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Page[0]=new Array("ABDOMINAL AORTIC ANEURYSMS Part 1: Pathogenisis, Diagnosis, Screening.","Search this site for Vascular help","BACK Introduction to Abdominal Aortic Aneurysms.","The infra-renal aorta is the commonest site for arterial aneurysms with a prevalence of 5% (elderly males).","The aorta becomes aneurysmal when its diameter exceeds 3cm.","AAAs kill 1.5% of males over 55 years of age and their prevalence is increasing.Actiology.","The AAA wall is characterised by a loss of elastin and medial smooth muscle with an increase in protein and collagen associated with an inflammatory cell infiltrate.","Loss of elastin has been attributable to increased proteolytic activity systemically and locally due to infiltrating leukocytes.","there are three hypotheses about why aneurysms develop.","(1) Genetic - inherited defects in structural proteins like type 3 collagen.","These are rare.","(2) Atherosclerosis - where atherosclerotic plagues cause medial thinning and wall dilatation.","(3) An inflammatory response in the vessel wall producing enzymic degredation of connective tissue matrix.","Workers like Tilson feel that this is akin to an auto-immune reaction similar to destruction of joints in rheumatoid arthritis.Imaging","Imaging Modality","Use","Disadvantages","Ultrasound","Screening","Sizing of AAA is operator dependent and it is often difficult to define the relationship of the sac to the renal arteries.","CT Scan","Accurate assessment of size and will show inflammatory AAAs","Often does not show relationship of aneurysm sac to renal arteries","MRA/Spiral CT","Good for sizing; good to assess relationship of aneurysm sac to renal arteries; good to access suitability for endoluminal repair.","More expensive than above two modalities General Work-Up","Patients with no cardiac history and a normal ECG probably need no further work-up.","Patients with cardiac impairment, greater than 70 years old, or diabetic should have an echo cardiogram and probably a dipyridamole-thallium stress test.","Patients with marked cardiac dysfunction need coronary catheterisation.","Approximately 10% of patients will require coronary artery bypass prior to aneurysm repair.Natural History.","Patients with AAA's have half the life expectancy of age-matched controls.","Aneurysm grow at 2-8mm per year (10%) but this is not linear.","Clearly aneurysm rupture rate is related to size.","Five year rupture rates for AAAs of diameters 5 - 5.9cm.","6 - 6.9cm and over 7cm are 25%, 35% and 75%.","However, the irregular growth pattern of AAA makes the predication of rupture difficult.","Factors affecting aneurymsal expansion and rupture: aneurysm diameter, hypertension, pulse pressure, smoking, thrombus content, expansion rate and family history.Presentation","The vast majority are asymptomatic.","Development of abdominal and back pain should be cause for concern.","Sudden onset back pain in an elderly patient should always carry the suspicion of a AAA and should be investigated before labeling it as degenerative spinal disease.","Pain, malaise and weight loss can indicate an inflammatory AAA.","Pain and hypotension usually indicates rupture.","Screening for AAA","There is good evidence that screening is beneficial.","A number of studies of men over 60 years of age have reported that 8% of such patients have aneurysms of 3cm or greater.","Lucarotti et al have suggested that one ultrasound scan in males of 65 years old would exclude 90% of the at risk population and reduce deaths from ruptured AAA by two thirds.","Scott et al showed that screening reduces rupture by 85%.","The yield from a screening programme can be increased from 8 to 10% if it targets high risk groups - males over 65 years old, co-existing atherosclerotic disease, hypertension, a first degree relative with a AAA and COPD.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","ABDOMINAL AORTIC ANEURYSMS - Part 1: Pathogenisis, Diagnosis, Screening.","http://www.londonsurgeon.co.uk/Abdominal_Aortic_Aneurysms_Part_1.htm","15.7","8 May 2003");
Page[1]=new Array("ABDOMINAL AORTIC ANEURYSMS Part 2: Treatment.","Search this site for Vascular help","BACK","1) Medial Management","Two agents have been identified in animal studies as being of potential clinical benefit.","Propranolol seems to increase J the tensile strength of connective tissue and reduces expansion rate of AAAs Doxycycline, a metalloproteinase inhibitor can inhibit the proteolytic process found in the aneurysm walls.","2) Surgical Management","A) Who should undergo surgical repair?","On the symptomatic side, clearly patients who have ruptured AAAS and those with documented AAAS with associated abdominal, or back pain need surgical intervention.","For asymptomatic AAAS the British Small Aneurysm Trial found that once an AAA has reached 5.Scm in diameter that the risk benefit ratio favours surgical repair.","Other AAAS that merit repair even if they are not yet larger than 5.Scm are those growing by lcm or more per year and patients with a strong family history of AAA rupture.","b) Modalities of repair","Conventional Repair.","This is performed under GA with muscle relaxation, full monitoring and an epidural catheter for post operative pain control.","Exposure is via a midlife vertical, or transverse abdominal incision.","The neck of the aneurysm is clamped as are the iliac arteries.","The sac is opened and then replaced with a prosthetic graft.","If the iliac arteries are aneurysmal as well, the graft may need to be taken to the groins to exclude these aneurysms from the circulation.","The post-operative course involves anything from 24-48 hours in the ITU, or sometimes longer and then 7-10 days in the ward.","The mortality of an open repair is approximately 5-6%.","Mortality is related to the exposure of the aorta and to cross clamping the aorta predisposing to pneumonia, renal compromise and myocardial ischaemia.","Minimally Invasive Repair.","This is also called endoluminal repair, or scent grafting of a sortie aneurysm and was introduced in 1991.","Endoluminal AAA repairs can be done in any patient with a suitable AAA.","It is, however, particularly, attractive for patients with significant comorbidity - cardiac, respiratory and renal.","Because we do not know about the long term durability of these grafts most Vascular Surgeons would tend not to use them in younger patients.","Not all AAAS are suitable for endoluminal repair.","The two factors that determine this are the neck of the aneurysm and the iliac arteries.","The neck is that part of the aorta between the renal arteries and the SSC.","It is where the top of the graft engages the aorta and is crucial to the stability of the graft and a successful seal between the graft and the aorta.It should be at least 1Smm long and preferably not greater than 30mm wide, not bell shaped and not excessively regulated in relation to the sac (Fig 1)3 Acute regulation pre-disposes to a leak between the graft and the aorta (endoleak) (Fig 2).","Tortous and calcified iliac arteries may make graft deployment difficult and hazardous as the delivery system is fairly rigid (Fig 2).","Two types of grafts are used - aorto bi-iliac and aorto uni-iliac.","The aorto bi-iliac consists of two parts.","The main graft consisting of the body and one limb (to one iliac artery) together with the origin of the second iliac artery; a passenger limb which docks with the main graft (Fig 3).","The aorto uniiliac graft goes from the sortie neck to one iliac artery only.","The other iliac artery must be vascularised with a routine femora femoral crossover graft.","It is used if one iliac is unsuitable (too tortous/aneurysmal).","Most commercial grafts are made up of a self-expanding metal skeleton (Nitolol) covered with graft material.","The graft is mounted on a deliverv rod approximately the diameter of a pencil and kept in place by a sheath over it.The graft is deployed by pulling back the sheath and the graft expands - like opening an umbrella.","The attraction of the endoluminal graft is that it can be deployed by a small incision in each groin.","The main graft is passed on its delivery rod up one iliac artery until it is just below the renal arteries (performed under radiological screening) and then deployed.","The passenger limb is passed up the other iliac artery and docks with the main graft.","The whole graft thus goes from the neck of the aneurysm to the iliac arteries.","Stent grafting is also used for thoracic aneurysms.","Investigations","The Authors use a spiral CT scan (Figs 12) to assess suitability for endoluminal grafting and to measure the geometry of the aneurysm so that the endograft can be built to suit the patient.","Routine CT scans and angiograms can also be used.","Problems","The main problem with endoluminal grafts are endoleaks mainly at the neck, or the iliac arteries.","The incidence of this is approximately 2-15%.","Endoleaks can pre-dispose to rupture as the sac is still exposed to the blood pressure.","They can be treated with additional scents.","Long term follow-up is necessary as endoleaks can occur after a successful initial repair.","A published result show a mortality rate of 1-3%4 for endoluminal repairs.","Endoluminal sortie aneurysm repair is an exciting development that will significantly affect the way AAAS are repaired in the future.","The Ashford/St.","Peter's Vascular Unit now offers this modality of treatment.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","ABDOMINAL AORTIC ANEURYSMS - Vascular Publications and information on Varicose Veins","http://www.londonsurgeon.co.uk/ABDOMINAL_AORTIC_ANEURYSMS_part_2.htm","15.9","8 May 2003");
Page[2]=new Array("Aneurysm surgery BACK","An aneurysm is a localised diliation of an artery (similar to what you see if you blow up a bicycle tube too much).","These dilitations get bigger and eventually rupture.","This is frequently fatal (in 40 - 60% of cases).","Most aneurysms occur in the main artery of the body - the aorta.","Particularly in the part that runs through the abdomen.","Repair of aneurysms is usually recommended when they reach a size of 5.5 cms.","This can be done by replacing them with a dacron tube or endoluminally with a stent graft - a relatively new minimally invasive type of therapy.","For further information on this subject, please see our publication on:-","ABDOMINAL AORTIC ANEURYSMS: Treatment.","(Sept 2000)","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Aneurysm Surgery","http://www.londonsurgeon.co.uk/Aneurysm_surgery.htm","8.7","8 May 2003");
Page[3]=new Array("Part 2: Antiplatelet Therapy","BACK","Introduction to Antiplatelet Therapy:","Antiplatelet agents are used as background therapy in both the medical and surgical arms of carotid endarterectomy trials.","Antiplatelet Agents:","Aspirin:  The cheapest and most commonly used.","It inhibits platelet function by acetylating prostaglandin synthesis which impairs platelet aggregation.","This effect lasts for the lifetime of the platelet.","Low dose aspirin (75-325mg/day) reduces the risk of vascular events in patients with prior stroke or TIA by 13%.","There is no dose-effect relationship.","Dipyrimadole:  Its mechanism of action is unclear.","Clinical trials have failed to demonstrate significant anti-thrombotic efficacy used alone.","Nor does it add to the benefit of aspirin in secondary prevention of stroke1.","Ticlopidine:   Inhibits platelet aggregation by inhibiting ADP-induced aggregation.","Its effect starts within 48 hours, peaks in 3-5 days and lasts for the lifespan of the platelet.","Three trials including the Ticlopidine Aspirin Stroke Study (TASS)2 reported that ticlopidine results in a 21% reduction in stroke risk and a 12% reduction in risk for stroke and death when compared to aspirin2,3.","However, Ticlopidine has more side effects than aspirin including diarrhea, rash, minor bleeding and severe neutropema (1%).","It requires bimonthly neutrophil counts for three months.","Recommended dose is 250 mg b.d.","It does appear to be more effective than aspirin in preventing strokes in patients with TIA's without high grade carotid stenosis and in vertebrobasilar TIA's4 It is recommended for use in aspirin intolerant patients or in break through on aspirin therapy.","Clopidogrel:  A new agent that also inhibits ADP induced platelet aggregation.","In the Caprie Study5 it showed a 8.7% relative risk reduction over aspirin for ischaemic stroke, Ml and vascular death.","It is safer than ticlopidine in terms of side effects and will probably replace ticlopidine as the main second line antiplatelet drug after aspirin.","Dose is 75mg/day.","Platelet GPIIb/IIIa Antagonists: These are a new generation of antiplatelet agents which block the platelet glycoproton 1lb/lIla receptor.","They inhibit platelet aggregation but leave platelet adhesion intact.","They are thus more platelet specific.","Not available for general use at present.","CAROTID STENOSIS","Asymptomatic","Symptomatic","Mild Severe <70% >70%","Low Medical Surgical Risk","No Antiplatelet therapy","Antiplatelet therapy","Antiplatelet therapy","CEA (NASCET) then Antiplatelet therapy","High Medical Surgical Risk","Antiplatelet therapy for reasons other than stroke prevention","Antiplatelet therapy","Antiplatelet therapy","Antiplatelet therapy Consider CEA","Abbreviations:","CEA - Carotid Endarterectomy2.","TASS - Ticlopidine Aspirin Stroke Study8.","NASCET - North American Carotid Endarterectomy Study9.","Current Recommendations:","Low risk patients: Meta-analysis of two large trials of aspirin shows no benefit in prevention of stroke or vascular death6.","There is no indication for using antiplatelet drugs for primary stroke prevention in low risk patients.","High risk patients: In patients with signs and symptoms of cerebro-vascular disease due to atherosclerosis, risk factor modification and anti-platelet therapy should be initiated for most patients.","Aspirin is the drug of choice.","Clopidogrel should be for patients who are aspirin intolerant, have a history of gastric ulcer or who continue to have symptoms on aspirin (aspirin failure).","Asymptomatic and symptomatic carotid stenosis: see table.","Secondary Stroke: Secondary prevention with aspirin after prior stroke or TIA reduces vascular events by 13%7.","The Canadian-American Ticlopidine Study8 showed a 33.5% risk reduction of secondary stroke over placebo over a 24 month period.","Post Carotid Endarterectomy: Such patients are high risk and should continue on anti-platelet therapy following surgery.","Combination Anti-platelet therapy: No study has shown a significant benefit of combination therapy over aspirin alone6.","Anticoagulation: Eight randomised studies have shown no benefit of anticoagulation over antiplatelet therapy in preventing non cardio-embolic stroke.","References","Schafor, AS; Anti platelet Therapy .","Am J Med 1996; 101:199-209.","Hass WK, Easton 3D, Adams HP, Pryce-Phillips W, Molony BA, Anderson 5, Kamm B, and the Ticlopidine Aspirin Stroke Study Group.","A randomised trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients.","N Engl J Med.","1989;321: 50 1-507.","Van Gijn J, Alga A.","Ticlopidine, Trials and Torture.","Stroke.","1994; 26(6):1090-1098.","Murray, JC, Kelly MA, Gorelicca PB.","Ticlopidine: A New Antiplatelet Agent for Secondary Prevention of Stroke.","Clin Neurophannacol.1994; 17(l):23-31.","Caprie Steering Committee: A Randomised Blinded Trial of Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (Caprie).","Lancet.","1996; 348:1329-1339.","Cohen SH.","Antiplatelet drugs in Patients with Carotid Bifurcation disease.","Sem Vasc Surg 1995; 8(l):2-10.","Tijssen JGP.","Low Dose and High Dose Salicylic Acid with and without Dipyridamole.","Neurology.","1998; 51 (suppl.) 515-516.","Gent M, Blakely JA Easton 3D et al.","The Canadian American Ticlopidme Study in Thromboembolic Stroke.","Lancet.","1989; 1:1215-1220.","North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial Effect of Carotid Endarterectomy in Symptomatic Patients with High Grade Stenosis.","Amer.","J Med.","1991; 325:445-453.","CAROTID ATHEROSCLEROSIS","Part III: The Symptomatic Patient","BACK","These trials have defined the beneficial role of carotid endarterectomy for symptomatic carotid stenosis.","The European Carotid Surgery Trial (ECST)","randomised 2518 patients with carotid territory stroke, T.I.A or amaurosis fugax to medical or surgical treatment.","The ECST concluded that at a 3 year follow-up, the risk of ipsilateral stroke in the 70-99% carotid stenosis group was 2.8% in the surgical group and 16.8% in the medical treatment group.","The Veterans Administration Trial randomised 189","patients with symptomatic carotid disease into surgical and medical treatment.","At 9 months follow-up the neurological event rate for surgical patients was 7.7% compared to 19.4% for the medical group.","The North American Symptomatic Carotid Endarterectomy Trial (NASCET) used 50 clinical centres to enroll patients with hemispheric transient ischemic attack monocular blindness or non disabling stroke in the presence of 30-99% carotid stenosis.","Carotid endarterectomy was shown to be highly beneficial in patients with carotid stenosis of 70-99% compared to medical treatment.","The cumulative risk of ipsilateral stroke at 2 years was 9% of patients randomised to surgery and 26% for medically treated patients.","Severity of Stenosis","The risk of stroke declined with decreasing severity of","stenosis.","Absolute Risk Reduction","   Stenosis     (at 2 Years after surgery.)","   90-99%     26%","   80-89%     18%","   70-79%     12%","This confirmed the importance of the degree of carotid","stenosis in predicting outcome after the initial ischemic event.","Fourteen risk factors were evaluated by NASCET:","70 years.","Male sex.","160/90mm Hg blood pressure.","Entry event less than 30 days.","Minor stroke rather than T.I.A.","Stenosis greater than 80%.","Obvious ulceration on angiogram.","History of smoking.","Hypertension.","Myocardial infarction.","Congestive heart failure.","Intermittent claudication.","Diabetes.","Hyperlipidemia.","The two year stroke risk was significantly higher for patients in the medical group with more than 6 risk factors (17% from 0-5, 23% for 6, and 39% for more than 6 risk factors)2 .The similar stroke rate for the various risk groups following carotid endarterectomy translates into greater surgical benefit for patients at highest risk.","A low perioperative myocardial morbidity justifies proceeding with carotid surgery and later addressing stable coronary disease, which is twice more likely than stroke to be the cause of death following uncomplicated endarterectomy.","Plaque Ulceration","NASCET angiographically defined ulceration was shown to have an increased risk of ipsilateral stroke in the medically treated group1.","Hazard stroke rates at 24 months escalated from 26.3 to 73.2% as the degree of stenosis increased from 70 to 99%3.","Surgically treated patients had only a slight increase of ipsilateral stroke at the highest degree of stenosis.","Ulceration in the presence of a lesser stenosis (<70%) may therefore upgrade the risk of a lesion that would otherwise not benefit from endarterectomy.","Hemispheric vs Retinal T.I.A.","The relative risk of ipsilateral stroke in the medical subgroup of patients who experienced a single hemispheric T.I.A.","was 3 times the risk for a retinal","T.I.A.","Benefit from carotid endarterectomy was however realised in both groups.","Early Surgery Following Minor Stroke","Early endarterectomy after minor nondisabling ischemic stroke is supported by NASCET.","The study reported a recurrent ipsilateral stroke rate of 4.9% within 30 days after entry into the trial and similar morbidity for carotid endarterectomy performed before and after 30 days.","No relation was identified between an abnormal preoperative CT result and the risk of perioperative stroke in either group4.","Functional Status Following Surgery","Carotid endarterectomy prevented 17 strokes for every 100 patients submitted to surgery5.","There is no doubt that carotid endarterectomy dramatically reduced the risk of disabling functional impairments in symptomatic patients with severe stenosis.","References","North American Symptomatic Carotid Endarterectomy Trial Collaborators.","Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.","N Engl J Med.","1991;325:445-453.","Ferguson GG.","Current status of the prospective randomized trials of symptomatic carotid bifurcation disease.","Seminars in Vasc Surg.","1995;8 (1):46-54.","Eliasziw M.","Streifler JY, Fox AJ, Hachinski VC, Gerguson GG, Barnett HJ.","Significance of plaque ulceration in symptomatic patients with high-grade carotid stenosis.","Stroke 1994;22 (2):304-308.","Gasecki AP, Ferguson GG, Eliasziw M, Clagett GP, Fox AJ.","Hachinski V.","Barnett HJ.","Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke: Results from the North American Symptomatic Carotid Endarterectomy Trial.","J Vasc Surg.","1994;20:228-95.","Hughes RB.","Taylor DW, Sackett DL, et al: Prevention of functional impairment by endarterectomy for symptomatic high grade stenosis.","JAMA.","1994; 271:1256-1259.","CAROTID ATHEROSCLEROSIS","Part IV: Asymptomatic Carotid Stenosis","BACK","Introduction","While the management of symptomatic carotid stenosis is now well defined, the management of asymptomatic carotid stenosis (ACS) remains controversial.","Surgery for ACS aims to prevent neurological events.","Since the risk of such events in high grade stenosis is low, significant benefit can only be achieved if the risk of operation is very small (less than 3%).","The risk of a stroke in ACS may be increased by the severity of stenosis, the type of plaque1,2 (soft friable plaques are more likely to cause strokes or Transient Ischaemic Attacks (TIAs) than firm collagenous ones), the presence of bilateral stenosis or contralateral occlusion and progressively occlusive carotid disease3.","Natural History","Of symptomatic high grade carotid stenosis indicates that the lesions are not entirely benign.","The annual stroke rate for critical ACS is 2-5% pa.","Carotid artery stenosis is usually identified after TIA but for many people cerebral infarction caused by embolic or carotid occlusion is the initial event.","When the carotid artery occludes, a disabling stroke may occur in 20 % of patients and thereafter in 1.5 to 5 % annually4.","A serial follow-up study based on duplex scanning strongly suggested that the finding of an 80-99% stenosis of the internal carotid artery identified a group of patients at high risk of TIA, stroke or occlusion.","Such patients had a 46% incidence of one of these events within a 36-month period.","The risk of stroke alone in this group of patients was 12.5% 5.","Does Carotid Endarterectomy (CEA) change the natural history?","A non-randomised study by Moneta et al.6 suggested that in patients with high grade ACS, those treated medically were","more likely to experience neurological symptoms and carotid occlusion (45%) than the surgically treated group (9%).A number of trials have looked at this question.","The Casanova Trial (1991) from Germany and the Veterans Administration Trial (1991) suggested that CEA does offer an advantage over medical treatment in high grade ACS, but felt that large studies were necessary to evaluate this.","The largest randomised study to date is the Asymptomatic Carotid Artery Study (ACAS) in the USA which recruited 1662 patients who had 60-99% internal carotid artery stenosis and were randomised to receive medical therapy or surgery.","The results of this trial have been interpreted by different groups to back up their own viewpoints.","The trial showed that the estimated 5-year risk of ipsilateral stroke or any perioperative stroke or death was 11% for the medical group and 5.1% for the surgical group, i.e.","a reduction of 55%.","The benefit was mainly in men.","This has led many physicians in the USA to feel that CEA has a clear role in haemodynamically significant ACS.","Looking at it from another viewpoint, the overall estimated stroke reduction was only from 2% to 1% per year meaning that 100 operations would need to be done to prevent one stroke.","Many feel that this is not cost effective.","Thus the general feeling in the UK at present is that ACS should be treated medically.","The Future","This lies in identifying high-risk subgroups with ACS who may benefit from prophylactic carotid endarterectomy.","The ACAS failed to do but hopefully the current British trial (ACST) will.","There may be a suggestion7 that those patients with bilateral critical carotid stenosis or a tight stenosis ipsilaterally and a contralateral occlusion may be the subgroups that may benefit from surgery.","References","Bassiouny HS, Davis H, Massana et al.","Critical carotid stenosis: Morphological and chemical similarities between symptomatic and asymptomatic plaques.","J Vasc Surg 1989; 9:202-2 12.","Sterpetli AV, Schult RS, Feldmans RS et al.","Ultrasongraphic features of carotid plaques and the risk of subsequent neurological defects.","Surgery 1988; 104:652-668.","Hafner CD.","Totally and nearly occluded extra cranial internal carotid arteries.","In Ernst CB, Stanley IC (eds) Current therapy in vascular disease, Philadelphia PA, BC Decker, 1987: pg 46.","Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.","Endarterectomy for asymptomatic carotid stenosis.","JAMA; vol 273 (18): 1421-1428.","Roederer GO, Langlois YE, Jager KA et al.","The natural history of carotid arterial disease in asymptomatic patients with cervical bruits.","Stroke 1984; 15: 605.","Moneta GL, Taylor DC, Nicholls SC et al.","Operative versus non-operative management of asymptomatic high grade internal carotid artery stenosis.","Improved results with carotid endarterectomy.","Stroke 1987; 18: 1005-1010,","Schneider JR.","Which asymptomatic patients should have carotid endarterectomy? J Vasc Surg 1998; Vol 11(1): 12-18.","Collins R, Pots R et al.","Blood pressure, stroke and coronary artery diseases.","Part 2.","Short term reduction in blood pressure: overview of randomised trials in their epidemologique context.","Lancet 1990; 335: 827-838.","Hennerici M, Kleophas W, Gries FA.","Regression of carotid plaques during LDL cholesterol elimination.","Stroke 1992; 23: 693-696.","Kushner M, Nencini P et al, Relation of hypoglycaemia early in ischaemic brain infarcation to cerebral anatomy, metabolism and clinical outcome.","Ann Neurology 1990; 28: 129-135.","Donahue RP, Abbott RD et al.","Alcohol and haemorrhagic stroke.","JAMA 1986; 255: 2311-2314.","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Antiplatelet Therapy Information Page 2","http://www.londonsurgeon.co.uk/antiplatelet_therapy_information.htm","37.3","8 May 2003");
Page[4]=new Array("Carotid disease","The carotid arteries run on each side of the neck and supply the brain with blood."," These often become furred up and this causes a narrowing of the carotid artery."," These can cause mini - strokes (transient ischaemic attacks) or a full blown stroke."," This can be prevented by a simple operation called carotid endarterectomy.","Back","Home Carotid Endarterectomy: 1","Carotid endarterectomy, pioneered by Dr.","(Sir) Charles Rob, remains a durable operation for atherosclerotic carotid disease.","Symptomatic plaque throwing emboli or reaching critical stenosis (50-70%) are clear indications.","With asymptomatic significant stenoses operated by experienced surgeons, the benefits probably outweigh morbidity.","Carotid Endarterectomy: 2","The incision is deepened through platysma and the investing layer of deep cervical fascia at the edge of the sternocleidomastoid muscle.","The muscle is bluntly dissected off the loose underlying carotid sheath exposing the internal jugular vein.","Carotid Endarterectomy: 3","The carotid sheath is opened, the common facial vein crossing the carotid bifurcation is ligated and divided, and the internal jugular vein is gently retracted posteriorly.","The ansa hypoglossi may be mobilized out of the way or may be divided without significant consequences.","The internal and external carotid origins are visualized along with the origin of the superior thyroid artery.","The hypoglossal nerve is visualized high in the field along with the vagus nerve deep between the vessels.","Carotid Endarterectomy: 4","Vessel loops are tightened for proximal and distal control around soft portions of the vessel.","Some surgeons use angled Pott's clamps for this purpose but these are slightly more traumatic and cannot be used with a shunt.","An incision is started with an 11 blade in the common carotid and carried up along the internal carotid with angled Pott's scissors.","Carotid Endarterectomy: 6","The use of a shunt allows more time for careful dissection by maintaining normal cerebral blood flow and decreasing the risk of CVA.","Many excellent surgeons use it routinely, especially in training programs, and many use it selectively, especially if their clamp time is routinely under 10 minutes.","Measurement of stump pressure indicating degree of flow across the circle of Willis provides some guidance for whether to shunt.","Criteria vary among surgeons, 40mm of Hg generally being considered a minimal safe pressure.","The shunt is looped or bowed with a suture sling to provide working room around it.","The remaining images are shown without a shunt for clarity.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Carotid disease description and pictures","http://www.londonsurgeon.co.uk/carotid_disease.htm","13.4","8 May 2003");
Page[5]=new Array("Endoluminal surgery","Please click here to read about this topic.","BACK","Contact: Neil Browning","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Endoluminal surgery - information on Endoluminal Surgery","http://www.londonsurgeon.co.uk/Endoluminal_surgery.htm","7.5","8 May 2003");
Page[6]=new Array("Femoro - distal bypass","BACK","Critical ischaemia is a term to describe a severe deficiency of blood to a limb, usually the leg.","It may present with gangrene of the toes, ulcers or pain in the foot which can make sleeping impossible.","Treatment usually requires a bypass from the femoral artery in the groin to an artery in the distal part of the leg, at or just above the ankle.","The patients own vein is used as the bypass conduit.","This operation is performed to avoid limb amputation.","For further information on this subject please see our publication on:-","Peripheral Arterial Disease; Clinical Evaluation and Investigation.","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Information on Femoro - distal bypass","http://www.londonsurgeon.co.uk/Femoro_distal_bypass.htm","8.5","8 May 2003");
Page[7]=new Array("Surrey UK Vascular, Endocrine, General Surgery Specialist.","(Varicose Veins)","Search this site for Vascular help Varicose Veins Facts:-","Varicose veins occur when the vein becomes distended or swollen and the valves which move blood to the heart cannot close properly and start to leak.","These veins are most commonly found in people who sit or stand in one position for prolonged periods of time, people who habitually sit with their legs crossed, and those who lack proper regular exercise.","Excess weight, heavy lifting, and pregnancy also increase the likelihood of developing varicose veins as they all put increased pressure on the body.","Increasing age, menopause, genetic weaknesses in the vein walls or in their valves, excessive pressure within the veins due to a low fiber diet which causes an increase in straining during bowel movements, and damage to the veins or to their valves resulting from inflammation also increase the risk of developing varicose veins.","About 10 - 15% of men and 20 - 25% of woman have varicose veins.","Smaller varicose veins that are near the surface generally do not pose a serious problem and can be managed with simple home measures.","Varicose veins are not just a cosmetic problem.","They can also cause problems like ulcers and bleeding.","Varicose veins may or may not be accompanied by symptoms such as:-","Fatigue","Aching discomfort","Feelings of heaviness or pain in the legs","Fluid retention","Swelling and pain in the feet and ankles","Discoloration.","Neil Browning M Med (Surg) FRCS FCS (SA)","Consultant Vascular, Endocrine and General Surgeon.","Specific interest in varicose veins.","NHS appointments/consultations: 01784 884688","Private appointments/consultations: 01753 743422","FREE regular Varicose Veins News Letter Vascular Surgery Links","Varicose veins","Carotid disease","Aneurysm surgery including thoracic and thoraco-abdominal aneurysms","Femoro - distal bypass for critical ischaemia","Endoluminal surgery particularly endoluminal stenting of aortic aneurysms","The RBCs of vascular surgery - Repair, Bypass and Chemistry - September 2002","The RBCs of vascular surgery - Hyperhidrosis - January 2003 Endocrine Surgery Links","Thyroid disease Other Vascular Links","Vascular Publications","Contact Us","Varicose Veins & Medical Links","FastCounter by bCentral","UK Vascular, Endocrine, General Surgery Specialist.","http://www.londonsurgeon.co.uk/index.htm","14.4","8 May 2003");
Page[8]=new Array("PERIPHERAL ARTERIAL DISEASE (PAD) Part 1: Epidemiology, Natural History, Risk Factors and Prevention.","Search this site for Vascular help","BACK Definition of Peripheral Arterial Disease (PAD)","Intermittent claudication (IC) is diagnosed by a history of leg pain on excersise that is relieved by rest.","In men over 60 years the prevalence of IC is 3 - 6%.","The prevalence of asymptomatic peripheral arterial disease (PAD) ranges from 0.9 - 22%.","Risk factors for developing IC","Diabetes mellitus.","IC is twice as common among diabetics.","Smoking.","Smokers have IC three times more commonly than non-smokers.","PAD occurs a decade earlier in smokers.","Its severity increases with the number of cigarettes smoked.","With cessation of smoking comes a rapid decline in the incidence of IC and the risk for ex-smokers one year after giving up is the same as for non-smokers.","Hypertension.","This causes a 2.5 fold risk increase for men and 3.9 fold increase risk for women for PAD.","Hyperlipidaemia.","A fasting cholesterol > 7 mmol/l has twice the incidence of IC.","The ratio of total to HDL cholesterol is the best predictor of this.","Smoking enhances the effect of raised cholesterol.","Hyperhomocysteinamia.","Its incidence is as high as 60% in the vascular population vs.","1% in the general population and can be detected in 28 - 30% of patients with premature PAD.","Genetic risk.","Although a link has been found in coronary artery disease (CAD), this has not been found to be a risk factor in PAD.","Exercise.","Regular exercise is protective against PAD.","Co-existing Vascular Disease.","PAD, CAD and cerebrovascular disease (CVD) frequently co-exist.","CAD is present in 40 - 60% of patients with PAD.","In fact, in the well known Cleveland Clinic Study (1978) where all patients with PAD had a coronary angiography, the prevalence was as high as 90%.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","PERIPHERAL ARTERIAL DISEASE (PAD) - Part 1: Epidemiology, Natural History, Risk Factors and Prevention.","http://www.londonsurgeon.co.uk/peripheral_arterial_disease_pad_p1.htm","12.2","8 May 2003");
Page[9]=new Array("PERIPHERAL ARTERIAL DISEASE (PAD) Part 2: Clinical Evaluation and Investigation.","Search this site for Vascular help","BACK","Clinical Evaluation of Peripheral Arterial Disease.","The aim of a clinical evaluation is to be able to put patients into one of three categories.","a) Claudication - mild/moderate.","This patient gets pain usually in the calf, bought on by exercise, relieved by rest.","He can walk from 100 yards to 1/4 mile.","b) Incapacitation claudication.","The symptoms are the same but the claudication distance is much shorter to the extent that the patient cannot do his job or if retired, has difficulty performing survival functions like shopping, housekeeping etc.","c) Critical ischaemia.","The patient has rest pain which often wakes him at night and may force him to sleep in a chair.","It may be accompanied by ulceration or gangrene with ankle pressure of 40mm Hg or less.","Clinical Examination","The presence of elevation pallor and dependency rubor and/or trophic changes usually indicate significant chronic ischaemia.","It is usually found in patients with incapacitating claudication or critical ischaemia.","The finding of a normal (2), reduced (1) or absent (0) pulse is the most telling sign indicating the presence of absence of PAD.","It is also useful to listen for bruits.","A bruit over the femoral artery in the groin indicates femoral or iliac stenotic disease proximally.","It is also possible to hear a superficial femoral artery (SFA) bruit by listening over the medial thigh.","Ideally bruits should be listened for before and after exercise.","In the presence of a significant stenosis (>50%), after exercise the pulse gets weaker and the bruit louder.","A patient with an SFA occlusion will have a palpable femoral but absent popliteal pulse.","There will be no trophic changes or Buerger's sign or ischaemic ulcers.","If these are present it usually means that there is disease at another level such as the infracrural vessels.","An occlusion of the aorta or iliac vessels usually presents only with claudication.","The skin nutrition can be normal.","This is because of good collaterals round the pelvis.","By contrast, a diabetic can present with critical ischaemia of a foot yet have normal vessels all the way to the popliteal artery.","This is because the disease is infracrural and the more distal the disease, the less the capacity to develop collateral circulation and hence the more severe the disease.","Biochemical Investigations:","Duplex Scanning.","This can assess the whole lower limb arterial tree but it is time consuming.","We find it useful to evaluate whether a patient is suitable for an iliac or femoral angioplasty - particularly in elderly patients where one is looking for the smallest intervention to alleviate symptoms.","ii.","Magnetic Resonance Angiography (MRA).","This is useful for patients who won't tolerate contrast.","it is also useful to evaluate renal artery stenosis, aorto-iliac and femoral disease but is less useful for more distal disease.","At some stage it will probably replace angiography but not quite yet.","iii.","Angiography.","This is still our gold standard.","Modern angiography is digital subtraction allowing the bony skeleton to be subtracted from the picture leaving only the arteries.","A good study should include the renal arteries t the feet.","For patients with poor renal formation - CO2 angiography is an option.","It is a 'day surgery' procedure.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","PERIPHERAL ARTERIAL DISEASE (PAD) - Information on PAD","http://www.londonsurgeon.co.uk/peripheral_arterial_disease_pad_p2.htm","14.7","8 May 2003");
Page[10]=new Array("PERIPHERAL ARTERIAL DISEASE (PAD) Part 3: Management.","Search this site for Vascular help","BACK","1) Pharmocotherapy","Although controlled trials on drugs like pentoxyfylline, naftidrofuryl and cilostazol have shown some benefit in walking distance, this benefit is small.","There is little data to support the routine use of these agents in all claudicants.","2) Exercise","This is becoming increasingly important as a treatment modality.","It can increase initial walking distance by 180% and maximum walking distance by 100%.","Supervised programmes are better than unsupervised home walking.","The programme should take place for one hour, three times a week for 3 -6 months.","The most suitable patients are those with mild to moderate claudication.","It can be used for patients with incapacitating claudication if they are not suitable or surgery.","Exercise can be adapted to patient mobility but clearly a level of mobility is needed to derive benefit from the exercise programme.","3) Intervention treatment - Surgical endovascular","These are used for patients with incapacitating claudication or critical ischaemia.","With one of these is chosen is determined by the anatomical location and type of atherosclerotic lesion.","a) Aortic - iliac disease","For stenoses < 3 cm long, angioplasty should be used.","Stenting is not routinely recommended unless the stenosing plaque is extremely difficult to dilate or the angioplasty result is unsatisfactory or causes a dissection in the artery.","For long or multiple stenoses or occlusions, surgery is the better option - usually an aorto-femoral graft.","For very high risk patients, a graft is taken from the axillary artery and tunneled under the skin to the groin - an axillo-bifemoral graft.","Endovascular techniques have largely taken over from surgery for aorto-iliac disease.","b) Femoro-popliteal disease","Angioplasty gives better results for stenosis or occlusions < 3 cm long and in patients with claudication rather that critical ischaemia.","Stenting below the inguinal ligament gives poor results.","For multiple stenosis or long occlusions (> 5 cm), the standard femoro-popliteal bypass graft using a synthetic graft or vein (if the distal anastomosis is below the knee) is still the procedure of choice.","There is now also an endoluminal femoro-popliteal bypass where by the atherosclerotic plaque is cored out of the superficial femoral artery.","This artery is then lined by a synthetic graft which is passed down the inside of the artery and then inflated with a balloon to take the shape of the inside of the artery.","This is done through a single groin incision.","c) Proximal and distal disease","For a patient with an iliac artery stenosis and superficial artery occlusion, the current approach would be an angioplasty of the iliac artery lesion and a femoro-popliteal bypass - open or endoluminal.","The author's practice is to do this in theatre as a single procedure.","d) Infracrural / infrapopliteal disease.","These are usually the patients who present with critical ischaemia and frequently have disease in the femero-popliteal or even the aorto-iliac segments as well.","The commonest method of treatment is by way of a femoro-distal bypass where a vein graft is taken from the common femoral artery to the infrapopliteal artery with the best run-off to the foot - usually the anterior or posterior tibial artery.","Angioplasty does have a role at this level of disease mainly for localised disease at the origins of the anterior tibial artery or tibio-perineal trunk.","Summary","The management of PAD is changing considerably, Risk factor management is a very important aspect of management at primary care level.","All patients with PAD should be on antiplatelet agents and I think in time will also be on a statin.","Supervised exercise programmes are becoming the method of choice for those with mild to moderate claudication.","Intervention should be reserved for patients with incapacitating claudication or critical ischaemia.","Endovascular intervention is being increasingly used, especially in the aorto-iliac segment.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","PERIPHERAL ARTERIAL DISEASE (PAD) - Part 3 Management of PAD","http://www.londonsurgeon.co.uk/peripheral_arterial_disease_pad_p3.htm","15.8","8 May 2003");
Page[11]=new Array("the RBCs of vascular surgery","Repair, Bypass and Chemistry of the vascular system","The Diabetic Foot.","Search this site for Vascular help","BACK","Diabetics present with a myriad of problems.","Of these, none is more challenging or demanding of resources than the diabetic foot.","It is the commonest major end point among diabetic complications.","The diabetic foot presents as three clinical problems: ulceration (neuropathic or ischaemic), peripheral gangrene and infection.","These may often co-exist.","Diabetic neuropathy and neuropathic ulcers","This affects 30-50% of diabetics.","The exact pathogensis remains unclear but it is probably caused by micro vascular disease resulting in nerve hypoxia or the adverse effect of hyperglycaemia on nerve metabolism causing abnormalities in nitric acid matabolism and hence perineural vasoconstriction and nerve damage.","this results in sensory neuropathy (burning paresthesia and shooting pain) which predisposes to unrecognised foot trauma, ulceration and infection.","Autonomic neuropathy reduces sweating, leading to dry cracked skin and to infection.","Motor neuropathy causes wasting of the intrinsic foot muscles leading to an altered foot shape with claw toes and prominent metatarsal heads.","This, together with sensory loss, predisposes to repetative injury to high pressure areas over the metatarsal heads resulting in neuropathic ulcers.","Neuropathy causes 60% of foot ulcers.","Clinical Aspects.","The neuropathic ulcer is located over a pressure point (e.g.","matatarsal head), is painless, deep and often surrounded by skin callus.","The foot itself is warm with bounding pulses.","Treatment.","The 'foot at risk' should be recognised early.","Such patients should be instructed in daily foot examination, avoiding foot trauma from ill fitting shoes or walking barefoot and reminded to carefully dry between the toes after bathing.","Those with major foot deformities should be referred to an orthotist to have cutomised shoes made to avoid pressure ulcers.","Regular podiatry relieves callus which reduces pressure.","For established ulcers, the best treatment is a modified pressure relieving slipper or, in advanced cases, a total contact cast which transfers wieght from the metatarsal heads to the heel and leg.","This can heal up to 90% of ulcers.","For persistently relapsing ulcers, we have resorted to excision of the metatarsal heads, thus removing the pressure areas, allowing overlying ulcers to heal.","Treatment.","The 'foot at risk' should be recognised early.","Such patients should be instructed in daily foot examination, avoiding foot trauma from ill fitting shoes or walking barefoot and reminded to carefully dry between the toes after bathing.","Those with major foot deformities should be referred to an orthotist to have cutomised shoes made to avoid pressure ulcers.","Regular podiatry relieves callus which reduces pressure.","For established ulcers, the best treatment is a modified pressure relieving slipper or, in advanced cases, a total contact cast which transfers wieght from the metatarsal heads to the heel and leg.","This can heal up to 90% of ulcers.","For persistently relapsing ulcers, we have resorted to excision of the metatarsal heads, thus removing the pressure areas, allowing overlying ulcers to heal.","Ischaemic ulcers and gangrene","Peripheral vascular disease (PVD) is 20 times commoner in diabetics.","The risk factors are similar to non-diabetics but the disease tends to be more aggresive and occurs at an earlier age.","Diabetes tends to particularly affect the infrapopliteal arteries.","Clinical Aspects.","The ischaemic ulcer is often shallow and painful with surrounding erythema.","There is no surrounding callus.","The foot is cool with absent pulses.","The ABI may be high due to medial calcification of the vessel wall but often the wave form is monophasic rather than triphasic - easily heard with a hand-held Doppler.","Gangrene usually involves tips of the toes.","Treatment.","Ischaemic ulcers or gangrene present some of the most challenging problems in vascular surgery.","Gangrenous tissue must be removed.","Where gangrene is well demarcated, a local amputation may succeed.","If not, a bypass is required to salvage the limb.","A full angiogram showing vessels from groin to foot is needed.","It may be possible to do something relatively simple like an angioplasty or femoro-popliteal bypass.","Often, however, one is faced with occluded or diseased femoral, popliteal and infracrural vessels with only a single vessel patent in the foot.","Here, a bypass from the groin to a single cural vessel in the calf or at the ankle, is required.","These bypasses can give gratifying results allowing healing of a distal amputation site (digit or ray amputation).","Failure to achieve adequate revascularisation will result in a major amputation.","Infection","Diabetic feet are particularly prone to sepsis due to a combination of increased susceptibility to infection (impared neutrophil function, phagocytosis and chemotaxis), inability to feel or see foot trauma and cracked or ulcerated skin.","Infections are often multi-bacterial and synergy can increase pathogenicity of organisms.","Gas forming organisms are not infequently isolated.","Clinical Aspects.","Failure to recognise infection can have devastating effects leading to major amputation.","Infections are more often than not worse than they seem.","Systemic signs of infection (fever / leulocytosis) are frequently absent.","A good examination of the foot is essential.","This may show an ulcer or gangrene with surrounding erythema.","It is important to look between the toes for any sisuses.","The presence of pus here or from an ulcer confirms severe infection.","I find it useful to squeeze over the metatarsal heads or plantar surface of the foot.","Eliciting fluctuance or pain often indicates a deep collection of pus.","Gas forming bacteria can cause crepitus which can be easily felt.","An x-ray of the foot is essential to look for underlying osteomyelitis and gas in soft tissue.","Treatment.","I have a very low threshold for admitting patients with an infected diabetic foot to hospital.","After a foot x-ray and swap, I start broad spectrum antibiotics to cover gram +ve cocci and gram -ve bacilli.","Infected and neurotic tissue and bone needs aggressive debridement.","This may require repeated visits to theatre.","Once infection has been controlled, revascularisation may be necessary to improve blood supply to facilitate healing.","At times, infection is so severe and deep seated that a below knee ampuation is the only solution.","In recognition of the difficulties of providing good care for patients with diabetic feet, we now run a special diabetic foot clinic which can be accessed by phoning one of the numbers listed on this publication.","the RBCs by Neil Browning, FRCS Martin Thomas, FRCS Kieran Dawson, FRCS","Published By: The Julie Andrews Vascular Unit","Ashford & St.","Peter's Hospitals NHS Trust","01784 884688 / 01932 872000 ext.","2542","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","the RBCs of vascular surgery - Repair, Bypass and Chemistry of the vascular system - The Diabetic Foot","http://www.londonsurgeon.co.uk/RBCs_of_vascular_surgery_Diabetic_foot.htm","19.3","8 May 2003");
Page[12]=new Array("The RBCs of vascular surgery Repair, Bypass and Chemistry of the vascular system HYPERHIDROSIS","Search this site for Vascular help","BACK","Hyperhidrosis","Is a pathological condition characterised by excess sweating commonly affecting the axillae, palms of the hands and soles of the feet.","It may also affect the face and the perineum.","It can cause significant disruption to work and social life - wetness and staining of clothes, sodden shoes and difficulties in performing simple tasks like handling paper or holding a pen.","It causes embarrassment and social isolation.","Primary hyperhidrosis affects about 1% of the population, usually young adults, but may persist into adult life.","Pathophysiology","Sweating is controlled by circulating catecholarmines and sympathetic innervation where the main neurotransmitter is acetylcholine.","Sweating is mediated mainly by eccrine glands found in greatest density in the axillae, palms and soles.","Each gland consists of a coiled sccrctory part located within the dermis, surrounded by a capillary plexus and supplied by sympathetic post ganglionic fibres (see diagram).","Central control is via the hypothalamus.","The head and neck are supplied by T2 to T4, the upper limbs by T2 to T8 and the lower limbs by T11 to L2 sympathetic ganglia.","Eccrine sweat glands are also stimulated by cholinergic as well as a adrenergic agonists.","Treatment","Topical applications.","These include aluminium chloride and glutaralderhyde.","These reduce sweating by blocking the excretory ducts of sweat glands.","They can be useful in treating local hyperhidrosis e.g.","face.","However, they need frequent application, are messy and often cause skin irritation.","Glutaralderhyde causes brown staining of the skin.","Iontophoresis.","This involves introducing an ionised substance through the skin.","This is by application of a direct current of 15-30 mA delivered with a galvanic generator via an electrode applied to the affected area of the body.","Good results can be achieved in palms and soles but is less successful in the axillae.","It requires about 15 treatments to achieve an anhidrosis and this lasts from 2-14 months.","Systemic / topical anticholinergics.","Favourable results have been reported with topical 0.5% glycopyrrolate solution.","This is an anti-cholinergic agent similar to but 5 to 6 times more potent than atropine.","It inhibits acetycholine.","It is especially good for facial hyperhidrosis.","Anti-cholinergics have side effects like dry mouth, blurred vision and urinary retention but this applies mainly to systemic forms.","a adrenergic blockers.","Some success had been recorded with phenoxybenyamine in doses of 10-40mg twice a day.","It works by binding to c adrenergic receptors.","The main side effects are orthostatic hypotension and inhibition of ejaculation.","Botulism toxin.","This is a fairly new form of treatment and works by blocking the release of acelytchline and hence synaptic transmission.","It thus produces chemical denervation of the sweat gland.","It is useful to treat focal areas of hyperhidrosis.","It is applied by multiple injections into the hyperhidrotic areas.","Injections are spaced 1-2.5cm apart.","For an axilla or palm, about 50 units of toxin need to be injected.","This brings about a 70-80% reduction in sweating in the axilla, but only 25-30% in the palms.","A treatment lasts 3-8 months, but this can be prolonged to 1 year with higher doses.","Side effects include weakness of small muscles of the hand and face (if used here).","Multiple injections also cause significant discomfort.","It is probably best used in the axillae as it is better tolerated here and there is no real risk of muscle weakness.","Excision of axillary tissue.","This may involve excision of subcutaneous tissue alone or removal of skin and","subcutaneous tissue.","This is only applicable to the axillae and produces a marked reduction in sweating in 70 - 90% of patients.","However, it can cause hidradenitis and can reduce mobility of the shoulder due to scarring.","Axillary liposuction.","This works by disrupting the nerve supply to sweat glands or removal of sweat glands themselves.","Little is known about its true efficacy.","Thorascopic sympathectomy.","Interruption of the T2 to T4 ganglia of the thoracic sympathetic chain is a very effective way of curing hyperhidrosis of the palms, axillae and head.","Thorascopic sympathectomy has virtually done aw ay with the traditional supraclavicular open operation.","Both sides can easily be done at the same time.","A thorascope is passed between the 2nd and 3rd ribs in the axilla via a small puncture incision.","Once the lung has been collapsed, the sympathetic chain is easily visible running over the necks of the ribs.","It is cauterised.","The stellate ganglion is not seen so is not really at risk.","I use laser to perform the cauterisation of the chain rather than electrical cautery.","This transmits less heat up the chain thus further ensuring that the stellate ganglion is unharmed.","The success rate is 87 - 98%.","Potential complications include pneumothorax, phenic nerve damage and Horner's syndrome due to stellate ganglion damage.","These are all rare.","The major side effect is compensatory sweating in other areas, which can vary greatly in the severity and extent.","It responds to a blockers.","Thorascopic sympathectomy gives a quick, effective and permanent cure for upper limb and facial hyperhidrosis.","Lumbar sympathectomy.","This is performed for pedal hyperhidrosis but with caution since it can cause impotence and anorgasmia if done bilaterally.","the RBCs by Neil Browning, FRCS Martin Thomas, FRCS Kieran Dawson, FRCS","Published By: The Julie Andrews Vascular Unit","Ashford & St.","Peter's Hospitals NHS Trust","01784 884688 / 01932 872000 ext.","2542","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","the RBCs of vascular surgery Repair","http://www.londonsurgeon.co.uk/The_RBCs_of_vascular_surgery_Hyperhidrosis.htm","17","8 May 2003");
Page[13]=new Array("Information on Thyroid disease","BACK","This information to be posted soon.","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Thyroid disease - Information and help on Thyroid disease","http://www.londonsurgeon.co.uk/Thyroid_disease.htm","7.6","8 May 2003");
Page[14]=new Array("For more information on Varicose Veins Treatment please contact:- Neil Browning M Med (Surg) FRCS FCS (SA) Consultant Vascular, Endocrine and General Surgeon","BACK","Department of Surgery Ashford/St Peter's Hospitals NHS Trust London Road Ashford, Middlesex TW15 3AA","NHS appointments/consultations -","Tel: 01784 884688.","Facsimile: 01784 884334","Private appointments/consultations -","Telephone : 01753 743422.","Facsimile: 01753 743438","Please use this form for more information on Varicose Veins treatment.","Contact Name:","Telephone: Country (Outside UK):","Email:","I am interested in more information on Varicose Veins Treatment.","Please note this form is for people who wish to find out more information on Varicose Veins treatment with Neil Browning.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Contact Neil Browning for more information on Varicose Veins Treatment in the UK","http://www.londonsurgeon.co.uk/Varicose_veins_contact_details.htm","12.7","8 May 2003");
Page[15]=new Array("Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Varicose Veins Index - Links page for Varicose veins information","http://www.londonsurgeon.co.uk/Varicose_veins_index.htm","6","8 May 2003");
Page[16]=new Array("Varicose veins Information","Search this site for Vascular help BACK","If you are suffering from varicose veins and require immediate help and advice, please contact my Private Secretary on 01753 743422.","For further information on Varicose veins, read the articles on the publications pages, covering Varicose Veins:-","Symptoms and diagnosis","Treatment.","Interesting facts Varicose veins affect about 20% of the population.","They are more common in women (20 - 25%), than men (10 - 15%).","Pregnancy is often an initiating event in women.","They tend to get worse with age.","There is a genetic element.","Being overweight and having an occupation that involves standing a lot aggravates varicose veins.","Walking or running do not have an adverse effect.","Causes of varicose veins The veins are the means by which blood is returned from the legs to the heart.","Muscles in the foot, calf and thigh act as pumps to push blood from the foot to the heart and from the superficial veins ( long saphenous and short saphenous veins ) to the deep veins via perforator veins.","When muscles relax, blood is prevented from running back to the feet and from the deep to the superficial veins, by valves in the veins which close like gates, once blood tries to run in the wrong direction.","Varicose veins occur when these valves or gates no longer work properly, allowing blood to bank up in the veins.","The varicose veins you see in your legs are due to blood damming up in superficial veins and their branches.","Why these veins fail is not completely understood.","It may be due to a weakness in the valve itself or in the vein wall.","Types of varicose veins 1.","Thread or Spider Veins These occur mainly in women, and are more common in the thigh.","There may be no other varicose veins.","Primary Varicose Veins These are the most common type and occur in the long and short saphenous veins and their branches.","Secondary Varicose Veins These act as bypass veins when the deep veins have been damaged or occluded.","They should not be removed.","Vulval Varices They occur in women as a complication of pregnancy or infection.","How do varicose veins present 1.","Cosmetic problems - they look bad but don't feel bad.","Localised discomfort - in the leg, especially after standing.","Usually at the site of a visible varicose vein.","Generalised discomfort - aching and discomfort particularly at the end of the day.","Night cramps.","Acute bleeding - this can be alarming and even life threatening.","It is treated by putting the leg in the air and applying pressure.","Thrombophlebitis - an inflammatory condition in which a portion of a varicose vein becomes red and painful.","If varicose veins are due to damage to the deep veins, then they may cause itching, brown discolouration round the ankle, swelling of the leg and large ulcers.","The latter may last for years and be very resistant to treatment.","Special tests 1.","Hand Held Doppler Examination: this is a small instrument used in the clinic by a vascular surgeon to listen to the direction of blood flow in the main superficial veins in the leg and so determine if the blood is running back in the leg (reflux).","Duplex Ultrasonography: this is the most common laboratory test for varicose veins.","It enables the veins and blood flow to be visualised as well as listened to.","With this test, back-flow (reflux) in the main superficial veins and their tributaries can be mapped out.","The junctions of the superficial veins with their deep veins can be localised (especially important behind the knee) and incompetent perforators can be located ( and marked before surgery).","The duplex ultrasound can also visualise whether there is reflux or obstruction of the deep veins.","This test is performed by putting an ultrasound probe in the skin over the vein.","It is completely painless.","No injections are required.","Venography: this involves placing a needle in a vein in the foot and injecting contrast media into the vein.","This is useful to see if there is evidence of old clots (deep vein thrombosis) in the deep veins.","It can also identify incompetent perforators.","This test has largely been superseded by duplex ultrasound.","Varicography: This involves injecting contrast directly into a varicose vein.","This requires a needle puncture of the vein.","It outlines (road maps) the varicose vein and where they connect with the deep veins.","I don't use it routinely but find it useful in patients who have recurrent varicose veins - usually from inadequate initial surgery.","Treatment Non operative treatment Patients with varicose veins usually request treatment for two reasons - cosmetic or because the varicose veins are causing problems.","Compression stockings: These can relieve symptoms, hide veins and slow down deterioration of skin changes.","They need to be worn every day - summer and winter.","Many people find this irksome.","Stockings need to be replaced every six months since they wear out.","They need to be graduated - with the highest pressure at the ankle, dropping to 75% at the calf and 50% at the thigh.","Most people only need the below knee stockings which are easier to wear than full length ones.","Indications:","Varicose veins developing during pregnancy.","- Patients who have varicose veins but don't want or are unfit for surgery.","- Patients with secondary varicose veins.","Sclerotherapy: This procedure involves injecting a sclerosant solution into varicose veins.","This irritates the inside of the vein wall which is then compressed with a bandage which cause the wall to stick together and obliterate the lumen ( that part through which the blood flows) of the vein.","Sclerotherapy is easily done in the consulting room without anaesthetic.","Bandages remain on for 10 days to 2 weeks and patients are encouraged to walk for about an hour a day until next seen at the clinic.","Most vascular surgeons feel that patients with incompetence of the long and short saphenous veins and their major branches should have surgery since the recurrence rate is less.","Indications:","The sclerotherapy works well for patients with isolated varicose veins and thread veins.","It is less satisfactory for short veins above the knee than below the knee, since they are more difficult to compress.","Complications of scelotherapy include - ulceration ( sclerosant injected outside the vein ), thrombophlebitis ( inflammation and thus pain in the injected vein), skin pigmentation in the injected site ( this usually fades ), and deep vein thrombosis.","Surgery Most varicose vein surgery can be done as day surgery.","It can be done under general, regional or local anaesthetic.","I prefer the former two methods.","Following surgery I prefer to keep a compression bandage on for 24 hours.","This can be replaced by a stocking until the first clinic visit one week later, and then dispensed with.","Following surgery patients can walk, carry on with their social activities, go shopping etc.","Driving can be undertaken once there is no groin tenderness.","Surgery is associated with very little pain or tenderness.","Most patients can commence work a week after surgery or less.","If the laser frequency ablation technique is used this can be as short as 36 hours.","For patients with long saphenous vein incompetence the standard procedure involves a small groin incision.","The long saphenous vein is tied off and divided from the femoral vein ( together with surrounding branches ).","It is then stripped down to just below the knee (under the skin).","The varicose branches (which are premarked before surgery) are avulsed through a series of stab incisions about 2mm in length.","The lesser saphenous vein is similarly dealt with except that the incision is behind the knee where this vein drains into the popliteal vein.","Minimally invasive surgery: A new technique - endeveuous laser ablation is now available.","This involves passing a laser catheter up the long saphenous vein.","The laser catheter is then activated and slowly withdrawn down the vein.","This heats up the inside of the vein wall causing it to stick together thus obliterating the inside of the vein.","This procedure avoids a groin incision and largely eliminates the brusing in the thigh that occurs with the open procedure.","Stab incisions are however still necessary.","Patients can be back at work after 36 hours.","S.E.P.S (subfascial endoscopic perforator surgery).","This is also a minimally invasive technique of obliterating incompetent perforator veins through a 1.5- 2cm incision on the inside of the calf.","A thin hollow tube is passed down in the space between the muscle and its cover (fascia).","The perforator veins that traverse this space are clipped off.","This is often used in conjunction with standard surgery particularly in patients with venous ulcers where an incompetent perforator has been identified (on duplex ultrasound) at the location of the ulcer.","Thread veins.","These can occur on their own or in association with long or short saphenous vein incompetence.","In the latter case the main superficial vein incompetence should be dealt with surgically.","Then the thread veins can be injected.","This may involve several treatments.","Thread veins can also be treated with laser therapy but this may also involve many treatments and may also leave areas of skin pigmentation.","The newest technique is called VEINWAVE.","(See publication on Varicose Veins and treatment)","Complications of varicose vein surgery 1.","Damage to major arteries or veins.","This should not occur when the procedure is done by an experienced vascular surgeon.","Nerve damage.","In long saphanous vein surgery the sural nerve may be damaged causing anaesthesia in the local part of the leg.","In short saphenous vein surgery the common peroneal nerve may be damaged causing foot drop.","These are uncommon when surgery is peformed by a vascular surgeon.","Development of the thread veins can occur after venous surgery.","Deep vein thrombosis.","This is rare in healthy patients having uncomplicated varicose vein surgery.","Telephone : 01753 743422","Facsimile: 01753 743438","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Varicose veins - Interesteing Facts and help with Varicose veins","http://www.londonsurgeon.co.uk/Varicose_Veins_information.htm","29","8 May 2003");
Page[17]=new Array("Vascular Links and useful medical related sites for Varicose Veins related information Varicose Veins Links","MediLinks...Varicose Veins","General Medical Links","CNN Health News - Various articles and information from CNN about health.","CBS Health Watch - Various articles and information from CBS about health.","World Health News - From the Harvard school of public health.","AOL Health Section - Health section on AOL.","AmericasDoctor.com - AmericasDoctor, a unique pharmaceutical services company, combines and integrates leading physician researchers, strategic marketing and consumer outreach capabilities, distinguished hospitals and advanced Internet resources to assist the pharmaceutical industry in developing, positioning and promoting its products.","National Library of Medicine - PubMed was developed by the National Center for Bio technology Information (NCBI) at the National Library of Medicine (NLM), located at the National Institutes of Health (NIH).","It was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journals at Web sites of participating publishers.","Center For Hyperhidrosis - Information and surgical treatment for hyperhidrosis - also known as excessive sweating.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Vascular Links and useful medical related sites for Varicose Veins related information","http://www.londonsurgeon.co.uk/varicose_veins_links.htm","11.9","8 May 2003");
Page[18]=new Array("VARICOSE VEINS Part 1: Symptoms and diagnosis.","Search this site for Vascular help","BACK","Varicose veins are enlarged dilated tortuous veins in the legs.","The essential abnormality of varicose veins is the failure or incompetence of the valves within the veins.","Incompetent valves allow reflux of blood under pressure, either from gravity or from the calf muscle pump, and so cause the veins to distend and become varicose.","Varicose veins are commoner in women, often run in families and are made worse by obesity and pregnancy.","Varicose Veins Symptoms","Simple varicose veins Many patients seek advice because they do not like the appearance of the veins in their legs.","However, primary uncomplicated varicose veins can lead to symptoms of aching and tiredness in the leg or a feeling of heaviness of the leg.","Veins are often more distended by the end of the day when symptoms may be worse.","Standing for a long time can exacerbate symptoms in varicose vein sufferers.","Simple varicose veins are usually not a cause of swollen legs.","Dermal thread veins","These have an unfortunate cosmetic appearance and cause some patients considerable distress.","They do not give rise to other symptoms.","Thrombophlebitis","Patients with varicose veins are at risk of thrombophlebitis, which is a painful inflammation of the vein and can require time off work and even bed rest in severe cases.","Rest, analgesia and antiinflammatory treatment is required.","Hemorrhage","Varicose veins can bleed following surprisingly minor traumas.","The haemorrhage can be spectacular.","Elevation of the leg, local pressure and a bandage will stop the bleed.","Some definitive treatment such as surgery or injection sclerotherapy may be needed.","Venous insufficiency This is a general term for patients with venous reflux, usually in the deep system, sufficient to cause skin changes.","Initially the skin may be pruritic, then a venous flare may appear at the ankle, followed by pigmentation, lipodermatosclerosis with a thickened plaque of sub dermal fibrosis in the gaiter area and eventually ulceration.","Varicose Veins Diagnosis","Clinical","The key to diagnosis is to identify the main source of venous reflux into the varicose veins.","This is usually saphenofemoral reflux into the long saphenous vein in the groin.","Other sites lower down the long saphenous vein may also be the source of incompetence.","The saphenopopliteal junction behind the knee may be incompetent and fill the short saphenous vein and its tributaries in the calf.","The distribution of the varicose veins in the leg gives a good clue as to which system is involved.","Tourniquet testing will help identify the primary site of the valvular incompetence.","A hand held Doppler probe can be used in clinic to confirm reflux.","Duplex scan","This scan uses ultrasound and combines B-mode imaging with Doppler.","It should be used for all patients with recurrent veins for which an operation is planned, as the anatomy will have been affected by previous surgery.","Patients suspected of having a short saphenous problem or incompetent perforating veins should also undergo scanning.","Simple varicose veins associated with the long saphenous system probably do not need scanning.","Who should be referred to a vascular surgeon?","Patients with obvious varicose veins and symptoms.","Patients with skin changes (varicose eczema or lipodermatosclerosis).","Patients with venous ulcers Please note: At the request of the health authority, patients with thread veins cannot be given treatment on the NHS as this is considered to be a cosmetic problem.","Treatment is however available in the private sector.","A typical venous duplex ultrasound report.","Note that all deep and truncal veins of the right leg have been scanned.","In this case, the long saphenous vein is shown to be grossly incompetent.","More information on Varicose Veins Treatment.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Varicose Veins - Symptoms and diagnosis. Information on Varicose veins symptons and diagnosis.","http://www.londonsurgeon.co.uk/Varicose_veins_Symptoms_and_Diagnosis.htm","13.9","8 May 2003");
Page[19]=new Array("VARICOSE VEINS Part 2: Treatment (Feb 2002)","Search this site for Vascular help","BACK","This article discusses the treatment of uncomplicated varicose veins.","The treatment of complications such as phlebitis, haemorrhage and ulceration is not included.","Varicose veins may require treatment for symptoms or for cosmetic reasons.","Many patients have had their lives made a misery from the appearance of their veins.","Injection Sclerotherapy","Superficial varices below the knee, which are not associated with long or short saphenous vein reflux, may be injected.","This can be done with STD or Sclerovein in a strength of 1% or less.","The longterm results can be disappointing.","Extravasation of sclerosant can cause pain or even ulceration.","Staining of the skin over the injected vein can occur.","Surgical Treatment","Most symptomatic veins will require surgery for effective treatment.","The connections between the superficial varicose veins and the deep veins must be tied off.","This connection is usually the saphenofemoral junction, sometimes the saphenopopliteal junction and occasionally a perforating vein.","The recurrence rate from varicose vein surgery is reduced if the long saphenous vein is stripped.","People harbour memories of their mothers in pain and nursing large scars following this procedure.","Nowadays varicose tributaries are teased out with small hooks through tiny stab incisions.","The scars are much smaller.","Patients require a bandage for a day and a stocking for a week.","Patients can resume driving when they can safely perform an emergency stop, usually about one week.","The amount of time taken off work depends on age, fitness and occupation, normally two weeks is sufficient.","New Techniques","There are a number of interesting new techniques for the treatment of varicose veins.","Unfortunately none are as yet available on the NHS but our patients will still ask us about them.","VNUS Closure Technique","This is a new technique introduced into the UK in early 1999 and as yet only available in a small number of hospitals.","In the VNUS closure technique a radio frequency probe is inserted into the long saphenous vein at the ankle through a tiny puncture and passed up the vein to the groin.","A scanner is used during the procedure to place the probe in exactly the correct position.","The vein is then sealed along its length in the leg.","The scanner allows pinpoint accuracy and also means that the veins can be seen so that none are missed.","Once the main vein is sealed then the small varicose tributaries can be removed through stab incisions in the usual way.","No groin incision is needed and there is no bruising from the stripping as no strip is required.","Support stockings therefore need only be worn for a day or two or in some cases not at all.","Recovery is quicker.","Patients can return earlier to everyday activities, including driving a car.","Subsequent scans show that by a few months the main saphenous vein has completely disappeared.","Recurrence of the vein has not been a problem.","The potential advantages of the technique are:","+ No groin incision","+ Faster recovery","+ No bruising","+ No requirement for stockings","VNUS Probe laser Probe.","Endovenous Laser","Pictures courtesy of Mantis Surgical","Endoveuous Laser Ablation","This technique has recently become available in the UK.","The principle is similar to VNUS ablation.","A laser catheter is passed up the long saphenous vein (LSV) under ultrasound guidance to the sapheno femoral junction.","The laser is activated and withdrawn down the LSV obliterating it by thermal ablation.","The procedure takes about 45 minutes.","It can be done as an office procedure under local anaesthetic, leaves no bruising and requires no groin incision.","Because very little heat is transmitted outside the vein it has the potential to treat short saphenous vein (SSV) incompetence.","This eliminates the need for an incision in the popliteal fossa and reduces the risk of common peroneal nerve injury and foot drop.","Like VNUS, this is not available on the NHS.","TriVex Technique","At operation once the long saphenous vein has been dealt with, either by conventional stripping or by the laser/VNUS closure method, some patients still have moderate or even huge varicose veins.","These varicose tributaries cannot easily be removed by small stab incisions.","It is sometimes necessary in these cases to make numerous larger incisions.","For these patients veins can be removed using a new method called transilluminated powered phlebectomy with an instrument called the TRIVEX.","This entails endoscopic resection and ablation of the superficial veins using a powered vein rejector and an illuminator.","In this technique a bright light is introduced into the leg so that the veins can be easily visualised.","A second instrument is then introduced for removing the veins.","It has a powered oscillating end which dislodges the veins and cuts them.","The pieces of vein are then gently retrieved by suction down a tube.","The advantage of this procedure is that large areas of the leg can be treated and all the veins removed through only two small incisions.","The illumination allows precise removal of the veins under direct vision.","For moderate or large veins this is a useful method.","SEPS (Subfacial Endoscopic Perforation Surgery.)","This procedure has replaced older ooperations where a long incision was made down the back of the calf to tie off incompetent perforator veins.","With SEPS, a 2cm incision is made on the medial side of the calf.","The fascia covering the muscle is opened and a scope passed into the subfascial space.","The perforator veins can be seen traversing this space from the muscle to the superficial veins.","They are ligated with clips.","Dermal Thread Veins","Patients find the leashes of dermal thread veins very unsightly and distressing.","The treatment can be disappointing.","They can be treated by microsclerotherapy in which sclerosant is injected through tiny needles.","The main complications are skin staining and ulceration.","It is best avoided on the face.","This is still the treatment of choice in most cases.","Laser treatment offers similar results but is more time consuming, more uncomfortable, more expensive and can cause abnormal pigmentation of the skin.","It is useful for smaller areas of residual veins.","A new procedure is Vein Wave.","Here, a tiny needle is placed over the thread vein.","A microcurrent is discharged through the needle, obliterating the thread vein.","The advantages of Vein Wave is that it requires no anaesthetic, causes no ulceration or abnormal pigmentation, needs no bandaging and can be used on skin anywhere on the body, including the face.","Truex Procedure","More information on Varicose Veins Symptoms and Diagnosis.","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","VARICOSE VEINS Treatment - Information on treating Varicose Veins","http://www.londonsurgeon.co.uk/Varicose_veins_treatment.htm","17.5","8 May 2003");
Page[20]=new Array("FREE Vascular Newsletter","Sign up today for your free newsletter giving help and information on Varicose veins treatment and cures.","The news letter is put together by:","Neil Browning","M Med (Surg) FRCS FCS (SA) Consultant Vascular, Endocrine and General Surgeon","To get your FREE periodic Vascular News letter please complete the following form.","Contact Name","Email Address","Close","Free Vascular News letter - Get free information on Varicose Veins","http://www.londonsurgeon.co.uk/Vascular_newsletter.htm","3.7","8 May 2003");
Page[21]=new Array("Vascular Publications The RBCs of vascular surgery Repair, Bypass and Chemistry of the Vascular System...","A Quarterly Publication for GPs and Health and Medical Professionals.","Search this site for Vascular help","BACK","CAROTID ATHEROSCLEROSIS Part 1: Methods of Measurement (Nov/Dec 1998)","Part 2: Antiplatelet Therapy (Mar/Apr 1999)","Part 3: The Symptomatic Patient (Sept/Oct 1999)","Part 4: Asymptomatic Carotid Stenosis (Mar/Apr 2000) ABDOMINAL AORTIC ANEURYSMS Part 1: Pathogenisis, Diagnosis, Screening.(Sept 2000)","Part 2: Treatment.","(Sept 2000) PERIPHERAL ARTERIAL DISEASE (PAD).","Part 1: Epidemiology, Natural History, Risk Factors and Prevention.","(Dec 2000)","Part 2: Clinical Evaluation and Investigation.","(Mar 2001)","Part 3: Management.","(June 2001) Varicose Veins.","Part 1:Symptoms and diagnosis (Oct 2001)","Part 2:Treatment (Feb 2002) Preview the RBCs of vascular surgery online now...","see below Repair, Bypass and Chemistry of the Vascular System...","A Quarterly Publication.","CAROTID ATHEROSCLEROSIS","Part 1: Methods of Measurement Though the prevalence of significant cervical carotid atherosclerotic disease in the elderly population is less that 10%, severe narrowing at the carotid bifurcation is clearly associated with neurological events.","The benefits of medical and surgical treatment of various degrees of carotid stenosis have been debated for years.","Only recently have large prospective randomised studies demonstrated the benefit of treatment for patients with significant carotid disease.","The concomitant development of diagnostic imaging technology now offers the clinician several means of objectively assessing the severity of carotid disease in the process of developing appropriate patient management plans.","Duplex ultrasonography and magnetic resonance angiography (MRA) have emerged alongside contrast angiography as practical methods of measuring carotid stenosis.","Each method has its own particular advantages and limitations which are compared in the table below:","Ultrasonography MRA Contrast Angiography","Equipment portability","mobile","fixed site","fixed site","Examination cost","low (approx.","£50)","moderate (approx.","£150)","high (approx.","£700)","Operator technique dependence","high","moderate","low","Inter-observer variation in interpretation","low","moderate","moderate","Invasiveness","none","none","high","Accuracy in mild (30%) stenosis","high","moderate","high","Accuracy in moderate stenosis","moderately high","moderate","high","Accuracy in severe (>70%) stenosis","high","high","high","False-positive occlusion diagnosis rate","5% (grey scale method)","<5%","0 to 5%","Ulceration visibility","high for >2mm ulcers","poor","moderate","Extent of anatomic coverage","carotid bifurcation","carotid bifurcation to circle of Willis (aortic arch can be done)","aortic arch to cerebral vessels","Currently, Duplex Ultrasonography is the most commonly used technique, enjoying high diagnostic accuracy in the hands of skilled operators.","It is an excellent tool for screening symptomatic patients, and asymptomatic patients with multiple risk factors for atherosclerosis.","Continuous and pulsed Doppler techniques may be combined with transcranial Doppler blood flow information to yield highly accurate estimates of luminal diameter reduction.","If cerebral infarction or other intracranial pathology indicates the need for magnetic resonance imaging of the brain, MRA examination of the carotids may easily be added.","When noninvasive study results are inconclusive or contradictory, contrast angiography is generally required to settle the diagnosis.","However, angiography is not required when ultrasound and MRA studies agree on complete occlusion.","Contrast Angiography is indicated when: [1] duplex examination cannot precisely define the degree of stenosis relative to the distal carotid lummal diameter, and carotid surgery is anticipated, [2] symptomatic patients with mild to moderate carotid bifurcation stenosis have failed to improve with medical therapy, and are being considered for surgery, [3] intracranial lesions are suspected, [4] high grade stenosis cannot otherwise be differentiated from complete occlusion, and [5] vertebrobasilar symptoms are present in addition to occlusive carotid disease.","References","Mittl RL Jr, Broderick M.","Carpenter JP, et al: Blinded-reader comparison of magnetic resonance angiography and duplex ultrasonography for carotid artery bifurcation stenosis.","Stroke 25:4-10, 1994.","Pan XM, Saloner D, Reilly LM, Bowersox JC, Murray SP, Anderson CM, Gooding GA, Rapp JH: Assessment of carotid artery stenosis by ultrasonography, conventional angtiography, and magnetic resonance angiography: correlation with ex vivo measurement of plaque stenosis.","Jour Vasc Surg.","21(1) 82-8, discussion 88-9, 1995 Jan.","Wassennan BA, Haacke em, Li D: Carotid Plaque formation and its evaluation with angiography, ultrasound, and MR angiography.","[Review].","Jour Magnetic Res Imag.","4(4):5 15-27, 1994 Jul-Aug.","Toole JF, Castaldo Je: Accurate measurement of carotid stenosis, Chaos in methodology: Jour of Neuroimaging.","4(4):222-30, 1994 Oct.","Mattos MA, Hodgson KJ, Faught WE, Mansour A, Barkmeier LD, Ramsey DE, Sumner DS: Carotid endarterectomy without angiography: is co1or-flow duplex scanning sufficient: Surgery.","1 16(4):776-82, discussion 782-3, 1994 Oct.","Neale ML, Chambers JL, Kelly AT, Connard 5, Lawton MA, Roche J, Appleberg M: Reappraisal of duplex criteria to assess significant carotid stenosis with special reference to reports from the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgeiy Trial.","Jour Vase Surg.","20(4):642-9, 1994 Oct.","Faught WE, Mattos MA, Van Bemmelen PS, Hodgson KJ, Barkmeier LD, Ramsey DE, Sumner DS: Color-flow duplex scanning of carotid arteries: new velocity criteria based on receiver operator characteristic analysis for threshold stenoses used in the symptomatic and asymptomatic carotid trials: Jour Vase Surg.","1 9(5):8 1 8-27;discussion 827-8, 1994 May.","Antiplatelet Therapy & Carotid Atherosclerosis","Index","Publications","Carotid disease","Varicose veins","Aneurysm surgery","Femoro - distal bypass","Endoluminal surgery","Thyroid disease","Vascular Surgery","Thyroid disease","Links","Contact us","FREE News letter","Publications","http://www.londonsurgeon.co.uk/vascular_publications.htm","30.1","8 May 2003");
Page[22]=new Array("Search this site for Vascular help","Vascular Search page - Use this to find information on Varicose veins","http://www.londonsurgeon.co.uk/vascular_search.htm","0.9","8 May 2003");
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Result1+="<p style=\"margin-left: 4; margin-right: 4; margin-bottom: 0\" align=\"center\"><font face=\"Arial\"><B><FONT COLOR=\"#000000\" size=\"2\" face=\"Arial\">Neil Browning&nbsp;</FONT></B></font></p>\n";
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