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Objectives In patients with carotid stenosis the risk of stroke is highest in the first few days after onset of symptoms and it is low in asymptomatic patients. The ability to identify patients with a high (or low) probability of having a histologically unstable plaque might become a complimentary method that can refine the indications for surgical intervention. Methods Two histopathologists, using validated American Heart Association criteria, independently graded plaques harvested during carotid endarterectomy. Preoperative Duplex images were independently assessed for juxtaluminal black area, plaque type, plaque area, and grey-scale median (GSM) following image normalization. Logistic regression analysis was then performed to create a model for predicting predominantly histologically unstable or stable plaques. Results A total of 126 patients were included in the study. Based on the presence and extent of histological features including haemorrhage, thrombus, fibrous tissue, lipid core, inflammation, neovascularity, foam cells, and cap rupture, 39 plaques were graded as predominantly stable, while 87 were predominantly unstable. Unstable plaques were associated with a plaque area >95 mm² (OR 4.15; 95% CI 1.34-12.8 p = .009), a juxtaluminal black area >6 mm² (OR 2.77; 95% CI 1.24 to 6.17 p = .01) and a GSM <25 (OR 3.76; 95% CI 1.14-12.39). Logistic regression indicated that patients with the first two features had a 90% probability of having a histologically unstable plaque. The model was used to calculate the probability of having an unstable plaque in each patient. The receiver operating characteristic curve using the p value was 0.68 (95% CI 0.59-0.78). Conclusions Computerized plaque analysis has the potential to identify patients with histologically unstable carotid plaques. This model requires validation, but offers the potential to influence patient selection for emergency interventions and the monitoring of medical therapy. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To develop and validate an “in house” risk model for predicting perioperative mortality following elective AAA repair and to compare this with other models. Design: Multivariate logistics regression analysis was used to identify risk factors for perioperative-day mortality from one tertiary institution''s prospectively maintained database. Materials and methods: Consecutive elective open (564) and endovascular (589) AAA repairs (2000–2010) were split randomly into development (810) and validation (343) data sets. The resultant model was compared to Glasgow Aneurysm Score (GAS), Modified Customised Probability Index (m-CPI), CPI, the Vascular Governance North West (VGNW) model and the Medicare model. Results: Variables associated with perioperative mortality included: increasing age (P = 0.034), myocardial infarct within last 10 years (P = 0.0008), raised serum creatinine (P = 0.005) and open surgery (P = 0.0001). The areas under the receiver operating characteristic curve (AUC) for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. AUCs for GAS, m-CPI and CPI were poor (0.63, 0.58 and 0.58 respectively), whilst VGNW and Medicare model were fair (0.73 and 0.79 respectively). Conclusions: In this study, an “in-house” developed and validated risk model has the most accurate discriminative value in predicting perioperative mortality after elective AAA repair. For purposes of comparative audit with case mix adjustments, national models such as the VGNW or Medicare models should be used. [Copyright &y& Elsevier]

Abstract: Objectives: Outcomes following prosthetic patch infection after carotid endarterectomy (CEA). Methods: Retrospective audit and systematic review. Results: 22 patients were treated between January 1992 and April 2012, 5 having undergone their original CEA at another institution. The commonest infecting organism was Staphylococcus. One patient was treated by antibiotic irrigation, one was stented, while 20 underwent debridement and patch excision plus; carotid ligation (n = 3), vein patching (n = 3) or vein bypass (n = 14). There was one peri-operative stroke, but no peri-operative deaths. There were no reinfections at a median follow-up of 54 months. A systematic review identified 123 patients with prosthetic patch infection in the world literature. Thirty-six (29%) presented <2 months, 78 (63%) presented >6 months after the original CEA. Seventy-nine of/87 patients (91%) with a positive culture yielded Staphylococci or Streptococci. Seventy-four patients were treated by patch excision and autologous reconstruction. Four (5%) developed reinfection <30 days, but later reinfections have been reported. Seven of nine patients (78%) undergoing prosthetic reconstruction either died or suffered reinfection. Five patients were treated with a covered stent, none developing reinfection (median followup 12 months). Conclusion: Patch infection following CEA is rare. Few have undergone stenting and long term data are awaited. For now, patch excision and autologous reconstruction remains the ‘gold standard’. [Copyright &y& Elsevier]

Abstract: Objective: To report the experience of endovascular repair (ER) in patients with ruptured and symptomatic abdominal aortic aneurysms (rAAA and sAAA), comparing results with a cohort of controls who underwent open repair (OR) of sAAA or rAAA. Design: A historically controlled cohort study. Materials: Retrospective data from 21 patients who underwent ER and prospective data from 23 patients who underwent OR. Methods: Results were compared using the Mann–Whitney U-test. Results: Eleven ER patients had sAAAs and 10 had rAAAs. Nine OR patients had rAAAs and 13 had sAAAs. Thirty-day mortality was 11% in patients with rAAA in the ER group, and 54% in the OR group (p=0.03). There were no post-operative deaths in the patients who had an sAAA in the ER group, and one death in the patients who had sAAA in the OR group. Results as expressed as mean ER value versus mean OR value and p-value. ER was associated with significant reductions in the length of operation (2.6 versus 3.1h, p=0.03), blood transfusion requirements (0.86 versus 10.7 units p<0.01), time in critical care (1.5 versus 6.1 days, p=0.02), and total hospital stay (8.5 versus 17.5 days, p=0.01) compared with OR. There was no difference in time from admission to arrival in theatre between the two groups (3.4 versus 5.0h, p=0.35). Conclusions: In patients with rAAA and sAAA that are suitable for stenting, ER has reduced mortality compared with open repair. Assessment for ER does not cause a pre-operative delay, operating time is reduced, blood transfusion requirements are reduced and there is a faster recovery. [Copyright &y& Elsevier]

Introduction: Literature regarding pharmacological manipulation of aneurysm development and progression is abundant; however studies looking at preventing rupture are sparse. Moreover, best medical therapy is ill-instituted, and continued in this high-risk cohort. This paper aims to identify factors which affect the risk of AAA-rupture. Materials & methods: A retrospective review of patients undergoing non-screen detected AAA-repair at a single tertiary-referral centre was performed. Age, cardiovascular history, medication use and the nature of surgical repair (elective or emergency) were converted to binary characteristics and a binomial logistic regression performed. Results: We included 315 admissions for ruptured AAA, and 668 referrals for elective repair of large aneurysms (n = 983). Multifactorial analysis showed that the cohort which was prescribed statins experienced fewer ruptured AAA ([OR] 0.50, [95% CI] 0.32-0.77). Factors associated with increased risk of rupture include female gender (2.49, 1.63-3.80), history of hypertension (3.5, 1.6-3.8) or renal failure (8.08, 4.15-15.4), age over 80 (2.77, 1.79-4.27) and current smoking (1.80, 1.09-2.96). Discussion and conclusions: This is the largest study, interrogating individual patient data, to suggest an association between statins and prevention of large AAA-rupture. As patients with AAA are at high risk of cardiovascular events, and statins may decrease the risk of the devastating consequence of the condition, healthcare teams should maintain pharmaco-vigilance in instituting and continuing best medical therapy, including a statin. [ABSTRACT FROM AUTHOR]