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Objective This study aimed to develop and internally validate risk prediction models for predicting groin wound surgical site infections (SSIs) following arterial intervention and to evaluate the utility of existing risk prediction models for this outcome. Methods Data from the Groin wound Infection after Vascular Exposure (GIVE) multicentre cohort study were used. The GIVE study prospectively enrolled 1 039 consecutive patients undergoing an arterial procedure through 1 339 groin incisions. An overall SSI rate of 8.6% per groin incision, and a deep/organ space SSI rate of 3.8%, were reported. Eight independent predictors of all SSIs, and four independent predictors of deep/organ space SSIs were included in the development and internal validation of two risk prediction models. A systematic search of the literature was conducted to identify relevant risk prediction models for their evaluation. Results The “GIVE SSI risk prediction model” (“GIVE SSI model”) and the “GIVE deep/organ space SSI risk prediction model” (“deep SSI model”) had adequate discrimination (C statistic 0.735 and 0.720, respectively). Three other groin incision SSI risk prediction models were identified; both GIVE risk prediction models significantly outperformed these other risk models in this cohort (C statistic 0.618 – 0.629; p Conclusion Two models were created and internally validated that performed acceptably in predicting “all” and “deep” groin SSIs, outperforming current existing risk prediction models in this cohort. Future studies should aim to externally validate the GIVE models.

Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes.The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail.Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity.Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Background: Living in deprived areas is associated with poorer outcomes after certain vascular procedures and surgical site infection in other specialties. Our primary objective was to determine whether living in more income-deprived areas was associated with groin wound surgical site infection after arterial intervention. Secondary objectives were to determine whether living in more income-deprived areas was associated with mortality and clinical consequences of surgical site infection. Methods: Postal code data for patients from the United Kingdom who were included in the Groin Wound Infection after Vascular Exposure (GIVE) multicenter cohort study was used to determine income deprivation, based on index of multiple deprivation (IMD) data. Patients were divided into three IMD groups for descriptive analysis. Income deprivation score was integrated into the final multivariable model for predicting surgical site infection. Results: Only patients from England had sufficient postal code data, analysis included 772 groin incisions (624 patients from 22 centers). Surgical site infection occurred in 9.7% incisions (10.3% of patients). Surgical site infection was equivalent between income deprivation tertiles (tertile 1 = 9.5%; tertile 2 = 10.3%; tertile 3 = 8.6%; p = 0.828) as were the clinical consequences of surgical site infection and mortality. Income deprivation was not associated with surgical site infection in multivariable regression analysis (odds ratio [OR], 0.574; 95% confidence interval [CI], 0.038-8.747; p = 0.689). Median age at time of procedure was lower for patients living in more income-deprived areas (tertile 1 = 68 years; tertile 2 = 72 years; tertile 3 = 74 years; p

Purpose: To assess the incidence and predictors of severe, persistent postprocedural hypotension (PPH) after carotid artery stenting (CAS). Materials and Methods: A total of 146 patients (mean age 72.8 years; 104 men) who underwent 160 CAS procedures using a standardized protocol at 3 vascular centers were retrospectively analyzed. The primary endpoint was postprocedural hypotension, defined as a reduction in systolic blood pressure (SBP) >40 mm Hg from baseline or an SBP of 1 hour after CAS. Potential prognostic factors for postprocedural hypotension were identified and subjected to logistic regression analyses; outcomes are presented as the odds ratios (ORs) with 95% confidence intervals (CIs). Results: PPH developed in 36 (24.7%) patients after 37 (23.1%) CAS procedures. These patients had significantly longer intensive care unit and hospital stays than those who did not develop hypotension (p

Introduction The management of peri-aortitis, a rare complication after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA), is described in a patient with a solitary kidney. Report A 64 year old man who developed peri-aortitis after elective EVAR for a 6.6 cm infrarenal AAA is reported. Peri-aortitis was diagnosed two months after the procedure and was successfully treated with corticosteroids. Conclusion There is no clear consensus on the best medical therapy for peri-aortitis secondary to EVAR. Peri-aortitis must be considered in patients with ongoing systemic symptoms of inflammation after EVAR, and early management is crucial to the early resolution of symptoms., Highlights • Peri-aortitis is a rare complication after endovascular aortic aneurysm repair. • Peri-aortitis commonly presents with abdominal pain or ureteric obstruction. • Peri-aortitis can be diagnosed with positron emission tomography-computed tomography and labelled white cell scan. • Peri-aortitis can be treated appropriately with oral steroids.

Purpose Improvement in long-term outcomes through innovative, cost-effective medical technologies is a focus for endovascular procedures aimed at treating symptomatic lower-limb peripheral arterial disease (PAD). The advent of drug-eluting stents (DES) has improved symptomatic PAD treatment via a reduction in high rates of target lesion revascularisation (TLR). The present study aimed to compare the 5-year financial impact of treatment with Eluvia, a new paclitaxel-eluting stent, versus treatment with Zilver PTX, a drug-coated stent, among patients in Australia by developing a budget impact model (BIM). Methods A BIM was developed from an Australian public hospital payer perspective using Australian national cost weights (AUD), published literature, and public hospital audit data. Clinical outcomes, including clinically driven TLRs (CD-TLRs), adverse events, and length of stay, were based on the 2-year results of the IMPERIAL trial, which compared Eluvia DES to Zilver PTX. Results Assuming EVP eligibility rate of 80% and DES uses rate ranging from 10 to 28% (superficial femoral artery lesions only), the 5-year model forecasted a treatment population between 14,428 and 40,399 patients. The model estimated 1499–4198 fewer CD-TLRs and 16,515–46,243 fewer hospital days with Eluvia DES use. This translated to 5-year potential savings of $4.3–$12.1 million to the Australian public hospital payer attributable to reduced CD-TLRs for Eluvia DES and $33.1–$92.6 million to Australian public hospitals owing to reduced adverse events and hospital bed days. Conclusion Eluvia DES use as treatment for symptomatic lower-limb PAD could lead to potential savings for the Australian public healthcare system based on improved patient outcomes.

Background: Surgical site infections (SSIs) of groin wounds are a common and potentially preventable cause of morbidity, mortality and healthcare costs in vascular surgery. Our aim was to define the contemporaneous rate of groin SSIs, determine clinical sequelae, and identify risk factors for SSI. Method: An international multicentre prospective observational cohort study of consecutive patients undergoing groin incision for femoral vessel access in vascular surgery was undertaken over 3 months, follow up was 90 days. The primary outcome was incidence of groin wound SSI. Results: 1337 groin incisions (1039 patients) from 37 centres were included. 115 groin incisions (8.6%) developed SSI, of which 62 (4.6%) were superficial. Patients who developed an SSI had a significantly longer length of hospital stay (6 vs 5 days, p=0.005), a significantly higher rate of post-operative acute kidney injury (19.6% vs 11.7%, p=0.018), with no significant difference in 90-day mortality. Female sex, Body Mass Index≥30kg/m2, ischaemic heart disease, aqueous betadine skin preparation, bypass/patch use (vein, xenograft or prosthetic) and increased operative time were independent predictors of SSI. Conclusion: Groin infections which are clinically apparent to the treating vascular unit are frequent and their development carries significant clinical sequelae. Risk factors include modifiable and non-modifiable variables.

Background. Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. Methods. A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. Results. A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.005) and have a history of coronary artery bypass grafting (11.2% versus 3.5%, p=0.042) and malignancy (24.1% versus 10.5%, p=0.014). No difference in 30-day mortality or composite endpoints was demonstrated for female patients compared with male patients (3.5% versus 0.3%, p=0.052 and 31.6% versus 27.8%, p=0.562, respectively). The Kaplan–Meier curves demonstrated similar 5-year mortality outcomes amongst male and female patients (p=0.928). Long-term survival analysis adjusting for covariates demonstrated no significant difference in long-term mortality, composite endpoints, and reintervention rate between sexes. Conclusion. This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.

Graphical Abstract This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. Graphical Abstract One of the most affected specialties

IntroductionImproving long-term outcomes like target lesions revascularizations (TLRs) is a focus for endovascular interventions aimed at treating symptomatic lower-limb peripheral arterial disease (PAD). EluviaTM, a paclitaxel-eluting drug-eluting stent (DES) was shown to further reduce TLRs when compared with the paclitaxel-coated Zilver® PTX® stent in the IMPERIAL trial, a global, randomized controlled study. This budget-impact evaluation investigated cost-savings from Eluvia-use when compared with Zilver PTX, relying on the 12- to 24-month outcomes from the IMPERIAL trial.MethodsA budget-impact model comparing Eluvia and Zilver PTX was developed from the Australian public healthcare payer, and an individual hospital perspective, with a 5-year time-horizon. Observed trial results were applied to each year's incident population and associated costs, and no extrapolation was conducted. The analysis used publicly available Australian national hospital cost data, population estimates, procedural statistics, epidemiological literature, and data from public hospital audits to verify eligible population for endovascular procedures (EVP) including DES. All costs were captured in Australian dollars (AUD), where AUD 1 = USD 0.69 (June 2020).ResultsAssuming 80-percent EVP eligibility, and a DES-use range of 10–28 percent, the 5-year model estimated potential national savings of AUD 4.3–12.1 million (M) [USD 3–8.3M] to the public healthcare payer, driven by reduced TLRs from Eluvia-use compared with Zilver-PTX. The model projected potential national savings of AUD 33.1–92.6M (USD 22.8–63.9M) to individual hospitals through reduced hospital bed days for adverse events (AE). The model forecasted 14,428–40,399 treated patients; 1,499–4,198 fewer TLRs; and 16,515–46,243 fewer hospital days for AE. At a state level, projected hospital savings were: New South Wales AUD 10.9–30.7M [USD 7.5–21.1M]; Victoria AUD 8.4–23.4M [USD 5.8–16.1M]; Queensland AUD 6.5–18.3M [USD 4.5–12.6M]; Western Australia AUD 3.4–9.5M [USD 2.3–6.5M]; South Australia AUD 2.3–6.4M [USD 1.6–4.4M].ConclusionsTreatment of symptomatic lower-limb PAD with the Eluvia DES could lead to potential savings for the Australian healthcare system, at the national, state, and the local hospital level, based on improved patient outcomes.

Background and Purpose— Magnetic resonance imaging (MRI)–defined carotid plaque hemorrhage (MRIPH) can predict recurrent cerebrovascular ischemic events in severe symptomatic carotid stenosis. It is less clear whether MRIPH can improve risk stratification despite optimized medical secondary prevention in those with moderate risk. Methods— One-hundred fifty-one symptomatic patients with 30% to 99% carotid artery stenosis (median age: 77, 60.5% men) clinically deemed to not benefit from endarterectomy were prospectively recruited to undergo MRI and clinical follow-up (mean, 22 months). The clinical carotid artery risk score could be evaluated in 88 patients. MRIPH+ve was defined as plaque intensity >150% that of adjacent muscle. Survival analyses were performed with recurrent infarction (stroke or diffusion-positive cerebral ischemia) as the main end point. Results— Fifty-five participants showed MRIPH+ve; 47 had low, 36 intermediate, and 5 high carotid artery risk scores. Cox regression showed MRIPH as a strong predictor of future infarction (hazard ratio, 5.2; 95% confidence interval, 1.64–16.34; P =0.005, corrected for degree of stenosis), also in the subgroup with 50% to 69% stenosis (hazard ratio, 4.1; 95% confidence interval, 1–16.8; P =0.049). The absolute risk of future infarction was 31.7% at 3 years in MRIPH+ve versus 1.8% in patients without ( P P =0.004). Conclusions— The study confirms MRIPH to be a powerful risk marker in symptomatic carotid stenosis with added value over current risk scores. For patients undergoing current secondary prevention medication with clinically uncertain benefit from recanalization, that is, those with moderate degree stenosis and intermediate carotid artery risk scores, MRIPH offers additional risk stratification.

Background The timing of carotid endarterectomy (CEA) following thrombolysis for acute ischemic stroke remains controversial. We have described our unit's experience and performed a systematic review and pooled data synthesis of the safety of CEA in this group of patients. Methods Retrospective analysis of patients who had undergone CEA following thrombolysis between 2010 and 2012 was performed. A systematic review of the literature was also performed using PUBMED, EMBASE, and major conference proceedings. The primary outcome measure was 30-day postoperative intracerebral hemorrhage (ICH) and ischemic stroke. The secondary outcome measures were 30-day postoperative all-cause morbidity and mortality. Results Seven patients underwent CEA following thrombolysis with mean age ± standard deviation of 70.57 ± 7.57. Five were men and five had CEA under local anesthesia. CEA was performed in median of 7 days (range, 2-12) after onset of stroke. Thirty-day morbidity was 14% (1/7) with one patient who experienced ICH postoperatively. There was no mortality. Nine studies were identified for systemic review. Seventy patients were included in the pooled data synthesis. One patient (1%) experienced postoperative ICH. When our series was included, the 30-day postoperative ICH was 3% (2/77). The overall 30-day postoperative morbidity was 4% (3/77), and there was no mortality. Conclusions Despite slightly higher rates of postoperative hemorrhagic strokes than those in randomized trials, CEA appears safe following thrombolysis for acute ischemic stroke. However, more data on the timing of surgery is needed.

Endovascular repair of popliteal artery aneurysms (PAA) has become increasingly popular; however, long-term patency and limb salvage rates are not fully established.A retrospective review of all endovascular PAA repairs at our institution (from 2005 to 2012) identified 34 PAAs in 26 patients, of which 32 % presented with acute symptoms. PAA were repaired with either Hemobahn(®) or Viabahn(®) endografts, using an entirely percutaneous approach. All patients were given Clopidogrel and/or aspirin postoperatively. Mean follow-up duration was 40 (range 4-86) months. Kaplan-Meier analysis was used to determine primary patency, secondary patency, and limb salvage rates. Complications and reintervention rates also were examined.At 1, 3, and 5 years follow-up, the primary graft patency was 88, 82, and 82 %, respectively, and secondary patency was 90, 86, and 86 %. Amputation-free survival at 1, 3, and 5 years was 97, 94, and 94 %, respectively. Technical success was achieved in 100 %. There were five graft occlusions: one was asymptomatic, one was treated with thrombolysis successfully, and one was thrombolysed but reoccluded resulting in nondisabling claudication. Two were not suitable for thrombolysis and required amputation. The overall reintervention rate was 12 %.The primary and secondary patency rates of endovascular repair of PAA are equivalent to the reported outcome of open repair. Reintervention and limb salvage rate appears better than open repair. With improved long-term outcomes, endovascular repair can be considered a credible treatment strategy for routine uncomplicated PAA.

Objective There is a recognized need to improve selection of patients with carotid artery stenosis for carotid endarterectomy (CEA). We assessed the value of magnetic resonance imaging (MRI)-defined carotid plaque hemorrhage (MRIPH) to predict recurrent ipsilateral cerebral ischemic events, and stroke in symptomatic carotid stenosis. Methods One hundred seventy-nine symptomatic patients with ≥50% stenosis were prospectively recruited, underwent carotid MRI, and were clinically followed up until CEA, death, or ischemic event. MRIPH was diagnosed if the plaque signal intensity was >150% that of the adjacent muscle. Event-free survival analysis was done using Kaplan–Meier plots and Cox regression models controlling for known vascular risk factors. We also undertook a meta-analysis of reported data on MRIPH and recurrent events. Results One hundred fourteen patients (63.7%) showed MRIPH, suffering 92% (57 of 62) of all recurrent ipsilateral events and all but 1 (25 of 26) future strokes. Patients without MRIPH had an estimated annual absolute stroke risk of only 0.6%. Cox multivariate regression analysis proved MRIPH as a strong predictor of recurrent ischemic events (hazard ratio [HR] = 12.0, 95% confidence interval [CI] = 4.8–30.1, p

The last two decades have seen a revolution in the treatment of aortoiliac occlusive disease (AIOD). Acceptable safety and durability outcomes have now been realized with endovascular treatments, which is increasingly finding a place in the treatment of AIOD. Evolution of stent technologies and endovascular techniques is seeing an expansion of AIOD lesions indicated for primary endovascular treatment. The literature evidence basis is continuously evolving, and questions remain as to the optimal form of vessel treatment. Covered stents have been increasingly promoted for their long-term durability, particularly in extensive, challenging AIOD lesions. Here, we explore the seminal evidence basis for covered stents in the treatment of AIOD, and aim to provide a sound evidence based argument for their use.

The Hardman index is a predictor of 30-day mortality after open ruptured abdominal aneurysm repair through the use of preoperative patient factors. The aim of this study was to assess the Hardman index in patients undergoing endovascular repair of ruptured aortic aneurysms.A retrospective analysis of 95 patients undergoing emergency endovascular repairs of computed tomography-confirmed ruptured aneurysms from 1994 to 2008 in a university hospital was performed. All relevant patient variables, calculations of the Hardman index, and the incidence of 30-day mortality were collected in these patients. Correlation of the relationship between each variable and the overall score with the incidence of 30-day mortality was undertaken.The 24-hour mortality was 16% and 30-day mortality 36%. Increasing scores on the Hardman index showed an increasing mortality rate. Thirty-day mortality in patients with a score of 0 to 2 was 30.5%, and in those with a score of ≥3 was 69.2% (P = .01, risk ratio = 2.26, 95% confidence interval = 0.98 to 5.17). This is lower than predicted in both patient groups based on Hardman index score. Loss of consciousness was the only statistically significant independent predictor of 30-day mortality with a risk ratio of 3.16 (95% confidence interval = 2.00-4.97, P.001).These data suggest that the Hardman index can predict an increased risk of 30-day mortality from endovascular repairs of ruptured aortic aneurysms. However, mortality from endovascular repair is much lower than would be predicted in open repair and it therefore cannot be used clinically as a tool for exclusion from intervention.

Purpose: To review the outcomes of patients undergoing emergency endovascular repair of aortocaval fistula (ACF) secondary to abdominal aortic aneurysm (AAA). Case Report: Four consecutive patients who underwent emergency endovascular repair of ACF associated with AAA in a tertiary institution between 2002 and 2009. Of the 4 patients, 3 had initially been misdiagnosed and managed for several days by other specialists for their symptoms prior to diagnosis of their ACF. Three patients died in the early postoperative period. The fourth patient made a satisfactory postoperative recovery but subsequently required further endovascular surgery to treat a persistent type 1 endoleak. Conclusions: Our experience illustrates the importance of early diagnosis and management of ACF. Even in experienced hands, the management of spontaneous ACF associated with AAA is challenging. Endovascular surgery may still have a role in improving outcomes in these patients.

Background MRI-defined acute cerebral infarctions (DWI+) and carotid plaque haemorrhage (MRIPH+) are risk factors for cerebrovascular ischaemic events. It is unclear whether their predictive power is independent, and whether a combined score would improve prediction of recurrent events. Methods 158 patients (mean 74 years, 40% female) with symptomatic (n=69 TIA)≥50% carotid stenosis underwent carotid and brain MRI, and clinical follow-up. Multivariate backward regression and Kaplan Meier survival analyses were used for event prediction. Akaike information criterion (AIC) values for single and combined models were compared. Results 83/158 patients were DWI+and 88/158 MRIPH+. 41 recurrent events were observed, and both DWI+ (HR 2.85; 95% CI 1.2–7; p=0.024) and MRIPH+ (HR 7.6; 95% CI 2.2–26.4; p=0.001) were independent predictors. The AIC value for the combined model (AIC 200.1) showed added value vs. DWI (AIC 220.5) and MRIPH (AIC 204.9). Survival analysis for patients with an index TIA illustrated significant shorter stroke-free survival (χ2=12.5, p Conclusion Brain DWI +and MRIPH +are independent predictors of recurrent stroke in symptomatic carotid disease with added prediction value for the combined model.

Purpose In patients with symptomatic carotid artery disease the predominant mechanism causing ischaemic injury is considered to be thromboembolic, however compromise of cerebral haemodynamics is considered to be a significant factor. Removal of the embolic source is accepted as the major benefit from Carotid Endarterectomy (CEA), however improvement in cerebral haemodynamics may be another beneficial outcome as suggested by Transcranial doppler (TCD). Blood Oxygen Level-Dependent (BOLD) hypercapnia functional Magnetic Resonance imaging (fMRI) can be used to map the Cerebrovascular Reserve (CVR). The aim of this study was to assess the effects of carotid surgery on cerebral haemodynamics in patients with carotid artery disease using a hypercapnia BOLD fMRI and assessment of hemispheric asymmetry. Materials and methods Seventeen patients with symptomatic internal carotid artery stenosis were scanned using a clinical 1.5T MR scanner. Scanning was done immediately prior to and between 4 and 8 weeks after CEA. 10% carbon dioxide was administered to achieve transient episodes of hypercapnia. The data was analyzed using FMRIB Software Library (FSL) software to derive percentage signal change (PSC) for the grey matter of the middle cerebral artery (MCA-GM) territory for both hemispheres. MCA-GM PSC was furthermore normalized to the contralateral hemisphere to derive an Hemispheric Asymmetry Index (hAI) for all patients pre- and postoperatively. Results Ipsilateral GM CVR improved significantly following CEA (2.47% preoperatively vs. 2.73% postoperatively, p = 0.038). There was no change in CVR in the contralateral grey and white matter MCA territories (p = 0.27, p = 0.1). Also, the hAI was significantly more shifted to the ipsilateral hemisphere after CEA (preoperative hAI −0.56, vs. −3.90 postoperatively, p = 0.02). Patients with an impaired hAI preoperatively were found to show the greatest improvement in PSC and hAI following CEA (p = 0.007). Conclusions CEA resulted in improved CVR in patients with carotid artery disease as shown by the absolute and hemispheric asymmetry of BOLD response to hypercapnia.. These findings show that benefits from recanalisation may go beyond removal of the embolic source, by improving the cerebrovascular reserve. Moreover, hypercapnia BOLD fMRI may be a useful clinical tool in predicting this therapeutic potential in patients with severe carotid artery disease.

White matter hyperintense lesions (WMHLs) are related to age, hypertension, and ischemia. They increase the risk of stroke in natural history and perioperatively during carotid endarterectomy. This may reflect an association with impaired cerebral hemodynamics. Hence, the authors studied whether ipsilateral WMHLs predict shunt requirement on clamping as an indicator of hemodynamic compromise.A retrospective analysis was done in patients with symptomatic and severe carotid stenosis (60%). Ipsilateral WMHL volumes were calculated from magnetic resonance imaging scans and association studied with the requirement of an intraoperative shunt.Seventy patients were included. Twelve (17%) patients required shunting and 2 developed perioperative strokes. Patients requiring shunting had a larger WMHL volume (adjusted means = 16.2 +/- 2.9 mL compared with 8.7 +/- 1.2 mL for the nonshunt group; P = .020).Ipsilateral WMHL volume is a significant predictive factor for shunt requirement during carotid endarterectomy. This may reflect cerebral hemodynamic compromise.

The aim of the study was to assess the suitability of radiofrequency ablation (RFA), endovenous laser ablation (EVLA), and foam sclerotherapy (FS) for patients with symptomatic varicose veins (VVs). The study comprised 403 consecutive patients with symptomatic VVs. Data on 577 legs from 403 consecutive patients with symptomatic VVs were collected for the year 2006. Median patient age was 55 years (interquartile range 45-66), and 62% patients were women. A set of criteria based on duplex ultrasonography was used to select patients for each procedure. Great saphenous vein (GSV) reflux was present in 77% (446 of 577) of legs. Overall, 328 (73%) of the legs were suitable for at least one of the endovenous options. Of the 114 legs with recurrent GSV reflux disease, 83 (73%) were suitable to receive endovenous therapy. Patients with increasing age were less likely to be suitable for endovenous therapy (P = 0.03). Seventy-three percent of patients with VVs caused by GSV incompetence are suitable for endovenous therapy.

To retrospectively assess the relationship between carotid intraplaque hemorrhage (IPH), which indicates plaque instability, and brain white matter hyperintense lesions (WMHLs) by using a within-patient design.All patients gave written informed consent for the initial magnetic resonance (MR) studies, and the institutional review board and local research ethics committee waived initial informed consent for the pooled analysis. A total of 190 patients with symptomatic carotid artery disease underwent fluid-attenuated inversion-recovery imaging of the brain and fat-suppressed black-blood T1-weighted MR imaging of the carotid arteries. The volumes of periventricular lesions, subcortical lesions, and total WMHLs were calculated and compared between hemispheres in relation to symptoms and IPH, and their interaction was calculated and compared by using repeated measures three-factorial multivariate analysis.After exclusion of 12 patients, 178 patients (116 men, 62 women; mean age, 70.2 years +/- 8.6 [standard deviation]) remained. There was no significant difference in WMHL volume between the symptomatic and asymptomatic hemispheres, and WMHL volume was not related to the degree of carotid stenosis. The presence of carotid IPH significantly interacted with the interhemispheric WMHL difference (Wilks lambda test, F = 9.95; df = 3; P.001). Univariate analysis showed larger total and periventricular WMHL volumes (P.05) in patients with ipsilateral IPH.Carotid artery disease and leukoaraiosis were associated with features that indicated plaque instability, namely IPH, whereas the degree of stenosis had no effect.

Background Microembolization detected during the dissection phase of carotid endarterectomy (CEA) is associated with plaque instability and might be associated with perioperative morbidity. Intraplaque hemorrhage is found in unstable plaques and is detectable using magnetic resonance imaging (MRI). We aimed to ascertain whether intraplaque hemorrhage as seen on carotid MRI predicts particulate embolization in the dissection phase of CEA. Methods Patients with high-grade symptomatic carotid stenosis undergoing CEA were prospectively enrolled. All underwent preoperative MRI assessment of the carotid arteries for intraplaque hemorrhage and transcranial Doppler scanning during the dissection phase of the CEA to assess the presence of microembolic signals. Associations between intraplaque hemorrhage and intraoperative microembolic signals were studied. Results Analysis was undertaken on 60 participants; of these, 36 (60%) showed ipsilateral carotid MRI intraplaque hemorrhage, and 24 (40%) did not. Microembolic signals were detected during the dissection phase in 23 (38.3%) participants, and 19 had MRI-detected intraplaque hemorrhage. The association between carotid intraplaque hemorrhage and the presence of dissection phase microembolic signals was significant (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.6 to 19.7, P = .007), even after controlling for age, sex, individual surgeon, degree of stenosis, and delay from symptom to CEA (adjusted OR, 5.8; 95% CI, 1.1 to 30.4, P = .037). Conclusion Intraplaque hemorrhage as detected by carotid MRI predicts particulate embolization during the dissection phase of CEA. This imaging technique can be used to identify patients with increased intraoperative thromboembolic risk, and this could influence preventive strategies.

BACKGROUND AND PURPOSE: MR imaging–detected carotid plaque hemorrhage is associated with an increased risk of recurrent ischemic cerebrovascular events and could be an indicator of disease progression; however, there are limited data regarding the dynamics of the MR imaging–detected carotid plaque hemorrhage signal. We assessed the temporal change of this signal and its impact on carotid disease progression. MATERIALS AND METHODS: Thirty-seven symptomatic patients with 54 carotid stenoses of >30% on sonography underwent serial MR imaging during 24 months. A signal-intensity ratio of >1.5 between the carotid plaque and adjacent muscle was defined as plaque hemorrhage, and a change in signal-intensity ratio of >0.31 between time points was considered significant. Sixteen patients underwent ≥2 carotid sonography scans to determine the peak systolic velocities and degree of stenosis with time. RESULTS: Of the 54 carotids, 28 had the presence of hyperintense signal on an MR imaging sequence (PH+) and 26 had the absence of hyperintense signal on an MR imaging sequence (PH−) at baseline. The signal-intensity ratio was stable in 33/54 carotid plaques, but 39% showed a change. Plaque hemorrhage classification did not change in 87% of carotid plaques, but 4 became PH+, and 3, PH−. As a group, PH+ carotids did not change significantly in signal-intensity ratio ( P = .585), whereas PH− showed an increased signal-intensity ratio at 24.5 months ( P = .02). In PH+ plaques, peak systolic velocities significantly increased by 22 ± 39.8 cm/s from baseline to last follow-up sonography ( Z = 2.427, P = .013). CONCLUSIONS: During 2 years, MR imaging–detected carotid plaque hemorrhage status remained stable in most (87%) cases with 4 (7%) incident plaque hemorrhages. PH+ plaques were associated with increased flow velocity during the follow-up period. MR imaging-PH : MR imaging–detected plaque hemorrhage PH : plaque hemorrhage PH+ : presence of hyperintense signal on an MR imaging sequence PH− : absence of hyperintense signal on an MR imaging sequence PSV : peak systolic velocity SIR : signal-intensity ratio

Objectives. The aim of this study was to determine whether unstable carotid plaques, a known risk factor for cerebral emboli, are associated with cerebral white matter lesions. Methods. Seventy-one symptomatic patients undergoing magnetic resonance imaging prior to carotid endarterectomy for high grade carotid stenosis were included in this study. The number and volume of white matter hyperintense lesions (WMHL) on fluid attenuated inversion recovery brain scans were compared according to the morphology of carotid plaque based upon the American Heart Association (AHA) histological classification. Results. Of the 57 patients who had good quality brain scans and non-fragmented carotid plaques, 15 plaques were defined as stable (type V) and 42 as unstable (type VI). After adjustment for the major risk factors affecting WMHL, unstable carotid plaques were found to be associated with more WMHL in the ipsilateral cerebral hemisphere than stable plaques (transformed means 2.50G1.2 vs. 1.53G1.1, pZ0.016), however, there was only a trend towards larger WMHL volumes (pZ0.079). Conclusions. The observed association between unstable carotid plaques and the number of white matter lesions suggest that thromboembolic plaque activity may contribute to the development of leukoaraiosis, in particular smaller individual lesions. Larger studies are warranted to confirm this finding and explore the potential clinical impact for selecting candidates for carotid endarterectomy.

An 83-year-old man presented 4 years after right carotid endarterectomy (CEA) with an infection of his prosthetic Dacron patch. Initial scans (CT angiogram and whole body labelled white cell scan) were clear with no infection or collection noted. Systemically, the patient presented well with no recorded fevers. With an occluded left internal carotid artery and severely stenosed vertebral arteries, surgery presented a high risk of major stroke due to the lack collateral supply and this was discussed extensively. The patient subsequently declined surgical management, and he was monitored closely on an outpatient basis. He presented again a year later with ongoing haemoserous ooze from the CEA site. Subsequently a two-stage procedure was performed, where initially a stent was inserted, followed by patch excision and debridement. A muscle flap was then mobilised over the opening. This new approach to carotid patch infections should gain traction over time as a safer alternative for high-risk patients.

Background The European Carotid Surgery Trial ( ECST ) risk model is a validated tool for predicting cerebrovascular risk in patients with symptomatic carotid disease. Carotid plaque hemorrhage as detected by MRI ( MRIPH ) and microembolic signals ( MES ) detected by transcranial Doppler ( TCD ) are 2 emerging modalities in assessing instability of the carotid plaque. The aim of this study was to assess the strength of association of MES and MRIPH with cerebrovascular recurrence in patients with symptomatic carotid artery disease in comparison with the ECST risk prediction model. Methods and Results One hundred and thirty‐four prospectively recruited patients (mean [ SD ]: age 72 [9.8] years, 33% female) with symptomatic severe (50% to 99%) carotid stenosis underwent preoperative TCD , MRI of the carotid arteries to assess MES , PH, and the ECST risk model. Patients were followed up until carotid endarterectomy, recurrent cerebral event, death, or study end. Event‐free survival analysis was done using backward conditional Cox regression analysis. Of the 123 patients who had both TCD and MRI , 82 (66.7%) demonstrated PH and 46 (37.4%) had MES . 37 (30.1%) cerebrovascular events (21 transient ischemic attacks, 6 amaurosis fugax, and 10 strokes) were observed. Both carotid PH ( HR =8.68; 95% CI 2.66 to 28.40, P MES ( HR =3.28; 95% CI 1.68 to 6.42, P =0.001) were associated with cerebrovascular event recurrence. Combining MES and MRIPH improved the strength of association ( HR =0.74, 95% CI 0.65 to 0.83; P ECST risk model was not associated with recurrence ( HR =0.86; 95% CI 0.45 to 1.65; P =0.65). Conclusions The presence of carotid plaque hemorrhage is better associated with recurrent cerebrovascular events in patients with symptomatic severe carotid stenosis than the presence of microembolic signals; combining MES and MRIPH , further improves the association while the ECST risk score was insignificant.

Introduction MRI-defined carotid plaque haemorrhage (MRIPH) can predict recurrent cerebrovascular ischaemic events in severe symptomatic carotid stenosis. It is less clear whether MRIPH can improve risk stratification in less severe disease. Methods 192 symptomatic participants with 30–99% carotid artery stenosis who were clinically deemed not to benefit from carotid endarterectomy were recruited to undergo MRI and clinical follow-up (mean 22 months; range: 3–1587 days). The clinical Carotid Artery Risk (CAR) score could be evaluated in 88 patients. MRIPH was defined as plaque intensity >150% that of adjacent muscle. Survival analyses were performed with recurrent stroke or diffusion-positive-cerebral ischaemia as the main endpoint. Results 151 fulfilled the inclusion criteria (age: 77, 60.5% men); 55 were MRIPH+ve. 47 had low, 36 intermediate and 5 high CAR scores. Cox regression showed MRIPH as a strong predictor of future infarction (HR=5.0, 95% CI=1.6–15.9, P=0.006, corrected for degree of stenosis), also in the subgroup with 50–69% stenosis (HR=4.1, 95% CI=1–16.8, P=0.049). The absolute risk of future infarction was 31.7% at 3 years in MRIPH+ve versus 1.8% in MRIPH-ve (P Conclusion MRIPH can identify a subgroup of patients with a higher risk than clinically predicted thus enabling targeted intervention.

Background and Purpose— Carotid intraplaque hemorrhage (IPH), known to be associated with plaque instability, may convey a higher stroke risk. The aim of this study was to assess whether the identification of IPH by MRI predicts recurrent clinical cerebrovascular events. Methods— Sixty-six patients with high-grade symptomatic carotid stenosis underwent MRI of the carotid arteries and were followed until carotid endarterectomy or 30 days. Results— Of the 66 patients with a median follow up of 33.5 days, 44 (66.7%) were found on MRI to have ipsilateral carotid IPH. Fifteen recurrent events were associated with ipsilateral carotid IPH. Only 2 recurrent events occurred in the absence of IPH. IPH increased the risk of recurrent ischemia (hazard ratio=4.8; 95% CI=1.1 to 20.9, P Conclusion— IPH as detected by MRI predicts recurrent cerebrovascular events in patients with symptomatic high-grade carotid stenosis.

Whilst malnutrition is prevalent in approximately 40% of general surgical patients, the prevalence of malnutrition and nutritional screening practices amongst vascular patients remain unknown. The Malnutrition Universal Screening Tool (MUST) is recommended for risk screening and provides 3 scores for risk classification: 0=low risk, 1=intermediate risk, 2=high risk. The aim of this preliminary study was to evaluate the use of MUST on vascular wards. This prospective study was undertaken in a tertiary referral vascular unit in the UK. Patient demographics, utilisation of MUST by nursing staff (N-MUST) and referral to nutritional support teams (NST) were studied. When MUST was not completed by nursing staff, the study team (S-MUST) performed it. Fifty-three patients, median (interquartile range, IQR) age 67 (59-75) years were initially studied. For N-MUST: Overall MUST score was recorded in 18/25 (72%) patients, of whom 1 (4%) scored 2, whilst the remainder scored 0. For S-MUST: Overall MUST scores were recorded in 28 patients, MUST=0 in 75% and ≥2 in 21%. An educational session on use of MUST was delivered to nursing staff, as well as a Trust-wide educational initiative to improve assessment of nutritional status and, after a 2-month period, the study was repeated. The second cohort comprised forty-two patients, median (IQR) age 72 (64-79) years. For N-MUST: Overall MUST score was recorded in 37/40 (93%) patients, of whom 3 (8%) scored ≥2. For S-MUST: Overall MUST scores were recorded in 2 patients, MUST = 0 in 67% and ≥2 in 33%. Despite the ease of use of MUST, it was under-utilised on vascular wards. However, following provision of a dedicated educational programme to ward nursing staff, utilisation of MUST for risk scoring patients on admission increased to over 90%.

WHAT THIS PAPER ADDSThis single-centre retrospective study demonstrates that young patients with abdominal aortic aneurysms havesignificant comorbidities and do not necessarily have a long life expectancy. It would be therefore reasonable tooffer endovascular repair to this subgroup of patients.Objectives: To compare the mid-term outcome and secondary intervention rate following elective open andendovascular aortic aneurysm repair (EVAR) in patients aged 65 years and younger.Methods: A retrospective analysis of patients aged 65 years and younger who had elective abdominal aorticaneurysm repair (AAA) between 1994 and 2012.Results: One hundred and sixty-five patients under the age of 65 years (mean age: 61 years 4; 8 women) hadelective abdominal aneurysm repair (97 EVAR and 68 open). The overall 30-day mortality rate was 3.7% (2.1%EVAR and 5.9% open). Forty per cent of patients had died at a median follow up of 77 months (interquartilerange, 36e140). Most deaths were not related to aneurysm.There was no difference in the long-term mortalitybetween the EVAR and open groups (hazard ratio [HR] ¼ 1.22; 95% confidence interval [CI] 0.75e1.98, p ¼ .43),but there was a trend of better outcomes with the use of commercially made endografts over open repair(HR ¼ 2.9; 95% CI 0.9e10.0, p ¼ .08) and custom-made endografts (HR ¼ 3.1, 95% CI 0.9e10.3;p ¼ .07). Elevenper cent of patients who had EVAR required a further procedure compared with 13% who had open repair. Allbut one of the re-interventions in the EVAR group was performed on patients who had custom-madeendografts.Conclusions: Young patients with AAA have significant comorbidities and do not necessarily have long lifespans.In the less fit younger patients with AAA, the results with EVAR are comparable with fit patients who had openAAA repair.The management of fitter young patients with AAA remains controversial, but improving results withEVAR over time may increase the role of EVAR in this group. 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.Article history: Received 21 December 2012, Accepted 22 April 2013, Available online XXXKeywords: Abdominal aortic aneurysm, Endovascular aortic aneurysm repair, OutcomesINTRODUCTIONRandomised studies have demonstrated benefit fromendovascular aneurysm repair (EVAR) when compared withopen repair of abdominal aortic aneurysms (AAAs).

Background Recent international guidance recommends the use of catheter-directed thrombolysis (CDT) in selected patients with symptomatic iliofemoral deep vein thrombosis (DVT). The aim of this study was to estimate the potential increase in workload as a result of this recommendation. Methods Using the radiology database, a review was performed of all DVTs diagnosed between August 2010 and February 2012 at a large tertiary referral hospital. The National Institute for Health and Clinical Excellence and American College of Chest Physicians guidance was applied retrospectively to this cohort, using case-note review by two independent clinicians to determine which patients would have been suitable for CDT. Results Some 563 patients had DVT confirmed radiologically over the 18-month interval. Fifty-three of the 128 patients with iliofemoral DVT would have been eligible for intervention with CDT, equivalent to 4·4 patients per 100 000 per year. Only eight (15 per cent) of the 53 were actually referred to vascular services for treatment. All eight patients had successful CDT, which involved a stay in critical care for monitoring (median 2 (range 1–3) sessions). Conclusion Vascular units should be prepared for a major increase in the requirement for CDT for iliofemoral DVT. This increase will affect inpatient beds, the interventional radiology suite, critical care and interhospital referrals.

Objective The Covered vs Balloon Expandable Stent Trial (COBEST) is the first multicenter trial to investigate the patency of covered stents (CSs) and bare-metal stents (BMSs) in the treatment of aortoiliac arterial disease. The short-term results demonstrated that CSs were superior to BMSs in maintaining patency for TransAtlantic Inter-Society Consensus (TASC) C and D lesions at 18 months and were equivalent to BMSs for TASC B lesions. The current study was conducted to determine if the initial patency advantage of CSs over BMSs was sustained at the 5-year follow-up. Methods A retrospective post hoc analysis of COBEST was performed. Originally, 125 patients with 168 iliac arteries were prospectively enrolled and randomly assigned to receive a CS or BMS. In this study, 77 of the 125 patients (61.6%; 119 limbs) were assessed at 60 months for the primary and secondary end points, with particular attention paid to the outcomes stratified according to TASC lesion severity. The primary end point was the rate of binary stenosis or freedom from stent occlusion of the treated area, as determined by ultrasound imaging or quantitative visual angiography. Results The 5-year results of the COBEST showed that the CS had a significantly higher patency rate than the BMS at 18, 24, 48, and 60 months (95.1%, 82.1%, 79.9%, 74.7% for CS vs 73.9%, 70.9%, 63% and 62.5% for BMS; log-rank test, P = .01). On multivariate analysis, the type of stent used (hazard ratio [HR], 2.797; 95% confidence interval [CI], 1.471-5.318; P = .002) and the Rutherford classification (HR, 2.019; 95% CI, 1.278-3.191; P = .026) significantly affected the adjusted primary patency. On subgroup analysis, the CS showed significantly higher patency and a survival benefit compared with the BMS in TASC C and D lesions (HR, 8.639; 95% CI, 54.253-75.753; P = .003). Moreover, fewer patients received target limb revascularization in the CS group than in the BMS group (odds ratio, 2.32; 95% CI, 1.47-3.36; P = .02); however, there was no statistically significant difference in the rate of amputations between the groups. Conclusions The 5-year results of the COBEST demonstrated that the CS has an enduring patency advantage over the BMS in both the short and long terms. Furthermore, the CS showed acceptable patency rates for the treatment of more severe TASC C and D lesions, and patients who received a CS required fewer revascularization procedures. However, the choice of stent did not affect the rate of major limb amputations.

Both magnetic resonance detected carotid plaque hemorrhage (MRI PH(+)) and features of inflammation are associated with increased risk of cerebrovascular events in patients with carotid stenosis. To further assess the potential of MRI PH as a biomarker for complicated carotid plaque, its relationship with inflammation needs to be assessed. In this study we assess whether MRI PH(+) carotid plaques are associated with inflammatory infiltration.Thirty-five consecutive patients with symptomatic, high-grade carotid stenosis scheduled for carotid endarterectomy had preoperative MRI. The carotid plaques removed at operation were assessed for inflammatory features and compared with MRI findings.Twenty-one (60%) carotid arteries were MRI PH(+) and 14 (40%) were MRI PH(-). The MRI PH(+) plaques were associated with histologic evidence of plaque hemorrhage, high lipid proportion, and low fibrous content. They also had higher levels of macrophage and lymphoid cells compared with MRI PH(-) plaques (P0.05, by χ² test) and were more likely to be AHA VI (P0.005, χ² test). MRI PH(+) plaques were also more likely to be graded as unstable based on morphology and cellular composition.These findings demonstrate an association between MRI PH and signs of active plaque disease. The relationship between inflammatory activity and plaque instability may thus explain the increased risk associated with MRI PH(+) plaques and increased risk of symptoms.

We read with interest the recent report by Saam et al. [(1)][1] describing the predictive value of magnetic resonance imaging–detected carotid plaque hemorrhage for cerebrovascular events. They undertook a meta-analysis of the published research through September 2012 assuming a constant event

To assess whether carotid plaque hemorrhage depicted with magnetic resonance (MR) imaging was associated with thromboembolic activity as assessed with transcranial Doppler imaging.The local research ethics committee approved the study, and all patients gave informed written consent. Between April 2005 and December 2006, patients with high-grade symptomatic carotid stenosis were prospectively recruited. All underwent MR imaging of the carotid arteries for plaque hemorrhage and diffusion-weighted imaging of the brain. Transcranial Doppler imaging of the symptomatic carotid artery was performed over 1 hour to assess the presence of microembolic signal. To determine the relationship between the presence of plaque hemorrhage and diffusion-weighted imaging-positive signal and presence of microembolic signal, a logistic regression analysis was performed.Fifty-one patients (23 women and 28 men; mean age ± standard deviation, 72 years ± 11) underwent complete MR imaging; 46 (86%) of these patients underwent complete transcranial Doppler imaging. In 32 (63%) patients, there was plaque hemorrhage in the index carotid artery. The presence of plaque hemorrhage increased the risk for ipsilateral abnormalities at diffusion-weighted imaging (odds ratio, 6.2 [95% confidence interval: 1.7, 21.8]; P.05). Multiple diffusion-weighted imaging-depicted abnormalities of multiple ages were present exclusively in patients with plaque hemorrhage shown at MR imaging (12 of 32 [38%] patients with plaque hemorrhage versus none of 19 patients without plaque hemorrhage; P.05). The presence of plaque hemorrhage also increased the presence of microembolic signal (odds ratio, 6.0 [95% confidence interval: 1.8, 19.9]; P = .003).In patients with carotid plaque hemorrhage demonstrated at MR imaging, there was increased spontaneous microembolic activity at transcranial Doppler imaging and cerebral ischemic lesion patterns suggestive of recurrent embolic events; these findings suggest that plaque hemorrhage shown at MR imaging might be a marker of thromboembolic activity and further validate the usefulness of carotid imaging in identifying patients with active carotid arterial disease.

Introduction Endovascular repair of aortic aneurysm (EVAR) has a lower mortality than open repair. The aim of this study was to assess mortality from EVAR for emergency AAA repair and the impact of fitness for operation and adverse anatomy. Methods One-hundred and forty two patients who had EVAR for a ruptured AAA (80, REVAR) or a symptomatic AAA (62, SEVAR) between 1994 and 2007 in a single specialist endovascular centre were reviewed. Fitness for surgery was assessed by Hardman's index (age>76, loss of consciousness, Hb 190, ischaemic ECG). CT scans were reviewed, compared with operative images and operation notes for adverse anatomy. Details of perioperative complications, and outcome were recorded. Results Overall mortality at 24-h, 30-days and one year were, respectively: 17%, 36%, 50% for REVAR and 5%, 8%, 23% for SEVAR. Overall adverse anatomy increased 30-day mortality. Hardman's index of three or more increased mortality HR=2.59 (1.24–5.41), p =0.01. On Cox regression Univariate analysis increasing Hardman's index score and adverse anatomy increased the overall mortality over time. In multivariate Cox regression analysis (controlled for the Hardman's index) adverse anatomy was associated with significant increase in graft related mortality. Conclusion The use of EVAR is feasible in patients who present with a ruptured or acutely symptomatic AAA. Care must be taken not to extend anatomical or clinical guidelines.

Response: We appreciate Hsieh and Chen’s interest in our study. We agree that understanding the pathomechansim of the development of intraplaque hemorrhage (IPH) is of key importance that may help to develop therapeutic strategies to arrest or reverse the processes of atherosclerosis. Although no direct causal relationship between IPH and embolic stroke has been established, a number of studies have highlighted IPH as a marker of plaque rupture.1–3 The noninvasive detection of MR IPH will prove very useful for future in vivo pathophysiological studies. We also thank Tang and colleagues for their interest in our work and the opportunity to clarify their misunderstanding. It was our study aim to evaluate the clinical relevance of a previously described and histologically validated MRI surrogate marker of the unstable plaque.4 From a clinical practice perspective it is desirable to identify patients at high or low …

Contrast-enhanced magnetic resonance angiography (CE-MRA) is a commonly used technique to assess the extracranial carotid arteries. We describe two patients (investigated for carotid artery atherosclerotic disease) who underwent CE-MRA. Results suggested pseudoaneurysms of the extracranial carotid arteries. Magnetic resonance direct thrombus imaging (MRDTI) showed that the appearances were due to intraplaque haemorrhage adjacent to the vessel, with the T1-shortening effect of methaemoglobin within the intraplaque haemorrhage mimicking blood flow on the CE-MRA sequence. The cases presented demonstrate this diagnostic pitfall and illustrate the contribution of simple magnetic resonance plaque imaging to establishing the correct diagnosis.

Background Carotid endarterectomy is beneficial in severe (>70%) symptomatic carotid stenosis. The risk of stroke in moderate carotid stenosis (50%-69%) is modest, and so the role of carotid endarterectomy in this group is unclear. Intraplaque hemorrhage is associated with advanced atherosclerosis and can be detected in the carotid arteries by magnetic resonance imaging. This study evaluates whether magnetic resonance imaging detected intraplaque hemorrhage (MR IPH) can identify patients with symptomatic mild to moderate carotid stenosis who are at higher risk of ipsilateral transient ischemic attack (TIA) and stroke. Methods Prospective longitudinal cohort study of symptomatic patients with mild to moderate (30%-69%) carotid stenosis followed up for 2 years after imaging for IPH using magnetic resonance imaging. Results Sixty four participants were followed up for a median of 28 months (interquartile range 26-30) after MRI of the carotid arteries. Thirty-nine (61%) ipsilateral arteries showed intraplaque hemorrhage. During follow-up, five ipsilateral strokes and a total of 14 ipsilateral ischemic events were observed. Thirteen of these ischemic events, of which five were strokes, occurred in those with ipsilateral carotid intraplaque hemorrhage (hazard ratio=9.8, 95% confidence interval 1.3-75.1, P = .03). Conclusions MR IPH is a good predictor of ipsilateral stroke and TIA in patients with symptomatic mild to moderate (30%-69%) carotid stenosis. This technique could help in the selection of patients for carotid endarterectomy.

To the Editor: Wasserman et al1 present a proof-of-concept case elegantly demonstrating that high-resolution MRI of carotid plaque can identify a lesion that was highly likely to be causing cerebrovascular symptoms even though it was not causing significant stenosis of the carotid lumen. The authors also acknowledge that acquiring high-resolution MR images is time-consuming and requires the injection of contrast. We too are interested in using MR techniques to find features of carotid artery plaque related to its biological behavior, rather than simply the degree of stenosis caused by it. We …

the imaging procedure of choice for diagnosis and followup. Gallium scanning and ACE measurement in serum and cerebrospinal fluid may be helpful but lack sensitivity and specificity. The same is true of increased protein and mild pleocytosis (usually lymphocytosis) in the cerebrospinal fluid. Definitive diagnosis of sarcoidosis requires biopsy evidence of non-caseating necrotizing granulomas.5 Hypothalamic-pituitary sarcoidosis is treated with corticosteroids together with anterior and posterior pituitary hormone replacement. Corticosteroids lower the CD4/CD8 lymphocyte ratio, decrease interleukin-2 production, and inhibit collagen synthesis, all of which are abnormal at the sites of active disease within the brain. When the dose of prednisolone is lowered to 20–25 mg daily the symptoms commonly recur. There are few data on other immunomodulatory therapies, but ciclosporin, radiotherapy, azathioprine, chlorambucil and cyclophosphamide have all been used with disappointing results.1 Surgical intervention is indicated in cases of hydrocephalus or when an expanding mass lesion causes an increase in intracranial pressure. Clearly, treatment of hypothalamic-pituitary sarcoidosis has made great advances since 1971, when the median survival was only 45 months.2 The patients reported here were two of only three diagnosed in our unit over that period. The third, a 26-year-old man, was seen in 1986 with panhypopituitarism. On replacement therapy he remains well 19 years later. Unfortunately the condition can still cause sudden unexpected death.6