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At the heart of general practice since 1960

Depressed at greater obesity risk

Dr Julian Wong and Professor Charles McCollum outline the five latest developments in their field

1. Carotid surgery or angioplasty?

It is widely accepted that carotid endarterectomy is indicated for symptomatic >70 per cent carotid stenosis where the risk of subsequent ipsilateral stroke can be reduced

six-fold.

Meta-analysis of the US and European trials has also demonstrated that the risk of stroke is reduced significantly in patients with 50-70 per cent symptomatic carotid disease, although the combination of aspirin or clopidogrel with a statin would be a reasonable option for the primary treatment of older patients with these moderate stenoses.

The European Carotid Surgery Trial (ECST) has recently demonstrated that in patients with asymptomatic 70 per cent stenosis, carotid surgery reduces the risk of stroke or death from 12 per cent to 6 per cent over five years, although the risk of stroke with conservative treatment is small at under 3 per cent, per year.

There is increasing evidence (not yet definitive) that carotid endarterectomy should be done early in patients who have suffered anterior circulation infarcts.

Currently research is focusing on endovascular treatments such as carotid angioplasty with stenting which initially carried an unacceptable risk of stroke due to embolism.

However, specialist centres now use cerebral protection devices and the choice between the very low risk of stroke but slightly higher mortality

(1-1.5 per cent) associated with carotid endarterectomy and a possibly slightly higher risk of stroke and lower mortality with angioplasty using cerebral protection is being evaluated in a large multicentre study.

Carotid endarterectomy is increasingly being done under local anaesthetic which is perhaps the safest option for those centres that do not have access to optimal cerebral monitoring techniques.

2. Screening and a

new treatment for aortic aneurysm

Interim results from a major national UK trial on EndoVascular Aneurysm Repair (EVAR) show the 30-day mortality was considerably lower after the procedure than after open surgical repair.

EVAR has a mortality across all ages of only 1.7 per cent (we have not suffered a mortality in our own unit in the last three years).

This technique is appropriate for approximately 40-50 per cent of abdominal aortic aneurysm (AAA) and requires an adequate aortic neck below the renal arteries without grossly aneurismal or tortuous iliac arteries.

Perhaps the main value of EVAR is that patients require only small vertical groin incisions, an inpatient stay of perhaps four-five days with complete recovery within two weeks.

This is clearly a major advance in the elderly where the increasing need for secondary procedures due to the development of endoleaks (18 per cent by three years) is less of a problem.

The recent MASS study confirmed the value of screening for AAA as being cost-effective for men aged over 65.

The UK Small Aneurysm Trials have confirmed that asymptomatic AAA under 5.5cm in diameter can be safely enrolled in surveillance programmes using ultrasound examination to measure the aneurysm at annual intervals up to 4.5cm but six-monthly between 4.5-5.5cm in men.

As women are smaller, with smaller aortas, AAAs above 5.0cm should be treated to avoid rupture.

Open surgical repair is durable and will almost certainly prove to be the treatment of choice for healthy younger patients aged under 70, or even 75 if fit. The mortality rate is just under 5 per cent.

3. Varicose veins

There are thought to be 1.5 million people in the UK with varicose veins. Some 600,000 approach their GPs for advice on treatment each year and yet the NHS is only able to offer treatment to 45,000-50,000.

It is now acceptable that incompetence in the long or short saphenous or other superficial venous system is the cause of varicose veins and that this incompetence must be diagnosed by either hand-held doppler in the outpatients (for the long saphenous system) or by duplex imaging in the vascular laboratory (for short saphenous or recurrent varicose veins).

Clinical examination alone is no longer acceptable. Where surgery is done skilfully, with disconnection of the proximal source of incompetence and removal of any competent vein trunk with avulsion of varices, the results are excellent and rates of recurrence for primary varicose veins should be under 10 per cent.

Newer alternatives include laser and radio frequency (VNUS) techniques to oblate the long saphenous vein.

These techniques require

extensive local anaesthesia (or even general anaesthesia) and are time-consuming.

Microfoam sclerotherapy has greater potential as the long saphenous system can be

obliterated in the majority of patients during a 20-30 minute outpatient procedure.

This specialist technique requires duplex ultrasound imaging and is technically demanding.

4. Cardiovascular risk factor management

Vascular surgeons should now be offering a comprehensive vascular service rather than merely diagnosis and surgery.

This service should include specialist clinics for the management of cardiovascular risk factors where advice is given on diet, weight loss, exercise, platelet inhibitory therapy and statins.

GPs welcome up-to-date advice on the management of diabetes, hypertension or ischaemic heart disease with the objective of reducing the risk of subsequent cardiovascular events. Atherosclerosis is a generalised disease and when a patient presents with claudication, investigations may be appropriate for carotid or coronary disease and to exclude AAA.

A good cardiovascular risk factor management service improves quality of life as well as reducing subsequent morbidity and mortality.

5. Claudication and limb ischaemia

Most patients with intermittent claudication require management of cardiovascular risk factors, aspirin and statin therapy.

The emphasis should be on the prevention of subsequent cardiovascular events.

For those patients with proximal arterial stenosis or occlusion, particularly involving the aorto-iliac segment, the diagnosis is confirmed by minimally invasive ultrasound techniques in the vascular laboratory and treatment is usually by transluminal angioplasty with or without stenting.

Femoro-distal reconstruction, even by endovascular techniques, should rarely be performed for claudication as the long-term risk of amputation is increased by early intervention.

But angioplasty, often by the subintimal technique, may achieve limb salvage in patients at risk of amputation, particularly in the elderly where surgery may carry unacceptable risks.

Where angioplasty is not an option, distal reconstruction using reversed or in situ saphenous venous achieves salvage for most patients over three-five years.

Clinical trials are evaluating the choice between angioplasty and vein reconstruction in patients where both are options in critical ischaemia.

Professor Charles McCollum is professor of surgery, academic surgery unit, South Manchester University Hospital

Julian Wong is a specialist registrar in vascular surgery, South Manchester University Hospital

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