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Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, Holt PJ. Lower extremity amputations--a review of global variability in incidence. Diabet Med 2011; 28:1144-53. [PMID: 21388445 DOI: 10.1111/j.1464-5491.2011.03279.x] [Citation(s) in RCA: 351] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus. METHODS An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. RESULTS Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 10(5) in the population with diabetes compared with 5.8-31 per 10(5) in the total population. Major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics. CONCLUSION Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally.
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Review |
14 |
351 |
2
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Loftus IM, Naylor AR, Goodall S, Crowther M, Jones L, Bell PR, Thompson MM. Increased matrix metalloproteinase-9 activity in unstable carotid plaques. A potential role in acute plaque disruption. Stroke 2000; 31:40-7. [PMID: 10625713 DOI: 10.1161/01.str.31.1.40] [Citation(s) in RCA: 269] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Acute disruption of atherosclerotic plaques precedes the onset of clinical syndromes, and studies have implicated a role for matrix metalloproteinases (MMPs) in this process. The aim of this study was to establish the character, level, and expression of MMPs in carotid plaques and to correlate this with clinical status, cerebral embolization, and histology. METHODS Plaques were obtained from 75 consecutive patients undergoing carotid endarterectomy and divided into 4 groups according to symptomatology (group 1, asymptomatic; group 2, symptomatic >6 months before surgery; group 3, symptomatic within 1 to 6 months; group 4, symptomatic within 1 month). All patients underwent preoperative and intraoperative transcranial Doppler monitoring. Plaques were subjected to histological examination and quantification of MMPs by zymography and ELISA. RESULTS The level of MMP-9 was significantly higher in group 4 (median 125.7 ng/mL for group 4, median <32 ng/mL for all other groups; P=0.003), with no difference in the levels of MMPs 1, 2, or 3. Furthermore, the MMP-9 concentration was significantly higher in plaques undergoing spontaneous embolization (P=0.019) and those with histological evidence of plaque instability (P<0.03). In situ hybridization demonstrated increased MMP-9 expression in highly symptomatic plaques in areas of intense inflammatory infiltrate. CONCLUSIONS The concentration, production, and expression of MMP-9 is significantly higher in unstable carotid plaques. If this proves to be a causal relationship, MMP-9 may be a strong candidate for pharmacotherapy aimed at stabilizing plaques and preventing stroke.
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25 |
269 |
3
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McCarthy MJ, Loftus IM, Thompson MM, Jones L, London NJ, Bell PR, Naylor AR, Brindle NP. Angiogenesis and the atherosclerotic carotid plaque: an association between symptomatology and plaque morphology. J Vasc Surg 1999; 30:261-8. [PMID: 10436445 DOI: 10.1016/s0741-5214(99)70136-9] [Citation(s) in RCA: 256] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Symptomatic carotid disease resulting from generation of thromboemboli has been associated with plaque instability and intraplaque hemorrhage. These features of the lesion could be influenced by the fragility and position of neovessels within the plaque. The purpose of this study was to determine whether any association exists between neovessel density, position, morphology, and thromboembolic sequelae. METHODS Carotid endarterectomy samples were collected from 15 asymptomatic patients with greater than 80% stenoses and from 13 highly symptomatic patients who had suffered ipsilateral carotid stenotic events within 1 month of surgery. Both groups were matched for gender, age, risk factors, degree of carotid artery stenosis, and plaque size. Samples were stained with hematoxylin/eosin and van Geison. Immunohistochemistry was performed by using an endothelial specific antibody to CD31. Plaques were assessed for histologic characteristics, and neovessels were counted and characterized by size, site, and shape. RESULTS There were significantly more neovessels in plaques (P <.00001) and fibrous caps (P <.0001) in symptomatic compared with asymptomatic plaques. Neovessels in symptomatic plaques were larger (P <.004) and more irregular. There was a significant increase in plaque necrosis and rupture in symptomatic plaques. Plaque hemorrhage and rupture were associated with more neovessels within the plaque (P <.017, P <.001) and within the fibrous cap (P <.046, P <.004). Patients with preoperative and intraoperative embolization had significantly more plaque and fibrous cap neovessels (P <.025, P <.001). CONCLUSION Symptomatic carotid disease is associated with increased neovascularization within the atherosclerotic plaque and fibrous cap. These vessels are larger and more irregular and may contribute to plaque instability and the onset of thromboembolic sequelae.
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26 |
256 |
4
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Holt PJE, Poloniecki JD, Gerrard D, Loftus IM, Thompson MM. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg 2007; 94:395-403. [PMID: 17380547 DOI: 10.1002/bjs.5710] [Citation(s) in RCA: 207] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
This study investigated the volume–outcome relationship for abdominal aortic aneurysm (AAA) surgery and quantified critical volume thresholds.
Methods
PubMed, EMBASE and the Cochrane library were searched for articles on the operation volume–outcome relationship in elective and ruptured AAA surgery. UK Hospital Episode Statistics data were also considered. Elective and ruptured AAA repairs were dealt with separately. The data were meta-analysed, and the odds ratios (95 per cent confidence interval) for mortality at higher- and lower-volume hospitals were compared. Volume thresholds were identified from each paper.
Results
The analysis included 421 299 elective and 45 796 ruptured AAA operations. Significant relationships between mortality and annual volume were noted for both groups. Overall, the weighted odds ratio was 0·66 (0·65 to 0·67) for elective repair at a threshold of 43 AAAs per annum and 0·78 (0·73 to 0·82) for ruptured aneurysm repair at a threshold of 15 AAAs per annum, both in favour of high-volume institutions.
Conclusion
Higher annual operation volumes are associated with significantly lower mortality in both elective and ruptured AAA repair. This suggests that AAA surgery should be performed only at higher-volume centres.
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18 |
207 |
5
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Choke E, Cockerill G, Wilson WRW, Sayed S, Dawson J, Loftus I, Thompson MM. A Review of Biological Factors Implicated in Abdominal Aortic Aneurysm Rupture. Eur J Vasc Endovasc Surg 2005; 30:227-44. [PMID: 15893484 DOI: 10.1016/j.ejvs.2005.03.009] [Citation(s) in RCA: 194] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 03/16/2005] [Indexed: 10/25/2022]
Abstract
Abdominal aortic aneurysm (AAA) rupture is the 13th commonest cause of death in the Western World. Although considerable research has been applied to the aetiology and mechanism of aneurysm expansion, little is known about the mechanism of rupture. Aneurysm rupture was historically considered to be a simple physical process that occurred when the aortic wall could no longer contain the haemodynamic stress of the circulation. However, AAAs do not conform to the law of Laplace and there is growing evidence that aneurysm rupture involves a complex series of biological changes in the aortic wall. This paper reviews the available data on patient variables associated with aneurysm rupture and presents the evidence implicating biological factors in AAA rupture.
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20 |
194 |
6
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Thrumurthy SG, Karthikesalingam A, Patterson BO, Holt PJE, Hinchliffe RJ, Loftus IM, Thompson MM. A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg 2011; 42:632-47. [PMID: 21880515 DOI: 10.1016/j.ejvs.2011.08.009] [Citation(s) in RCA: 157] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 08/12/2011] [Indexed: 11/29/2022]
Abstract
OBJECTIVE AND DESIGN The role of Thoracic Endovascular Repair (TEVAR) in chronic type B aortic dissection remains controversial and its mid-term success as an alternative to open repair or best medical therapy remains unknown. The aim of the present study was to provide a systematic review of mid-term outcomes of TEVAR for chronic type B aortic dissection. MATERIALS AND METHODS Medline, trial registries, conference proceedings and article reference lists from 1950 to January 2011 were searched to identify case series reporting mid-term outcomes of TEVAR in chronic type B dissection. Data were extracted for review. RESULTS 17 studies of 567 patients were reviewed. The technical success rate was 89.9% (range 77.6-100). Mid-term mortality was 9.2% (46/499) and survival ranged from 59.1 to 100% in studies with a median follow-up of 24 months. 8.1% of patients (25/309) developed endoleak, predominantly type I. Re-intervention rates ranged from 0 to 60% in studies with a median follow-up of 31 months. 7.8% of patients (26/332) developed aneurysms of the distal aorta or continued false lumen perfusion with aneurysmal dilatation. Rare complications included delayed retrograde type A dissection (0.67%), aorto-oesophageal fistula (0.22%) and neurological complications (paraplegia 2/447, 0.45%; stroke 7/475, 1.5%). CONCLUSION The absolute benefit of TEVAR over alternative treatments for chronic B-AD remains uncertain. The lack of natural history data for medically treated cases, significant heterogeneity in case selection and absence of consensus reporting standards for intervention are significant obstructions to interpreting the mid-term data. High-quality data from registries and clinical trials are required to address these challenges.
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Systematic Review |
14 |
157 |
7
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Karthikesalingam A, Hinchliffe RJ, Holt PJE, Boyle JR, Loftus IM, Thompson MM. Endovascular aneurysm repair with preservation of the internal iliac artery using the iliac branch graft device. Eur J Vasc Endovasc Surg 2009; 39:285-94. [PMID: 19962329 DOI: 10.1016/j.ejvs.2009.11.018] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Accepted: 11/17/2009] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Aortoiliac aneurysms comprise up to 43% of the specialist endovascular caseload. In such cases endovascular aneurysm repair (EVAR) requires distal extension of the aortoiliac endograft beyond the ostium of the internal iliac artery (IIA) and into the external iliac artery, conventionally necessitating the embolisation of one or both IIA. This has been associated with a wide range of complications, and the use of an Iliac Branch-graft Device (IBD) offers an appealing endovascular solution. DESIGN Medline, trial registries, conference proceedings and article reference lists were searched to identify case series reporting IBD use. Data were extracted for review. RESULTS Nine series have reported the use of IBD in a total of 196 patients. Technical success was 85-100%. Median operating times were 101-290min and median contrast dose was 58-208g, with no aneurysm-related mortality. Claudication developed in 12/24 patients after IBD occlusion. One type I endoleak and two type III endoleaks occurred and were managed endovascularly. Re-occlusion occurred in 24/196 patients. CONCLUSION IBD was performed with high technical success rates and encouraging mid-term patency. Formalised risk stratification and morphological data are required to identify the group of patients who will benefit most. Cost-effectiveness appraisals are needed for this technique.
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Review |
16 |
120 |
8
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Holt PJE, Poloniecki JD, Loftus IM, Michaels JA, Thompson MM. Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005. Br J Surg 2007; 94:441-8. [PMID: 17385180 DOI: 10.1002/bjs.5725] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The aim was to assess the relationship between hospital volume and outcome after abdominal aortic aneurysm (AAA) surgery in the UK.
Methods
Hospital Episode Statistics (2000–2005) were classified as elective, urgent or ruptured AAA repair. Analysis was by modelling of mortality rate, complication rate and length of hospital stay with regard to the annual operative volume, after risk adjustment.
Results
There were 112 545 diagnoses, or repairs, of AAAs, of which 26 822 were infrarenal aneurysms. The mean mortality rate was 7·4, 23·6 and 41·8 per cent for elective, urgent and ruptured AAA repair respectively. Elective AAA repair undertaken at high-volume hospitals showed volume-related improvements in mortality (P < 0·001). Patients were discharged from hospital earlier (P < 0·001). The critical volume threshold was 32 elective AAA repairs per year. For urgent repair, patients at high-volume hospitals had a reduced mortality rate (P = 0·017) with an increased length of stay (P = 0·041). There was no relationship between volume and outcome for ruptured AAA repairs.
Conclusion
Increased annual volumes were associated with significant reductions in mortality for elective and urgent AAA repair, but not for repair of ruptured AAAs.
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18 |
102 |
9
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Holt PJE, Poloniecki JD, Loftus IM, Thompson MM. Meta-Analysis and Systematic Review of the Relationship between Hospital Volume and Outcome Following Carotid Endarterectomy. Eur J Vasc Endovasc Surg 2007; 33:645-51. [PMID: 17400005 DOI: 10.1016/j.ejvs.2007.01.014] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 01/21/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study investigated the relationship between annual hospital volume and the outcomes in carotid endarterectomy and quantified critical volume threshold for this procedure. DATA SOURCES PubMed, EMBASE and the Cochrane library were searched for all articles on the volume-outcome relationship in CEA. REVIEW METHODS Articles were included if they presented data on post-operative mortality and/or stroke rates and annual hospital volume of CEA. The review conformed to the QUOROM statement. The data were meta-analysed and a pooled effect estimate of volume on the stroke and/or mortality rates from CEA quantified, along with the critical volume threshold. RESULTS Twenty-five articles, encompassing 936 436 CEA, were analysed. Significant relationships between mortality rate and stroke rate and annual volume were seen. Overall, the pooled effect estimate was odds ratio 0.78 [95% confidence interval 0.64-0.92], in favour of surgery at higher volume units, with a critical volume threshold of 79 CEA per annum. CONCLUSIONS Significantly lower mortality and stroke rates were achieved at hospitals providing a higher annual hospital volume of CEA. Hospitals wishing to provide CEA should adhere to minimum volume criteria.
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18 |
93 |
10
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Patterson BO, Holt PJE, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence. Eur J Vasc Endovasc Surg 2008; 36:637-45. [PMID: 18922709 DOI: 10.1016/j.ejvs.2008.08.016] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 08/27/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine and compare existing pre-operative risk prediction methods for elective abdominal aortic aneurysm (AAA) repair. DESIGN Systematic review. METHODS Medline, EMBASE and the Cochrane library were searched for articles that related to risk prediction models used for elective AAA repair. RESULTS 680 abstracts were reviewed and after exclusions 28 articles encompassing 10 risk models were identified. The most frequently studied of these were the Glasgow Aneurysm Score (GAS), the Physiological and Operative Severity Score for enUmeration of Mortality (POSSUM) predictor equation and the Vascular Biochemistry and Haematology Outcome Model (VBHOM). All models had strengths and weaknesses and some had unique features which were identified and discussed. CONCLUSION The GAS appeared to be the most useful and consistently validated score at present for open repair. Other systems were either not validated fully or were not consistently accurate. Some had significant drawbacks which appeared to severely limit their clinical application. Recent work has shown that no scores consistently predicted the risk associated with endovascular aneurysm repair (EVAR). Pre-operative risk stratification is a vital component of modern surgical practice, and we propose the need for a comprehensive new risk scoring method for AAA repair incorporating anatomical and physiological data.
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Review |
17 |
90 |
11
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Evans J, Powell JT, Schwalbe E, Loftus IM, Thompson MM. Simvastatin attenuates the activity of matrix metalloprotease-9 in aneurysmal aortic tissue. Eur J Vasc Endovasc Surg 2007; 34:302-3. [PMID: 17574455 DOI: 10.1016/j.ejvs.2007.04.011] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2007] [Accepted: 04/16/2007] [Indexed: 11/24/2022]
Abstract
To investigate whether statins reduce the concentration of MMP-9 in the aortic wall, we randomised patients undergoing elective open repair of an abdominal aortic aneurysm (AAA) to a pre-operative course of either simvastatin or placebo. MMPs in aortic biopsies were measured using gelatin zymography. Although recruitment closed early because of increasing statin use among eligible patients, with only 21 patients we demonstrated a 40% reduction in MMP-9 levels in the AAA wall in patients randomised to simvastatin. This provides a possible molecular mechanism to explain the reportedly beneficial effects of statins to slow AAA growth.
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Research Support, Non-U.S. Gov't |
18 |
89 |
12
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Molloy KJ, Thompson MM, Jones JL, Schwalbe EC, Bell PRF, Naylor AR, Loftus IM. Unstable Carotid Plaques Exhibit Raised Matrix Metalloproteinase-8 Activity. Circulation 2004; 110:337-43. [PMID: 15226217 DOI: 10.1161/01.cir.0000135588.65188.14] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The fibrous cap of atherosclerotic plaques is composed predominantly of type I and III collagen. Unstable carotid plaques are characterized by rupture of their cap, leading to thromboembolism and stroke. The proteolytic mechanisms causing plaque disruption are undefined, but the collagenolytic matrix metalloproteinase (MMP) -1, -8, and -13 may be implicated. The aim of this study was to quantify the concentrations of these collagenases in carotid plaques and to determine their relationship to markers of plaque instability. METHODS AND RESULTS Atherosclerotic plaques were collected from 159 patients undergoing carotid endarterectomy. The presence and timing of carotid territory symptoms were ascertained. Preoperative embolization was recorded by transcranial Doppler. Each plaque was assessed for histological features of instability. Plaque MMP concentrations were quantified with ELISA. Significantly higher concentrations of active MMP-8 were observed in the plaques of symptomatic patients (20.5 versus 11.4 ng/g; P=0.0002), in plaques of emboli-positive patients (22.7 versus 13.5 ng/g; P=0.0037), and in those plaques showing histological evidence of rupture (20.8 versus 14.7 ng/g; P=0.0036). No differences were seen in the levels of MMP-1 and MMP-13. Immunohistochemistry, in situ hybridization, and colocalization studies confirmed the presence of MMP-8 protein and mRNA within the plaque, which colocalized with macrophages. CONCLUSIONS These data suggest that the active form of MMP-8 may be partly responsible for degradation of the collagen cap of atherosclerotic plaques. This enzyme represents an attractive target for drug therapy aimed at stabilizing vulnerable plaques.
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21 |
87 |
13
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Karthikesalingam A, Holt PJE, Hinchliffe RJ, Nordon IM, Loftus IM, Thompson MM. Risk of reintervention after endovascular aortic aneurysm repair. Br J Surg 2010; 97:657-63. [PMID: 20235086 DOI: 10.1002/bjs.6991] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The role of symptomatic presentation in directing reintervention after endovascular aortic aneurysm repair (EVAR) was investigated. METHODS All patients undergoing infrarenal EVAR between 2001 and 2009 were studied. Those needing reintervention were divided into symptomatic and asymptomatic presentations. Kaplan-Meier survival curves were used to calculate freedom from reintervention, and log rank tests for subgroup analyses. Multivariable analysis identified risk factors for reintervention. RESULTS The study included 553 patients with a mean(s.d.) age of 75(7) years and aneurysm diameter of 65(13) mm. The 30-day mortality rate was 2.5 per cent. Median follow-up was 31 (range 1-97) months. There were 86 reinterventions in 69 (12.5 per cent) of 553 patients; 41 presented with symptoms and 28 were asymptomatic. Reintervention-free survival rates at 1, 3 and 5 years were 90.1, 85.3 and 81.2 per cent. The reintervention rate was higher in patients who needed an intraoperative adjunct during the index procedure (P = 0.014) and in those who did not have intraoperative computed tomography angiography (P = 0.024). Intraoperative adjuncts were an independent risk factor for future reintervention (hazard ratio 2.62, 95 per cent confidence interval 1.18 to 3.76; P = 0.012). CONCLUSION Most patients requiring reintervention presented symptomatically. A high-risk subgroup may be identifiable to rationalize a postoperative surveillance programme.
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Journal Article |
15 |
84 |
14
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Holt PJE, Karthikesalingam A, Poloniecki JD, Hinchliffe RJ, Loftus IM, Thompson MM. Propensity scored analysis of outcomes after ruptured abdominal aortic aneurysm. Br J Surg 2010; 97:496-503. [DOI: 10.1002/bjs.6911] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Background
This study examined the population outcome of ruptured abdominal aortic aneurysm (rAAA) in England, the role of endovascular repair (EVAR), and the relationship between outcome and hospital workload.
Methods
Data were retrieved from Hospital Episode Statistics between 1 April 2003 and 31 March 2008. Propensity scoring was used to compare the outcomes of stratified patients undergoing EVAR and open repair. The relationship between workload and outcome was determined.
Results
Some 3725 urgent and 4414 rAAA repairs were included. Mortality rates were 21·3 per cent for urgent repair and 46·3 per cent for rAAA repair. EVAR was employed for 16·3 and 7·6 per cent of urgent and rAAA repairs respectively. EVAR was associated with significantly reduced mortality for urgent repair (odds ratio (OR) 0·531, 95 per cent confidence interval 0·415 to 0·680; P < 0·001) and rAAA repair (OR 0·527, 0·416 to 0·668; P < 0·001). A propensity scored analysis confirmed the benefit of EVAR for rAAA repair (P < 0·001). Repair of rAAA at hospitals with a higher elective aneurysm workload was associated with lower mortality rates irrespective of the mode of treatment (P < 0·001). Higher-volume hospitals were more likely to operate on rAAA (P = 0·033).
Conclusion
EVAR offered a survival advantage over open repair for non-elective aneurysm procedures. Services for the treatment of rAAA should incorporate access to EVAR and would benefit from being based in units with a high elective caseload.
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15 |
82 |
15
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Wilson WRW, Anderton M, Choke EC, Dawson J, Loftus IM, Thompson MM. Elevated plasma MMP1 and MMP9 are associated with abdominal aortic aneurysm rupture. Eur J Vasc Endovasc Surg 2008; 35:580-4. [PMID: 18226564 DOI: 10.1016/j.ejvs.2007.12.004] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 12/11/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND The role of matrix metalloproteinases (MMPs) in abdominal aortic aneurysm (AAA) formation is well established. However the changes in plasma MMP levels with AAA rupture have not been reported. The aim of this study was to determine circulating levels of MMPs in non-ruptured and ruptured AAA immediately prior to open repair. METHODS Concentrations of MMPs and their endogenous tissue inhibitors (TIMPs) were quantified using ELISA in pre-operative plasma samples from non-ruptured and ruptured AAA. RESULTS MMP1 and MMP9 were elevated in the plasma of ruptured AAA versus non-ruptured AAA. A four-fold elevation in pre-operative plasma MMP9 was associated with non-survival at 30 days from rupture surgery compared with those surviving for greater than 30 days. CONCLUSION In conclusion, these findings support the role of MMPs in AAA pathogenesis. Elevation of MMP9 was associated with ruptured aneurysm related 30-day mortality and may represent a survival indicator in this group.
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Journal Article |
17 |
67 |
16
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Brownrigg JRW, de Bruin JL, Rossi L, Karthikesalingam A, Patterson B, Holt PJ, Hinchliffe RH, Morgan R, Loftus IM, Thompson MM. Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre. Eur J Vasc Endovasc Surg 2015; 50:157-64. [PMID: 25892319 DOI: 10.1016/j.ejvs.2015.03.024] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysms (AAA). The early clinical experience, technical refinements, and learning curve of EVAS in the treatment of AAA at a single institution are presented. METHODS One-hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology, and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention, and death. Postoperative imaging consisted of duplex ultrasound and computed tomographic angiography. RESULTS The mean age of the cohort was 76 ± 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10 mm (20%), neck diameter >32 mm (18%), β-angulation >60° (21%), and conical aneurysm neck (51%). There was one death within 30 days. The incidence of Type 1 endoleak within 30 days was 4% (n = 4); all were treated successfully with transcatheter embolisation. All four proximal endoleaks were associated with technical issues that resulted in procedure refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak rate at 30 days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting were performed for postoperative limb stenosis in three patients (3%). CONCLUSIONS EVAS appears to be associated with reasonable 30-day outcomes despite the necessity of procedural evolution in the early adoption of this technique. EVAS appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term follow-up, although the absence of Type 2 endoleaks is encouraging.
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Journal Article |
10 |
63 |
17
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Naylor R, Cuffe RL, Rothwell PM, Loftus IM, Bell PR. A systematic review of outcome following synchronous carotid endarterectomy and coronary artery bypass: Influence of surgical and patient variables. Eur J Vasc Endovasc Surg 2003; 26:230-41. [PMID: 14509884 DOI: 10.1053/ejvs.2002.1975] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Outcomes after synchronous carotid endarterectomy (CEA) plus coronary artery bypass (CABG) relative to surgical and patient based variables. DESIGN Systematic review of 94 published series (7863 synchronous procedures). RESULTS 11.5% of patients died or suffered a stroke/myocardial infarction in the peri-operative period (95% CI 10.1-12.9). The risk of death/stroke appeared to significantly diminish in studies published between 1993-2002, compared with 1972-1992 (7.2% (95% CI 6.5-9.1) versus 10.7% (95% CI 8.9-12.5), p = 0.03). However, increasing operative experience was not associated with significantly lower risks of death/stroke; (1-49 cases (9.6% (95% CI 7.5-11.8); 50-99 cases (9.1% (95% CI 6.4-11.8); 100+ cases (8.4% (95% CI 6.9-10.1) (p = 0.64)). Patients with severe bilateral carotid disease were significantly more likely to suffer death and/or stroke compared to patients with unilateral disease (odds ratio 2.5, 95% CI 1.4-5.0, p = 0.001). Similarly, patients with a prior history of stroke/transient ischaemic attack (TIA) were significantly more likely to suffer a further stroke than asymptomatic patients (odds ratio 1.8, 95% CI 1.1-2.8, p = 0.008). There was no difference in the risk of death/stroke relative to the timing of CEA (pre- versus on-cardiopulmonary bypass), but recent small studies indicate that improved outcomes might be achieved by performing CABG 'off-bypass'. CONCLUSIONS Synchronous CEA + CABG is associated with a not insignificant cardiovascular risk. No comparable information is available for similar patients undergoing CABG without prophylactic CEA.
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63 |
18
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Loftus IM, Naylor AR, Bell PR, Thompson MM. Plasma MMP-9 - a marker of carotid plaque instability. Eur J Vasc Endovasc Surg 2001; 21:17-21. [PMID: 11170872 DOI: 10.1053/ejvs.2000.1278] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to investigate whether peripheral blood levels of matrix metalloproteinases (MMPs) or their inhibitors are altered in patients with particulate cerebral embolisation. DESIGN a prospective study. MATERIALS AND METHODS using sandwich enzyme immunoassay, plasma levels of MMPs-1, -2, -3 and -9, plus TIMPs-1 and -2 were quantified in 70 consecutive patients undergoing carotid endarterectomy. Patients were monitored with transcranial Doppler (TCD) preoperatively and during the dissection phase of the operation to detect those with spontaneous particulate embolisation (n =21). RESULTS the plasma level of MMP-9 was significantly higher in those patients with evidence of spontaneous embolisation compared to those without. There were no differences in other MMP levels, or plasma concentrations of TIMPs. CONCLUSIONS plasma MMP-9 levels are elevated in patients with particulate cerebral embolisation, and this may represent a novel marker of atherosclerotic plaque instability.
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Loftus IM, Thompson MM. The abdominal compartment syndrome following aortic surgery. Eur J Vasc Endovasc Surg 2003; 25:97-109. [PMID: 12552469 DOI: 10.1053/ejvs.2002.1828] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND multi-organ failure is a leading cause of death following aneurysm surgery, especially in the emergency setting. Intra-abdominal hypertension is an important factor in the development of multi-organ failure. Prevention, early recognition and prompt treatment of abdominal hypertension and the abdominal compartment syndrome may reduce mortality following aneurysm surgery. METHODS a descriptive review of the literature from a Medline search. RESULTS AND CONCLUSIONS the abdominal compartment syndrome is the result of diverse physiological effects caused by increased intra-abdominal pressure. The syndrome has been most widely described in trauma victims, but occurs in patients following aortic surgery, particularly following ruptured aneurysm repair. Preventative therapy should be instituted to minimise its development in patients at risk, and monitoring of intra-abdominal pressure may allow prompt treatment of this condition.
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Review |
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47 |
20
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Karthikesalingam A, Holt PJE, Hinchliffe RJ, Thompson MM, Loftus IM. The diagnosis and management of aortic dissection. Vasc Endovascular Surg 2010; 44:165-9. [PMID: 20308170 DOI: 10.1177/1538574410362118] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aortic dissection represents the most common aortic emergency, affecting 3 to 4 per 100,000 people per year and is still associated with a high mortality. Twenty percent of the patients with aortic dissection die before reaching hospital and 30% die during hospital admission. Aortic dissections may be classified in 3 ways: according to their anatomical extent (the Stanford or DeBakey systems), according to the time from onset (acute or chronic), and according to the underlying pathology (the European Society of Cardiologists' system). Advances in endovascular technology have provided new treatment options. Hybrid endovascular and conventional open surgical repair represent the mainstay of treatment for acute type A dissection. Medical management remains the gold standard for acute and uncomplicated chronic type B dissection, though endovascular surgery offers exciting potential in the management of complicated type B dissection through sealing of the intimal entry tear.
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Review |
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47 |
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Conway AM, Malkawi AH, Hinchliffe RJ, Holt PJ, Murray S, Thompson MM, Loftus IM. First-year results of a national abdominal aortic aneurysm screening programme in a single centre. Br J Surg 2011; 99:73-7. [DOI: 10.1002/bjs.7685] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 11/08/2022]
Abstract
Abstract
Background
The UK Multicentre Aneurysm Screening Study (MASS) demonstrated reduced mortality from screening for abdominal aortic aneurysm (AAA). As a result, the National Health Service AAA Screening Programme was introduced in England. This study reports the results from an early-implementation screening centre.
Methods
Men aged 65 years were invited to attend an ultrasound assessment. Data were analysed for 15 months from the onset of the screening programme.
Results
A total of 6091 men aged 65 years were invited between April 2009 and June 2010, of whom 2037 (33·4 per cent) failed to attend. There were 162 self-referrals (median age 71·3 years) so that 4216 men were screened. Of those scanned, 4146 (98·3 per cent) had an aortic diameter of less than 3·0 cm, 65 (1·5 per cent) had an aneurysm measuring 3·0–5·4 cm, and five (0·1 per cent) had an aneurysm with a diameter of 5·5 cm and above. The presence of an aneurysm was more common in those who self-referred than in the invited group (P < 0·001). All 70 screen-detected aneurysms were found in white men.
Conclusion
The prevalence of AAA was lower than expected. This reflects the younger age of this cohort compared with those in published large multicentre studies and the diverse ethnic background of the local population. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Loftus IM, McCarthy MJ, Pau H, Hartshorne T, Bell PR, London NJ, Naylor AR. Carotid endarterectomy without angiography does not compromise operative outcome. Eur J Vasc Endovasc Surg 1998; 16:489-93. [PMID: 9894488 DOI: 10.1016/s1078-5884(98)80239-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Carotid angiography is associated with a 2% risk of stroke and, since the advent of colour-duplex ultrasound, its role in the assessment of patients with carotid disease has been the subject of debate. The aim of this study was to evaluate a policy of adopting routine duplex supplemented by selective angiography on operative outcome over a 5-year period. METHODS A prospective audit of the results of carotid endarterectomy without routine angiography from January 1992 to December 1996. Angiography was performed only if the ultrasonography was concerned about the distal or proximal extent of disease or to assess subocclusion. RESULTS During the study period, 494 carotid endarterectomies were performed but only 35 patients underwent carotid angiography. The indications for angiography were subocclusion/string sign in 22 patients, to assess the limits of proximal or distal disease in 12 and abnormal anatomy in one. During the 5-year study period the overall perioperative death and/or stroke rate was 4.2%. By 1997, the perioperative stroke rate had fallen to 1.3%. In no case in this series was the operation abandoned due to unexpected findings. CONCLUSION Although concerns exist about the precise duplex criteria for diagnosing a severe stenosis, this study has shown that a policy of selective angiography does not compromise patient safety or operability and avoids the unnecessary mortality, morbidity and costs associated with routine angiography.
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Holt PJE, Karthikesalingam A, Hofman D, Poloniecki JD, Hinchliffe RJ, Loftus IM, Thompson MM. Provider volume and long-term outcome after elective abdominal aortic aneurysm repair. Br J Surg 2012; 99:666-72. [DOI: 10.1002/bjs.8696] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2012] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Robust risk-adjusted analyses have demonstrated that a reduction in perioperative mortality is associated with the repair of an abdominal aortic aneurysm (AAA) in centres with a high operative caseload (volume). However, the long-term impact of this volume-related effect on mortality remains unknown.
Methods
Demographic and clinical data were extracted from UK Hospital Episodes Statistics for patients undergoing elective repair of an infrarenal AAA from 1 April 2000 to 31 March 2005. The long-term mortality of this cohort was investigated through linkage to the UK Office for National Statistics (ONS) registry. Risk-adjusted survival was analysed using Cox proportional hazards modelling to identify the effect of hospital volume on long-term mortality.
Results
A total of 14 396 patients with mean age of 72 years, of whom 85·7 per cent were men, underwent elective repair of an infrarenal AAA in England. They were linked to follow-up using ONS data. Risk-adjusted analysis of all-cause mortality by Cox proportional hazards modelling demonstrated a significant effect of hospital volume across all quintiles up to 2 years (P = 0·013). Remodelling the data after excluding in-hospital mortality still demonstrated the significant effect of hospital volume on late outcome.
Conclusion
There is a long-term benefit to patients who undergo elective AAA repair in a high-volume hospital.
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Loftus IM, McCarthy MJ, Lloyd A, Naylor AR, Bell PR, Thompson MM. Prevalence of true vein graft aneurysms: implications for aneurysm pathogenesis. J Vasc Surg 1999; 29:403-8. [PMID: 10069903 DOI: 10.1016/s0741-5214(99)70267-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Circumstantial evidence suggests that arterial aneurysms have a different cause than atherosclerosis and may form part of a generalized dilating diathesis. The aim of this study was to compare the rates of spontaneous aneurysm formation in vein grafts performed either for popliteal aneurysms or for occlusive disease. The hypothesis was that if arterial aneurysms form a part of a systemic process, then the rates of vein graft aneurysms should be higher for patients with popliteal aneurysms than for patients with lower limb ischemia caused by atherosclerosis. METHODS Infrainguinal vein grafting procedures performed from 1990 to 1995 were entered into a prospective audit and graft surveillance program. Aneurysmal change was defined as a focal increase in the graft diameter of 1.5 cm or greater, excluding false aneurysms and dilatations after graft angioplasty. RESULTS During the study period, 221 grafting procedures were performed in 200 patients with occlusive disease and 24 grafting procedures were performed in 21 patients with popliteal aneurysms. Graft surveillance revealed spontaneous aneurysm formation in 10 of the 24 bypass grafts (42%) for popliteal aneurysms but in only 4 of the 221 grafting procedures (2%) that were performed for chronic lower limb ischemia. CONCLUSION This study provides further evidence that aneurysmal disease is a systemic process, and this finding has clinical implications for the treatment of popliteal aneurysms.
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37 |
25
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Review |
12 |
36 |