanol sclerotherapy and a minimum of one year observation period. Nineteen patients attended a clinical control. To evaluate the quality of life after treatment, 23 patients filled in a questionnaire which included 20 multiple-choice questions exploring four dimensions: psychological, physical and social functioning, and pain.

RESULTS

At the clinical control seven patients had no clinical symptoms related to the malformation, six had slight, four moderate, and two severe symptoms. In 16 patients the symptoms had diminished after treatment. No deterioration of the initial situation was observed. The results concerning quality of life showed that most patients did well after endovascular treatment. Pain was the most important injurious factor for state of health among the four different dimensions. The poorest outcome was found in malformations that filled the whole muscle or muscle compartment and in larger lesions. The patients whose malformation at the clinical control caused swelling to the extremity affected had poorer quality indices than others.

CONCLUSION

Endovascular treatment for venous malformations is an effective treatment.

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience

BACKGROUND AND AIMS

In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry.

MATERIAL AND METHODS

A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry.

RESULTS

The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm.

CONCLUSIONS

According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Endovascular surgery for chronic limb ischaemia. Factors predicting immediate outcome on the basis of a nationwide vascular registry

PURPOSE

To evaluate the early results of endovascular treatment of chronic limb ischemia and the factors influencing outcome.

METHODS

The 5,575 endovascular procedures entered into the national vascular registry in 1991-1994 were reviewed retrospectively. Indication was claudication in 3,873 and chronic critical ischemia (CLI) in 1,702 procedures. In CLI most patients were women and older, with a higher proportion of diabetes mellitus, renal insufficiency and coronary heart disease than in claudication group although the incidence of smoking and hyperlipidaemia was lower. 60.2% of the procedures were performed in femoropopliteal arteries, 24.9% in iliac arteries and 14.9% in infrapopliteal arteries. The follow-up was 30 days.

RESULTS

In the claudication group there was clinical improvement in 2,719 (82.8%) and in the CLI group in 851 (70.9%) of patients. Patency was better in the claudication than in CLI group, 94.6% vs. 89.0% respectively. There was hemodynamic improvement, i.e. improvement of the ankle-brachial index of more than 0.15 in 1,680 (58.2%) patients with claudication and in 437 (59.7%) with CLI. In a logistic regression model diabetes mellitus and renal insufficiency increased the relative risk of amputations and mortality in CLI group, whereas, incidence of amputations was lower in patients with hyperlipidaemia. In claudication group femoropopliteal arteries had an adverse effect on patency.

CONCLUSION

The clinical characteristics of the groups may explain some of the outcome differences. Angioplasty is recommended to be used in the femoropopliteal arteries if the symptoms are severe and in CLI group with diabetes and renal failure only in selected cases.

The effect of revascularisation of an ischaemic lower limb on leukotriene E4 production

It has previously been shown that leukotriene E4 production is increased both in acute and chronic lower limb ischaemia. The aim of this study was to measure the effect of revascularisation on leuktriene E4 excretion in chronic lower limb ischaemia. Revascularisation did not affect significantly on leukotriene E4 excretion (preop. 34.9+/-7.1 pg/mg creatinine, postop. 24.5+/-4.7 pg/mg creatinine, n=10, P<0.238). We suggest that the enhanced leukotriene E4 production continues after revascularisation which may have a therapeutical implication.

Piezoelectric pulse sensor device (Pulse Chek)-monitoring after the treatment of lower leg ischemia

BACKGROUND

The aim of this study was to evaluate the usefulness of the piezoelectric pulse sensor device (Pulse Chek) as a continuous monitoring method in early surveillance after the treatment of lower leg ischemia with either surgical or interventional procedures.

METHODS

EXPERIMENTAL DESIGN

prospective study.

SETTING

institutional practice.

PATIENTS AND INTERVENTIONS

two patient groups with peripheral arterial occlusive disease were included; a surgical group undergoing femoropopliteal bypass grafting (22 patients) and a group undergoing PTA of the femoral or popliteal arteries (18 patients).

MEASURES

the piezoelectric pulse sensor was applied on the skin over the dorsalis pedis artery. A baseline waveform was recorded preoperatively and continuous monitoring begun immediately after the surgical or interventional procedure. Hard copy recordings of the pulse wave were done in the immediate postoperative period, the postoperative evening, the following morning or at any time the alarm was triggered. A late follow-up waveform was recorded after an average of 34 days. Simultaneous ABI measurements were recorded.

RESULTS

Preoperatively or pre-intervention, the pulse waveform was accurately recorded in 15/22 (68%) patients in the surgical group and 14/18 (78%) patients of the PTA group. In 20 (91%) surgical group patients and in 14 (78%) PTA group patients, postoperative monitoring was reliable, the pulse waveform confirmed patency of the vessel. Piezoelectric pulse sensor device monitoring did not detect graft occlusion in only one patient in the surgical group where interpretation of the pulse wave was complicated by a slow atrial fibrillation. There were 19 alarms in the pulse waveform during monitoring for 11 (55%) surgical group patients and 18 alarms for 9 (64%) PTA group patients. None of the alarms resulted from graft occlusion. Reliable pulse waveform recordings were obtained in 16/21 (76%) surgical group patients of the original 22 (one graft occluded) and for 15/18 (83%) PTA group patients in the follow-up assessment after the mean 34 days. One surgical patient was lost to follow-up.

CONCLUSIONS

The piezoelectric pulse sensor device can be recommended as a method of continuous monitoring immediately after the revascularization procedure in those patients who have a pedal artery where a reliable pulse waveform can be recorded.

Weekly and seasonal variation of hospital admissions and outcome in patients with acute lower limb ischaemia treated by surgical and endovascular means

BACKGROUND

The aim of this study was to investigate weekly and seasonal variation of hospital admissions, major amputations and mortality in patients treated for acute leg ischaemia by surgical and endovascular procedures.

METHODS

EXPERIMENTAL DESIGN

Retrospective study.

SETTING

University (5), central (16) and district (4) hospitals participating in the Finnish national vascular registry Finnvasc.

PATIENTS

1550 patients treated for acute leg ischaemia on the basis of the registry.

INTERVENTIONS

Surgical or endovascular revascularisation.

MEASURES

Day of the week of hospital admission, major amputation and death.

RESULTS

The weekly pattern of the hospital admissions was significantly non-uniform with a Monday peak and a weekend nadir. A tendency towards more hospital admissions in the winter season was found. PATIENTS hospitalised on Thursday or Friday tended to have a lower amputation rate compared to those hospitalised in any other day of week. The highest amputation and mortality rates were observed in the summer season.

CONCLUSIONS

PATIENTS with acute leg ischaemia seek medical help in a non-uniform weekly and seasonal pattern with varying outcomes.

Projected workload for a vascular service in 2020

OBJECTIVE

to estimate the workload of a vascular service during the next two decades as the proportion of people aged over 65 years increases.

METHODS

the study used the vascular registry data of Tampere University Hospital and the population data of Pirkanmaa region provided by the Central Statistical Office in Finland. The current workload is 1420 vascular procedures per million inhabitants yearly (951 surgical and 207 endovascular). Sixty-five per cent of all procedures are done on people over 65 years old. Pirkanmaa has a population of 440 000 persons of whom 15.6% are over 65 years. According to the population data the population will increase to 460 000 persons by the year 2020 and 22.9% of them will be over 65 years old.

RESULTS

The total amount of procedures will rise by 40.5% (1906) and the increase in endovascular and surgical group will be 39.2% (640) and 43.5% (1265) respectively. The proportion of treated patients over 65 years will rise from 65.0% to 70.5%. In the next two decades the amount of patients with claudication will increase by 35.4%, critical limb ischaemia by 44.2%, carotid surgery by 34.0%, abdominal aortic aneurysms by 40.7%, acute limb ischaemia by 45.0% and access surgery by 27.4%.

CONCLUSION

In the next two decades the number of elderly people will increase so rapidly that, whatever happens to the incidence and prevalence of peripheral vascular disease, the workload for a vascular service will increase significantly.

Carotid stenosis and abdominal aortic aneurysm at the follow-up examination in patients treated for acute extremity ischaemia

BACKGROUND

To evaluate survivors treated for acute extremity ischaemia as a risk-group for carotid stenosis and abdominal aortic aneurysm at the follow-up examination.

METHODS

EXPERIMENTAL DESIGN

Clinical study with median follow-up of 14 (8-32) months.

SETTING

Central Hospital of Central Finland.

PATIENTS

Eighteen survivors with median age of 77 (51-92) years treated for acute extremity ischaemia during two-year period intended to a separate follow-up examination median 14 (8-32) months after the acute episode of vascular occlusion. Ischaemia was considered as acute in 14 patients and acute on chronic in four patients.

INTERVENTIONS

Thromboembolectomy was the primary intervention excluding two patients with distal upper limb ischaemia who were treated by intravenous heparin.

MEASURES

Clinical examination, duplex scanning of carotid bifurcation and sonography of abdominal aorta were performed at the follow-up examination.

RESULTS

Significant asymptomatic carotid stenosis >60% was found in four patients (22%), two of these patients had significant bilateral carotid stenosis. One patient (60%) had abdominal aortic aneurysm of 5.2 cm.

CONCLUSIONS

In survivors treated for acute extremity ischaemia asymptomatic carotid stenosis >60% was found with significantly increased prevalence compared with general population and with equal prevalence when compared with patients with peripheral vascular disease. Occurrence of abdominal aortic aneurysm was parallel with findings in screening surveys.

DNA flow cytometry in surgically treated lung cancer--prognostic significance

Although DNA aneuploidy and high proliferative activity (S-phase fraction, SPF) of tumour cells, measured by flow cytometry, have proved to be indicators of poor prognosis in most solid tumours, there have been conflicting results in lung cancer studies. During a four-year period we studied the prognostic significance of DNA ploidy and SPF in 99 surgically treated lung cancer patients. Flow cytometric analysis was done from archival, formalin-fixed, paraffin-embedded tumour specimens. DNA index and SPF were determined, using MultiCycle software with sliced nuclear correction to compensate for debris. There were 61 DNA diploid and 38 DNA aneuploid tumours. The median SPF was 10.2%. Neither ploidy nor SPF was associated with previously known prognostic factors. Survival was poorer in patients with aneuploid tumours than in the other patients, but the difference was not statistically significant. DNA ploidy and SPF thus do not seem to be useful prognostic indicators in surgically treated lung cancer.

Prognosis of surgically treated lung cancer

BACKGROUND AND AIMS

This retrospective study clarifies the prognosis of surgically treated lung cancer in a teaching university hospital.

MATERIAL AND METHODS

During a four year period 141 patients were operated for lung cancer in a teaching university hospital. After five years follow up the case records were analysed. The operative and microscopical findings were classified using the AJC pTNM staging system and WHO's histologic classification of lung tumours. There were 120 (85 %) male and 21 (15 %) female. The median age for males was 62 years and females 64 years; range was 29 to 76 years for both sexes.

RESULTS AND CONCLUSIONS

The perioperative mortality of all patients was 5,0 %, of 84 patients operated with lobectomy 2.4 %, of 32 patients operated with pneumectomy 15,6 %, and of 25 patients operated with explorative thoracotomy 0 %, respectively. The five year survival of all patients was 33 % including perioperative mortality. The survival was significantly better for 83 patients with stage I disease (49 %) than 17 stage II (6 %), 24 stage IIIa (20.8 %), and 17 stage IIIb or IV disease (0 %). The survival was significantly better after lobectomy (44.1 %) than after pneumectomy (25.0 %) or explorative thoracotomy (8.0 %). Our study shows the good effect of surgery in stage I, and confirms it's usefulness in stage IIIa lung cancer. The histologic types of tumours did not affect survival.

Mesenteric infarction after aortoiliac surgery on the basis of 1752 operations from the National Vascular Registry

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.

Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group

OBJECTIVE

To assess mortality related to rupture of abdominal aortic aneurysm (RAAA).

DESIGN

A 4-year cross-sectional study based on a nationwide vascular registry Finnvasc and national cause-of-death registry (Statistics Finland).

MATERIALS AND METHODS

A total of 454 operations for RAAA among 11,747 surgical vascular reconstructions recorded in the Finnvasc registry and 1004 deaths due to RAAA during the same period based on Statistics Finland.

RESULTS

The operative mortality rate was 49% based on the Finnvasc registry and 54% based on Statistics Finland. With all RAAA deaths at hospitals included, total hospital mortality was 68%. No association existed between hospital volume of RAAA operations and surgical mortality, although an inverse association did exist between hospital volume of RAAA operations and all RAAA deaths in the hospital (p = 0.01). The case fatality for RAAA in Finland was 80%.

CONCLUSIONS

RAAA surgical mortality calculations for RAAA, based on a vascular registry, underestimate the true rate because some cases with fatal outcome tend to escape registration. Because surgical mortality rates may also be skewed by patient selection, total hospital RAAA mortality thus represents the results of RAAA treatment more accurately.

Accumulation of bisphosphonates in human artery and their effects on human and rat arterial function in vitro

Clodronate, etidronate and pamidronate are bisphosphonates introduced in the treatment of hypercalcaemia and osteoporosis. Interestingly, they also inhibit development of experimental atherosclerosis and affect smooth muscle tone of isolated rat tail artery. We have studied in vitro whether these hydrophilic compounds 1) accumulate in the wall of the human artery, 2) influence human arterial tone, and 3) interfere with the vascular action of L-type Ca2+ antagonists. Human internal mammary artery rings were incubated with 14C-labelled bisphosphonates. After a 2-hr incubation, the ratios of artery-to-incubate concentrations with 4 and 40 mumol/l of clodronate were, respectively, 3.0 +/- 0.5 (mean +/- S.E.M.) and 1.3 +/- 0.2, with 4 and 40 mumol/l of etidronate 7.4 +/- 0.9, and 3.2 +/- 0.4, and with 0.4 and 4 mumol/l of pamidronate 4.7 +/- 0.7 and 3.9 +/- 0.8. Both tested bisphosphonates, clodronate and pamidronate, reduced the arterial contractile force induced by alpha-adrenergic stimulation with noradrenaline and membrane depolarization with high concentration of KCl. Clodronate also decreased the arterial contraction induced by cumulative addition of Ca2+ with KCl as the agonist, and had an additive inhibitory effect on this response with the L-type Ca2(+)-channel blocker nifedipine. The results demonstrate that 1) bisphosphonates accumulate markedly in human artery, 2) clodronate and pamidronate reduce human arterial contactile force to alpha-adrenergic and depolarizing stimuli, and 3) as shown with clodronate, bisphosphonates may exert an additive inhibitory effect on human arterial contractions with an L-type Ca2(+)-channel blocker.

Resting ECG changes in long term survivors after carotid endarterectomy

OBJECTIVE

To evaluate the prevalence of resting ECG findings preoperatively and at the follow-up examination in long term survivors after carotid endarterectomy and to find out possible alteration in ECG pattern between preoperative and follow-up ECG records.

SETTING

Tampere University Hospital.

PATIENTS

150 patients intended to control examination. There were 97 men and 53 women with the mean age of 63.7 years.

INTERVENTIONS

Carotid endarterectomy.

MEASURES

Preoperative and follow-up ECG records were classified according to Minnesota coding system.

RESULTS

No reportable ECG items were found in 92.0% of patients preoperatively and in 78.5% at the follow-up examination. In 13.3% of patients ECG pattern was changed during the follow-up. Q-QS-changes were found in 6.7% of patients preoperatively and in 16.1% of patients at the follow-up examination. Atrial fibrillation appeared in 4.7% of patients during the follow-up. One new RBBB was found at the follow-up ECG.

CONCLUSIONS

In this selected material resting ECG changes in long term survivors after carotid endarterectomy were relatively few. ECG changes found were mostly suggestive of ischemic heart disease and progression to more frequent ischemic changes during the follow-up was obvious.

Do vascular registers affect decision-making? Finnvasc Study Group

Treatment activity of vascular diseases varies depending on population, preference of doctors and the availability of vascular surgical services. Vascular registry offers an opportunity to review practice, to compare outcome with a standard, and to implement change to improve practice. Prospective data collection of all reconstructive vascular procedures has been performed in Finland for seven years. According to a review of the first five years, combined vascular and endovascular activity has increased nation-wide from 3508 procedures done in 1991 to 5200 in 1995. There are marked regional differences in the frequency and selection of various treatment modalities, which can not be explained only by epidemiological data but as well by skewed vascular care delivery. This data can be used for decision-making and should be used for planning of the vascular surgical services in Finland.

Biochemical composition of human peripheral arteries examined with near-infrared Raman spectroscopy

PURPOSE

Near-infrared Raman spectroscopy provides an important new means of analyzing the chemical composition of the arterial wall. The objective of this study was to show that Raman spectroscopy can be used to evaluate the lipid and calcium salt contents of human peripheral arteries. The results extend a recently developed Raman-based method for analyzing the chemical composition of coronary arteries.

METHODS AND RESULTS

We studied 167 segments of carotid and femoral artery wall in various pathologic states. The Raman spectra from these samples was accurately modeled. The resulting chemical concentrations were compared with the amounts of cholesterol and calcium mineral determined at histologic evaluation by an experienced cardiovascular pathologist. Strong correlations between spectroscopic measurements and morphologic findings were demonstrated and validated the applicability of the method to peripheral arteries.

CONCLUSIONS

Raman spectroscopy can provide reliable histochemical information about peripheral and coronary arteries. Such information may help identify rupture-prone plaques before the onset of symptoms and allow aggressive and directed intervention. Accurate knowledge of the chemical composition of a lesion may be useful in selecting the most appropriate treatment.

Influence of surgical experience on the results of carotid surgery. The Finnvasc Study Group

OBJECTIVE

To assess the 30-day mortality and morbidity rates related to carotid endarterectomy on a nation-wide basis.

DESIGN

Retrospective cross-sectional study based on vascular registry Finnvasc.

MATERIALS AND METHODS

A total of 17,465 recorded vascular and endovascular procedures included exactly 1600 carotid endarterectomies performed by 104 surgeons in 23 hospitals. Fourteen per cent of the patients were operated on for asymptomatic carotid stenosis.

RESULTS

The combined mortality and permanent stroke rate was 3.3%, without any difference between operations done on symptomatic or asymptomatic patients. There was a clear inverse association between surgeon's carotid case load and poor outcomes in carotid surgery (p < 0.005), the critical patient mass per surgeon and year being 10 operations. There was no association between outcome after carotid surgery and hospital volume of carotid operations.

CONCLUSIONS

Surgeon's experience in carotid surgery clearly improves the results of carotid surgery.

Stent grafting for abdominal aortic aneurysms in Finland--a feasibility study

BACKGROUND AND AIMS

Endovascular repair of abdominal aortic aneurysms (AAA) is a feasible procedure in selected patients. In order to assess how many AAAs are suitable for such a procedure, a survey has been conducted in Helsinki, Kuopio, and Tampere University Hospitals.

MATERIAL AND METHODS

AAAs having a maximum diameter of 45 mm or more at ultrasonography were included for further evaluation and assessment by angiography and/or spiral CT angiography to determine the length and width of infrarenal aneurysmal neck as well as the dimensions of the distal abdominal aorta and iliac arteries.

RESULTS

Among a total of 75 patients with AAA examined in three centres, ultrasonography overestimated the size of the aneurysm in 12 cases that were demonstrated by angiography and CT to have a diameter of less than 45 mm. Among those patients with larger aneurysms, 17 (27%) were suitable for endovascular repair. Stent grafting has been performed in 10 patients until May, 1997. Perigraft leakage occurred in one patient who required the insertion of an additional collar stent graft.

CONCLUSIONS

Large numbers of suitable patients are not easy to find but, by performing joint screening in Finland, epidemiological data on suitable aneurysms and improving co-operation between centres can be achieved. Therefore, it would be wise to centralise endovascular repair of AAA.

Auditing a nationwide vascular registry--the 4-year Finnvasc experience. Finnvasc Study Group

OBJECTIVE

To assess the validity of a national vascular registry.

MATERIALS AND METHODS

17,465 vascular and endovascular procedures, immediate reoperations excluded, registered in the Finnvasc registry from 26 centres during the years 1991-1994.

CHIEF OUTCOME MEASURES

Comparison of the number of registered procedures with hospital records, comparison of initial registrations with a random sample of re-registration and comparison of the 1-year local data input of one major centre to the same data input of the central unit.

RESULTS

The rate of missing registrations was 19% ranging from 0-47%. The data of the re-registered forms were in agreement with the original data in 93% of all data points, the range being from 81-100%. There was a difference of 1.5% in the data between the major centre and the central unit.

CONCLUSIONS

The Finnvasc registry makes it possible to audit vascular surgery nationally, although a potential limitation is centres with low registration rates.

Mortality in abdominal aortic aneurysm surgery--the effect of hospital volume, patient mix and surgeon's case load

OBJECTIVE

Assessment of mortality in abdominal aortic aneurysm surgery.

DESIGN

A 4-year cross sectional study based on a nationwide vascular registry: Finnvasc.

MATERIAL AND METHODS

A total of 17,465 vascular interventions included 929 elective repairs for abdominal aortic aneurysms (AAA), and 610 emergency cases with 454 ruptures. Fifty-three percent of the operations were done in university hospitals, 44% in central hospitals and 3% in district hospitals.

RESULTS

The 30-day mortality rate for AAA repair was 5.1% in elective and 46% in ruptured cases. A clear dependence of operative mortality on surgeon's experience in AAA surgery was observed, both regarding the surgeon's total vascular case load (p < 0.01) and the number of operated elective aneurysms (p < 0.01), but not the number of operated ruptured aneurysms. However, no association was found between hospital volume and mortality in AAA surgery.

CONCLUSIONS

Vascular surgical experience clearly improves the results of elective aneurysm surgery.

Noninvasive vascular imaging in the diagnosis and treatment of adventitial cystic disease of the popliteal artery

This brief case report describes the successful outcome after surgical excision of multiple adventitial cysts of the popliteal artery in a 75-year-old man with rapidly worsening claudication. It highlights several unsettled points concerning the diagnosis, cause, and management of cystic adventitial disease of the popliteal artery and compares duplex ultrasound, computed tomography, and magnetic resonance angiography in the noninvasive diagnosis and treatment of this condition.

Percutaneous transluminal angioplasty increases thromboxane A2 production in claudicants

Percutaneous transluminal angioplasty is an acute, local stimulus to platelets which activation is regarded as an important factor for a later restenosis. The balance between the production of prostacyclin and thromboxane A2 is of (patho)physiological importance due to their opposite actions on vascular tone and platelet reactivity. In this study we investigated the influence of percutaneous transluminal angioplasty of the peripheral arteries on prostacyclin and thromboxane A2 productions in vivo by measuring the excretions of their urinary index metabolites, 2,3-dinor-6-ketoprostaglandin F1 alpha and 11-dehydrothromboxane B2, respectively, in 10 patients. We found a twofold increase in thromboxane A2, but no significant change in prostacyclin, production after peripheral transluminal angioplasty which shifted prostacyclin/thromboxane A2 balance to the direction of thromboxane A2 formation. This gives theoretical support to the use of thromboxane A2 synthase inhibitors and receptor antagonists as well as prostacyclin analogues in combination with peripheral percutaneous transluminal angioplasty to prevent thrombosis and restenosis.

Prostacyclin and thromboxane A2 synthesis are increased in acute lower limb ischaemia

Prostacyclin (PGI2) and thromboxane A2 (TXA2) play an important role in the pathophysiology of various cardiovascular diseases. The balance between PGI2 and TXA2 regulates the interaction between platelets and the vessel wall in vivo. In this study we measured PGI2 and TXA2 synthesis by analysing their urinary index metabolites 2,3-dinor-6-keto-PGF1 alpha and 11-dehydro-TXB2, respectively, in acute (10 patients) and chronic (10 patients) lower limb ischaemia. Both PGI2 and TXA2 synthesis were increased about two-fold in patients with acute lower limb ischaemia compared to chronic lower limb ischaemia. However, the PGI2/TXA2 ratio was more or less the same in acute and chronic lower limb ischaemia. In patients with acute lower limb ischaemia caused by thrombotic occlusion, PGI2 and TXA2 formation were about two times higher than in patients with acute lower limb ischaemia caused by embolic occlusion. Elevation of PGI2 and TXA2 synthesis in acute lower limb ischaemia may reflect increased platelet-vascular wall interactions without changing the PGI2/TXA2 ratio.

Frequency of repeated vascular surgery. A survey of 7616 surgical and endovascular Finnvasc procedures. Finnvasc Study Group

OBJECTIVE

To assess the incidence of repeated vascular surgical operations.

DESIGN

A population-based cross-sectional survey established on the Finnvasc registry.

SETTING

Multicentre, Finland.

MATERIAL

7616 vascular procedures consisted of 5201 open vascular operations and 2415 endovascular interventions done during the two years 1991-92.

MAIN OUTCOME MEASURES

Mortality and number of reoperations and major amputations.

RESULTS

A total of 5409 initial vascular procedures were done, 770 patients (10%) underwent a new procedure in the same anatomical segment as previously, and 1437 patients (19%) underwent a vascular or endovascular procedure on a new arterial segment excluding the coronary arteries; these patients had more risk factors than the two other groups, and were also treated more often for chronic leg ischaemia. Altogether 586 reoperations were needed in 487 patients (6%) during a 30-day postoperative period, more often after the initial surgical reconstruction than on other occasions. Altogether 126 postoperative below-knee and 170 above-knee amputations had to be done during the same period which corresponded to 14% of the total of 2128 surgical or endovascular revascularisations done for acute or chronic critical leg ischaemia. The risk of perioperative death was higher in patients with acute leg ischaemia undergoing their first vascular intervention than those having repeat operations.

CONCLUSION

Although the present data are cross-sectional and might be affected by the recent increase in vascular surgery in Finland they show that almost a third of vascular operations done are repeat procedures.

Blood coagulation and fibrinolysis activation during sudden arterial occlusion of lower extremities--an association with ischemia and patient outcome

We compared hemostatic and fibrinolytic plasma markers in 41 patients having acute or subacute occlusion of lower limb arteries with 20 patients suffering stable peripheral arterial occlusive disease (PAOD). During occlusion, the amount of thrombin-antithrombin III (TAT) complex was five-fold higher compared with stable PAOD, being 16 micrograms/l [95% confidence interval (CI) 11-21 micrograms/l] vs 3 micrograms/l (95% CI 2-4 micrograms/l), p < 0.003. Similarly, D-dimer was over four-fold (p = 0.0001), while tissue plasminogen activator and plasminogen activator inhibitor-1 (PAI-1) antigens were about two-fold (p = 0.02 and p < 0.003, respectively) higher than in PAOD. Coagulation and fibrinolysis markers were increased most in patients with recent symptom onset, which mainly represented embolus rather than thrombosis. The marker levels assessing coagulation and fibrinolysis were related with myoglobin and CK, indicators of skeletal muscle damage. Finally, increased TAT, PAI-1 antigen, and myoglobin concentrations associated with poor outcome.

Prevalence and predictive value of ECG findings in acute extremity ischemia

OBJECTIVE

To determine the prevalence and predictive value of ECG findings in patients treated surgically for acute extremity ischemia.

EXPERIMENTAL DESIGN

Retrospective study with follow-up for one month.

SETTING

Tampere University Hospital, Jyväskylä Central Hospital.

PATIENTS

114 patients with acute extremity ischemia treated surgically.

INTERVENTIONS

Emergency thromboembolectomy was performed to all patients.

MEASURES

ECGs, taken preoperatively at the emergency department, were analysed according to the Minnesota code. Death was regarded as the endpoint of the study.

RESULTS

ST-J depression (60.5%) and T-wave inversion (71.9%) were the most common single findings. The ECG was considered suggestive of ischemic heart disease in 64.0% of patients. The prevalence of atrial fibrillation was 37.7%. Atrial fibrillation was found in 25.0% of patients with acute thrombotic occlusion and in 43.6% of patients with embolic occlusion (chi 2 = 3.6, df = 1, p = 0.057). The ECG was suggestive of ischemic heart disease in 87.5% of patients who died within a month compared to 60.2% in those still alive (chi 2 = 4.4, df = 1, p = 0.034). In logistic regression analysis atrial fibrillation was found to increase the risk of mortality (B = 0.93, df = 1, p = 0.002); odds ratio 2.6 (95% CI 1.4-4.7).

CONCLUSION

Most patients with acute extremity ischemia had significant ECG findings with low prevalence of AF reflecting increased ratio of thrombotic occlusions. AF and ECG suggestive of ischemic heart disease were also associated to poor short-term prognosis. We think that acute thrombosis should be suspected in most patients with acute extremity ischemia.

Prognostic value of preoperative C-reactive protein concentration and white cell count in acute extremity ischaemia

OBJECTIVE

To find out if the C-reactive protein (CRP) concentration and the white cell count (WCC) are of any prognostic value in patients with acute extremity ischaemia.

DESIGN

Retrospective study.

SETTING

Tampere University Hospital and Jyväskylä Central Hospital, Finland.

SUBJECTS

129 patients with acute extremity ischaemia.

MAIN OUTCOME MEASURES

Preoperative CRP concentration, white cell count, packed cell volume, serum creatinine concentration, major amputation and death.

RESULTS

The median (range) CRP concentration was 50.0 (3-271) mg/l in the 28 patients who underwent major amputation or died (group 1) and 11.0 (1.175) mg/l in the 65 patients who survived with viable limbs (group 2) (p = 0.007). The median (range) WCC was 13.1 (5.9-42.0) x 10(9)/l in group 1 (30 patients) and 9.5 (2.2-23.9) x 10(9)/l in group 2 (79 patients) (p < 0.001). The cut-off point of 20 mg/l for CRP and 11.0 x 10(9)/l for WCC had negative predictive values of 0.83 and 0.85 for amputation and mortality, respectively.

CONCLUSION

Preoperative CRP concentration and WCC correlated with limb salvage and mortality in patients with acute extremity ischaemia.

Apolipoprotein E polymorphism, serum lipids, myocardial infarction and severity of angiographically verified coronary artery disease in men and women

In several populations, the apolipoprotein E (apo E) allele epsilon 4 is associated with high concentration of plasma total and low density lipoprotein (LDL)-cholesterol and coronary artery disease (CAD). We determined the apo E phenotypes of 309 patients with angiographically verified CAD and 38 patients without CAD by isoelectric focusing and Western blotting. In men with CAD, the plasma total and LDL-cholesterol increased according to apo E phenotype in the following order: E3/2 < E3/3 < E4/3 < E4/4 (P = 0.03 for total cholesterol, P = 0.007 for LDL-cholesterol). In women, there was a similar trend (P = 0.22 for total cholesterol, P = 0.15 for LDL-cholesterol). The relative frequency of men with three vessel CAD increased (P = 0.43) together with LDL-cholesterol levels (P = 0.05) according to apo E phenotype E3/2, E3/3, E4/3, E4/4. Total and LDL-cholesterol levels were higher in patients with three vessel CAD than in patients with less serious types of CAD (P = 0.02 for total cholesterol, P = 0.007 for LDL-cholesterol). The relative frequency of patients with myocardial infarction increased according to apo E phenotype (P = 0.51). Both in men and women, there were no differences between apo E phenotypes in age at occurrence of the first myocardial infarction. The apo E allele frequencies of patients with CAD vs. without CAD were 2.3% vs. 1.3% for epsilon 2, 79.0% vs. 76.3% for epsilon 3 and 18.7% vs. 22.4% for epsilon 4. There were no statistically significant differences in apo E allele or phenotype frequencies between patients with CAD and without CAD or between patients with CAD and the general Finnish population. Our results support previous studies in suggesting that the apo E allele epsilon 4 is a risk factor for atherosclerosis, which affects plasma total and LDL-cholesterol. In addition, our results suggest that the apo E allele determines the severity of CAD.

Deep hypothermia and circulatory arrest in the surgical management of renal cell carcinoma with vena caval involvement

Six patients operated on for renal cell carcinoma with vena caval involvement were prospectively studied. The mean age of the four men and two women was 58 (range 51-77) years. In four of them the tumour was excised during cardiopulmonary bypass and deep hypothermic circulatory arrest. The operation was radical in three of these patients and palliative in one. There were no major complications or deaths during hospitalisation averaging 9 (7-17) days. The mean follow-up was 9 (4-14) months, during which two patients had died of metastatic disease. The surgical approach with cardiopulmonary bypass and deep hypothermic circulatory arrest is well tolerated and can be used to facilitate complete tumour thrombectomy, with low operative risk. Need for caval tumour thrombectomy was found in 5% of all patients with renal cell carcinoma during the study period.

Perioperative outcome of acute lower limb ischaemia on the basis of the national vascular registry. The Finnvasc Study Group

OBJECTIVES

To determine the mortality and limb salvage rate in acute lower limb ischaemia and compare the risk factors and outcome after acute embolic and thrombotic peripheral arterial occlusion.

DESIGN

Retrospective, multicentre clinical study.

SETTING

24 Departments of Surgery in Finland.

MATERIALS

509 patients treated for acute lower limb ischaemia 1991-1992 as recorded in the Finnish national vascular registry (FINNVASC).

CHIEF OUTCOME MEASURES

Major amputation and death.

MAIN RESULTS

Previous major amputation or vascular surgery and smoking were found to be risk factors in patients with acute thrombosis (p < 0.001). The overall amputation rate was 16% during the postoperative period. The amputation rate in patients with acute thrombosis was 26% and in those with embolism 10% (p < 0.001). Overall mortality was 13%, in patients with thrombosis 16% and 11% in patients with embolism (p = 0.07). In a separate analysis of patients with acute thrombosis, major amputation was more common after thromboembolectomy than after reconstruction (p = 0.007).

CONCLUSION

The rate of major amputations and mortality were higher in acute thrombosis. The high amputation rate in this group was particularly associated with the need for reoperations and thromboembolectomy rather than reconstruction.

Introduction of a population-based vascular registry: validity of data and limitations of registration. The Finnvasc Study Group

A study was performed to assess the validity of the data in a nationwide vascular registry, Finnvasc, initiated in 1991. Data recorded during the first year were of 3507 procedures (immediate reoperations were excluded); 2436 (69 per cent) were surgical and 1071 (31 per cent) endovascular in nature. The Finnvasc data were compared with 2325 hospital records and re-registration of a random sample of 233 patients treated during October 1991 in nine centres was also carried out. In all, 21 per cent of patients from hospitals participating in Finnvasc were not registered and so it was calculated that about 4500 vascular procedures, 3125 surgical and 1375 endovascular, were performed in Finland in 1991. This represents an average of 900,625 and 275 procedures per million population per year respectively. The non-registration rate in October was 17 per cent. Apart from operation classification, and function and patency at 1 month, all simple binary and code data at re-registration were in agreement in at least 92 per cent of cases; checklist and numerical data did not show such good conformity. During the first year of the registry many data were either missing or inadequately recorded, emphasizing the need for cross-validation and re-registration of a random sample of cases. Furthermore, the non-uniformity of coding between hospital records and the Finnvasc registry illustrated deficiencies in the current coding system.

Platelet indices in patients with occlusive carotid artery disease

During the period 1965-1984 a total of 279 patients underwent carotid endarterectomy at the Tampere University Hospital; 160 of them were reexamined twenty-eight to two hundred nine months later to investigate whether there are any long-term differences in platelet properties according to the endpoint that led to operation. Platelet count, mean platelet volume (MPV), and plateletcrit were estimated and compared with the respective values for controls. Classified according to the indication for operation, patients with stroke had a significantly higher platelet count, 292 x 10(9)/L (SE 11), than patients with transient ischemic attack (TIA), 255 x 10(9)/L (SE 5, p < 0.01), or controls, 267 x 10(9)/L (SE 6, p < 0.05). Patients with stroke or TIA had a higher MPV than the controls. When the patients were grouped according to their physical condition at the time of the control examination, the largest platelets, 10.84 x 10(-15) L (SE 0.40), were found in the group of patients who felt well but who had a symptom or finding assumed to be due to a carotid disease.

The grade of carotid stenosis as a prognostic factor during a 14 years' follow-up in 40 angiographically documented patients with cerebrovascular disease

Forty consecutive patients underwent extracranial arteriography between 1974-1976 because of cerebrovascular disease and were treated nonoperatively. This period was chosen to ensure a sufficiently long follow-up. The treatment selection was made individually by the patient's doctor. Deaths (n = 22) during 14 years of follow-up were caused by cerebrovascular disease in 41%, by coronary heart disease in 27% and other in 32%. The median age of decreased patients (group A) was 60.5 years at the time of arteriography and of patients alive after follow-up (group B) 55.5 years, respectively (p = 0.007). Findings were more severe arteriographically in group A than in group B. Twelve patients had occlusion or > 50% stenosis in the common carotid artery or the internal carotid artery in group A and three in group B (p = 0.014). During follow-up there were 17/22 cerebrovascular events in group A and 8/18 in group B (p = 0.033). Smoking was significantly more common in group A (p = 0.002). When the patients were divided on the basis of haemodynamically significant carotid artery stenosis, patients with significant stenosis (group C) proved to be older than patients with non-significant stenosis (group D), 62.0 versus 57.0 years, respectively (p = 0.001). The incidence of cerebrovascular events was equal in these groups. Our data suggest that patients with over 50% carotid stenosis have a poor long term prognosis, associated with age and smoking.

Quality of life and cognitive performance after carotid endarterectomy during long-term follow-up

The quality of life and the cognitive performance of patients with extracranial carotid stenosis were investigated 8-11 years after treatment in 18 non-operatively treated patients and 44 patients treated with carotid endarterectomy. The cognitive performance was compared with data on a normal control group. Cognitive performance was assessed with neuropsychological tests and the quality of life by personal interview based on a questionnaire. Most of the carotid stenosis patients recovered well both subjectively and cognitively regardless of the type of treatment. Only the subgroup operated twice was subjectively worse compared to the other groups. Even 10 years later the cognitive performance of carotid stenosis patients was remarkably close to normal.

Is it possible to reduce the number of cerebral complications in carotid endarterectomy?

An effort was made to reduce the number of cerebral complications in carotid endarterectomy by focusing attention on the perioperative prevention of embolism and thrombosis in a prospective series of carotid endarterectomies (group I, n = 62) performed during a 24 months' period 1982-1984 in Tampere University Hospital. Controls were two other series of carotid endarterectomies (group II, n = 60, and group III, n = 60) comprising all 120 carotid endarterectomies carried out by other trained vascular surgeons in the same hospital during the years 1976-1984. During the first 30 postoperative days there were no deaths, one stroke and one TIA in group I. On the other hand there were three deaths, seven strokes and five TIAs in group II and four deaths, two strokes and three TIAs in group III. The number of cerebral complications in carotid endarterectomy was significantly less in the study group than in the control groups, and thus it was possible to reduce the perioperative complications in carotid endarterectomy possibly by pre- and postoperative drug treatment and routine intraoperative heparinization.

A randomized, double-blind, crossover comparison of iloprost with dextran in patients with peripheral arterial occlusive disease

Iloprost, a stable carbaprostacyclin analog, was infused (up to 2-4 ng/kg/min) for 12 h daily on 5 consecutive days into the forearm vein of 13 patients with peripheral arterial occlusive disease (PAOD) of legs (stages IIb-III). All vasodilatory and antiplatelet drugs were stopped three weeks earlier. For comparison, dextran was infused in a randomized, crossover, double-blind manner with an average interval of 3 months. Iloprost increased significantly ankle systolic pressure and ankle/arm pressure ratio for the follow-up period of one month. Foot skin temperature increased insignificantly. Pain-free walking distance was prolonged up to 1.51 times by iloprost and 1.14 times by dextran (p less than 0.05). Venous occlusion plethysmography showed no improvement in the blood flow of legs. Eight patients experienced a subjective improvement in their clinical status with iloprost. Ten patients suffered from mild to severe headache, nausea, transient rest pain of legs, and hypotension. One patient with gastric ulcer history was withdrawn because of mild hematemesis, not definitely drug-related. No significant changes occurred in standard laboratory safety control or in hemostasis. The results suggest that a 5-day iloprost infusion exerts a mild favourable effect on patients with PAOD.

Late results of surgical and nonoperative treatment of carotid stenosis. Eighty-four patients documented by angiography in 1974-1976

The long-term results of carotid endarterectomy are controversial. Here we report the late results of 44 surgically and 40 non-surgically treated patients with carotid stenosis documented by angiography in 1974-1976. The groups were similar with respect to sex-distribution, age, length of follow-up time (median 123.0 and 130.0 months in the surgical and non-surgical groups, respectively) and the occurrence of risk factors. Hypertension was more frequent (p less than 0.05) in the surgical group, as was medical treatment, mostly anticoagulants (p less than 0.06). The angiographic findings were also more severe in this group (p less than 0.001). During the follow-up period the occurrence of cerebrovascular complications (death, stroke and/or TIA) was more frequent in the nonoperated than in the operated group; however, survival of the patients was similar, as the cardiovascular deaths were an equalizing factor. The quality of life in patients alive examined for clinical and neurologic status and by neuropsychological tests and interview was similar, except that the operated patients were more satisfied. The progression of atherosclerosis in the carotid artery assessed by Duplex scanning was more frequent in the nonoperated group. Differences in medical treatment did not explain the results. Thus it is concluded that the late results were better in the operated patients with carotid stenosis than in the nonoperated ones.