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Dake M.D.,Stanford University | Thompson M.,St Georges Vascular Institute | Van Sambeek M.,Catharina Hospital | Vermassen F.,Ghent University | Morales J.P.,U.S. Food and Drug Administration
European Journal of Vascular and Endovascular Surgery | Year: 2013

Objective/Background Classification systems for aortic dissection provide important guides to clinical decision-making, but the relevance of traditional categorization schemes is being questioned in an era when endovascular techniques are assuming a growing role in the management of this frequently complex and catastrophic entity. In recognition of the expanding range of interventional therapies now used as alternatives to conventional treatment approaches, the Working Group on Aortic Diseases of the DEFINE Project developed a categorization system that features the specific anatomic and clinical manifestations of the disease process that are most relevant to contemporary decision-making. Methods and results The DISSECT classification system is a mnemonic-based approach to the evaluation of aortic dissection. It guides clinicians through an assessment of six critical characteristics that facilitate optimal communication of the most salient details that currently influence the selection of a therapeutic option, including those findings that are key when considering an endovascular procedure, but are not taken into account by the DeBakey or Stanford categorization schemes. The six features of aortic dissection include: duration of disease; intimal tear location; size of the dissected aorta; segmental extent of aortic involvement; clinical complications of the dissection, and thrombus within the aortic false lumen. Conclusion In current clinical practice, endovascular therapy is increasingly considered as an alternative to medical management or open surgical repair in select cases of type B aortic dissection. Currently, endovascular aortic repair is not used for patients with type A aortic dissection, but catheter-based techniques directed at peripheral branch vessel ischemia that may complicate type A dissection are considered valuable adjunctive interventions, when indicated. The use of a new system for categorization of aortic dissection, DISSECT, addresses the shortcomings of well-known established schemes devised more than 40 years ago, before the introduction of endovascular techniques. It will serve as a guide to support a critical analysis of contemporary therapeutic options and inform management decisions based on specific features of the disease process. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.


Paraskevas K.I.,St Georges Vascular Institute | Kalmykov E.L.,Royal Infirmary | Naylor A.R.,Royal Infirmary
European Journal of Vascular and Endovascular Surgery | Year: 2016

Background Randomised trials have reported higher stroke/death rates after carotid artery stenting (CAS) versus carotid endarterectomy (CEA). Despite this, the 2011 American Heart Association (AHA) guidelines expanded CAS indications, partly because of the Carotid Revascularization Endarterectomy versus Stenting Trial, but also because of improving outcomes in industry sponsored CAS Registries. The aim of this systematic review was: (i) to compare stroke/death rates after CAS/CEA in contemporary dataset registries, (ii) to examine whether published stroke/death rates after CAS fall within AHA thresholds, and, (iii) to see if there had been a decline (over time) in procedural risk after CAS/CEA. Methods PubMed/Medline, Embase, and Cochrane databases were systematically searched according to the recommendations of the PRISMA statement from January 1, 2008 until February 23, 2015 for administrative dataset registries reporting outcomes after both CEA and CAS. Results Twenty-one registries reported outcomes involving more than 1,500,000 procedures. Stroke/death after CAS was significantly higher than after CEA in 11/21 registries (52%) involving "average risk for CEA" asymptomatic patients and in 11/18 registries (61%) involving "average risk for CEA" symptomatic patients. In another five registries, CAS was associated with higher stroke/death rates than CEA for both symptomatic and asymptomatic patients, but formal statistical comparison was not reported. CAS was associated with stroke/death rates that exceeded risk thresholds recommended by the AHA in 9/21 registries (43%) involving "average risk for CEA" asymptomatic patients and in 13/18 registries (72%) involving "average risk for CEA" symptomatic patients. In 5/18 registries (28%), the procedural risk after CAS in "average risk" symptomatic patients exceeded 10%. Conclusions Data from contemporary administrative dataset registries suggest that stroke/death rates following CAS remain significantly higher than after CEA and often exceed accepted AHA thresholds. There was no evidence of a sustained decline in procedural risk after CAS. © 2015 European Society for Vascular Surgery.


Brownrigg J.R.W.,St Georges Vascular Institute | Apelqvist J.,Skåne University Hospital | Bakker K.,IWGDF | Schaper N.C.,CARIM and CAPHRI Institute | Hinchliffe R.J.,St Georges Vascular Institute
European Journal of Vascular and Endovascular Surgery | Year: 2013

Diabetic foot ulceration (DFU) is associated with high morbidity and mortality, and represents the leading cause of hospitalization in patients with diabetes. Peripheral arterial disease (PAD), present in half of patients with DFU, is an independent predictor of limb loss and can be difficult to diagnose in a diabetic population. This review focuses on the evidence for therapeutic strategies in the management of patients with DFU. We highlight the importance of timely referral of patients presenting with a new foot ulcer to a multidisciplinary team, which includes vascular surgeons and interventional radiologists. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.


Dumitriu I.E.,St George's, University of London | Baruah P.,St George's, University of London | Finlayson C.J.,St. Georges NHS Trust | Loftus I.M.,St Georges Vascular Institute | And 4 more authors.
Circulation Research | Year: 2012

Rationale: Patients with acute coronary syndrome (ACS) predisposed to recurrent coronary events have an expansion of a distinctive T-cell subset, the CD4 +CD28 null T cells. These cells are highly inflammatory and cytotoxic in spite of lacking the costimulatory receptor CD28, which is crucial for optimal T cell function. The mechanisms that govern CD4 +CD28 null T cell function are unknown. Objective: Our aim was to investigate the expression and role of alternative costimulatory receptors in CD4 +CD28 null T cells in ACS. Methods and Results: Expression of alternative costimulatory receptors (inducible costimulator, OX40, 4-1BB, cytotoxic T lymphocyte associated antigen-4, programmed death-1) was quantified in CD4 +CD28 null T cells from circulation of ACS and stable angina patients. Strikingly, in ACS, levels of OX40 and 4-1BB were significantly higher in circulating CD4 +CD28 null T cells compared to classical CD4 +CD28 null T lymphocytes. This was not observed in stable angina patients. Furthermore, CD4 +CD28 null T cells constituted an important proportion of CD4 T lymphocytes in human atherosclerotic plaques and exhibited high levels of OX40 and 4-1BB. In addition, the ligands for OX40 and 4-1BB were present in plaques and also expressed on monocytes in circulation. Importantly, blockade of OX40 and 4-1BB reduced the ability of CD4 +CD28 null T cells to produce interferon-γ and tumor necrosis factor-α and release perforin. Conclusions: Costimulatory pathways are altered in CD4 +CD28 null T cells in ACS. We show that the inflammatory and cytotoxic function of CD4 +CD28 null T cells can be inhibited by blocking OX40 and 4-1BB costimulatory receptors. Modulation of costimulatory receptors may allow specific targeting of this cell subset and may improve the survival of ACS patients. © 2012 American Heart Association, Inc.


Holt P.J.E.,St Georges Vascular Institute | Poloniecki J.D.,St Georges Vascular Institute | Poloniecki J.D.,St George's, University of London | Thompson M.M.,St Georges Vascular Institute
British Journal of Surgery | Year: 2012

Background: The aim was to compare the completeness and accuracy of the English Hospital Episode Statistics (HES) with a 'gold standard' data set for a sample of hospitals and to determine the effect of data quality on comparisons of hospital death rates. Methods: A multicentre audit of data quality was undertaken, based on a sample of all elective abdominal aortic aneurysm (AAA) repairs performed in England. All elective AAA repairs in nine collaborating hospital trusts were included over a 2-year interval. Cases were identified from HES, local databases, hospital administration systems and theatre records. The main outcome measures were the numbers of cases and deaths according to HES compared with case-note review. The recording of co-morbidities and the effect of data accuracy on mortality analyses and risk adjustment were quantified. Results: A total of 1102 elective AAA repairs were identified from HES data. Of 962 procedures with case-note review, 827 (86·0 per cent, 95 per cent confidence interval 84·0 to 88·0 per cent) were confirmed as elective AAA repair. The survival status with HES was 99·8 per cent accurate on comparison with the Office for National Statistics death registry. There was no significant difference in mortality assessment between the HES data and the 'gold standard' data set (5·3 versus 5·0 per cent; P = 0·753). Smaller hospitals were more affected by data inaccuracies than larger hospitals. Conclusion: This study confirmed that HES data can be used effectively to compare mortality between hospitals. Administrative data will be used increasingly for assessing performance and clinicians should accept responsibility to improve coding. Copyright © 2011 British Journal of Surgery Society Ltd.


Canaud L.,St Georges Vascular Institute | Ozdemir B.A.,St Georges Vascular Institute | Patterson B.O.,St Georges Vascular Institute | Holt P.J.E.,St Georges Vascular Institute | And 2 more authors.
Annals of Surgery | Year: 2014

Objective: To provide data regarding the etiology and timing of retrograde type A aortic dissection (RTAD) after thoracic endovascular aortic repair (TEVAR). Methods: Details of patients who had RTAD after TEVAR were obtained from the MOTHER Registry supplemented by data from a systematic review of the literature. Univariate analysis and binary logistic regression analysis of patient or technical factors was performed. Results: In MOTHER, RTAD developed in 16 of the 1010 patients (1.6%). Binary logistic regression demonstrated that an indication of TEVARfor aortic dissection (acute P=0.000212; chronic P=0.006) and device oversizing (OR 1.14 per 1% increase in oversizing above 9%, P < 0.0001) were significantly more frequent in patients with RTAD. Data from the systematic review was pooled with MOTHER data and demonstrated that RTAD occurred in 1.7% (168/9894). Most of RTAD occurred in the immediate postoperative (58%) period and was associated with a highmortality rate (33.6%). The odds ratio of RTAD for an acute aortic dissection was 10.0 (CI: 4.7-21.9) and 3.4 (CI: 1.3-8.8) for chronic aortic dissection. The incidence of RTADwas not significantly different for endografts with proximal bare stent (2.8%) or nonbare stent (1.9%) (P = 0.1298). Conclusions: Although RTAD after TEVAR is an uncommon complication, it has a high mortality rate. RTAD is significantly more frequent in patients treated for acute and chronic type B dissection, and when the endograft is significantly oversized. The proximal endograft configuration was not associated with any difference in the incidence of RTAD. Copyright © 2014 Lippincott Williams & Wilkins.


Bahia S.S.,St Georges Vascular Institute | Karthikesalingam A.,St Georges Vascular Institute | Thompson M.M.,St Georges Vascular Institute
Progress in Cardiovascular Diseases | Year: 2013

Abdominal aortic aneurysm (AAA) has a reported prevalence rate of 1.4% in the US. AAA rupture accounts for an estimated 15,000 deaths per year, rendering it the 10th leading cause of death in men over the age of 55. Endovascular repair (EVR) has proliferated in the last two decades as an increasingly popular alternative to traditional open surgery, and is now the default treatment in the majority of centres worldwide. This review article outlines the evidence supporting this stance. The development of EVR is reviewed, alongside trends in utilisation of this therapy over time. The evidence for the relative short-term and long-term outcomes of EVR and open AAA repair is discussed, and ongoing controversies surrounding the use of EVR are considered. © 2013 Elsevier Inc.


Malkawi A.H.,St Georges Vascular Institute | De Bruin J.L.,St Georges Vascular Institute | Loftus I.M.,St Georges Vascular Institute | Thompson M.M.,St Georges Vascular Institute
Journal of Endovascular Therapy | Year: 2014

Purpose: To present treatment of a juxtarenal aneurysm using the Nellix endovascular aneurysm sealing system (EVAS) and a chimney stent. Case Report: A 79-year-old woman was diagnosed with a 6-cm juxtarenal aneurysm. Standard endovascular aneurysm repair was not possible due to lack of an adequate infrarenal landing zone, and poor iliac access and angulated visceral aortic branches precluded a custom-made fenestrated solution. The patient was not a suitable candidate for open surgery due to significant comorbidity, so she underwent successful endovascular aneurysm repair with the Nellix EVAS system and a renal chimney stent. Follow-up imaging at 6 months showed a sealed aneurysm sac and patent renal chimney stent. Conclusion: The Nellix EVAS system obliterates the aneurysm sac using polymer-filled endobags. The ability of the endobags to conform to adjacent structures may offer advantages over conventional endografts when combined with parallel grafts designed to treat juxtarenal aneurysms. © 2014 International Society of Endovascular Specialists.


Karthikesalingam A.,St Georges Vascular Institute | Markar S.R.,University of Cambridge | Holt P.J.E.,St Georges Vascular Institute | Praseedom R.K.,University of Cambridge
British Journal of Surgery | Year: 2010

Background: Although there is plentiful evidence regarding the use of laparoscopic surgery for primary inguinal hernia, there is a paucity of literature concerning its role after recurrence. There has been no quantitative review of the evidence, despite suggestions that pooled analysis of existing data is required. Methods: Medline, Embase, trial registries, conference proceedings and reference lists were searched for controlled trials of laparoscopic versus conventional open surgery for mesh repair of recurrent hernia. The primary outcomes were recurrence and chronic pain. Secondary outcomes were operating time, visual analogue pain score, superficial wound infection, haematoma or seroma formation, time to return to normal activities and serious complications requiring operation. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes. Results: Four trials were included in the analysis. There was no effect on recurrence or chronic pain. Laparoscopic surgery was associated with significantly less postoperative pain, a quicker return to normal activities and fewer wound infections, at the cost of a longer operating time. There was no difference in haematoma formation or the need for additional operations. Conclusion: Careful patient selection and surgeons' experience are important in the selection of technique for recurrent inguinal hernia repair. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.


Hogg F.R.A.,St Georges Vascular Institute | Peach G.,St Georges Vascular Institute | Price P.,University of Cardiff | Thompson M.M.,St Georges Vascular Institute | Hinchliffe R.J.,St Georges Vascular Institute
Diabetologia | Year: 2012

Aims/hypothesis: Patient-reported outcome measures (PROMs) are increasingly used as key performance indicators in chronic illness. We sought to review the value of these tools in assessing health-related quality of life (HRQOL) in patients with diabetes-related foot disease and identify the impact of each foot problem on life quality. Methods: A systematic review of literature on HRQOL PROMs in diabetes-related foot disease was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The quality of eligible studies was evaluated within pre-existing criteria. Results: 53 studies written between 1995 and 2010 met the inclusion criteria. A variety of HRQOL PROMs were used. Disease-specific tools were better than generic at quantifying temporal changes in life quality and showed greater sensitivity to ulcer/neuropathic severity. No studies have simultaneously evaluated disease-specific tools. Generic and utility HRQOL PROMs are frequently used as secondary outcome measures in randomised trials and cost-utility analysis. HRQOL is depressed in diabetes, further impaired by the presence of foot disease. Ulcer healing is associated with improvements in HRQOL. Patients with active ulceration report poorer HRQOL than those whom have undergone successful minor lower extremity amputation (LEA) but there is a paucity of quality data on HRQOL outcomes for diabetes-related LEA. Conclusions/ interpretation: No one PROM was identified as a 'gold standard' for assessing HRQOL in diabetes-related foot disease. Specific areas for further development include the most valid HRQOL PROM with disease-specific content; HRQOL outcomes in minor and major amputations and the role of HRQOL tools in routine clinical care. © 2012 Springer-Verlag.

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