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Biomedical subjects

B D Braithwaite

Publications and source records attributed to B D Braithwaite.

At least 19 recordsLinked to original sources
PubMed2006

A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies.

INTRODUCTION: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.

Aged↗
PubMed2005

A prospective randomised controlled trial of VNUS closure versus surgery for the treatment of recurrent long saphenous varicose veins.

OBJECTIVE: This study aimed to assess the outcome of endoluminal thermal ablation (VNUS) and traditional redo groin surgery (RGS) and long saphenous vein (LSV) stripping in patients with bilateral recurrent long saphenous varicose veins. METHODS: This was a randomised patient controlled double blind study. Sample size calculations required 16 patients. Their median age was 54 and 11 were women. The median CEAP class was 3. At operation one leg, chosen at random, was treated with VNUS and avulsions using intra-operative duplex control. The other leg was treated with traditional RGS, exposure of the femoral vein, stripping of the LSV and multiple avulsions. Post-operatively patients completed 10 cm visual analogue scales for pain and bruising. Digital Image analysis was used to objectively assess bruising. Statistical analysis was done using Wilcoxon signed rank test for paired data. Results are expressed as median values (inter-quartile ranges). RESULTS: Time to perform VNUS was 25.5 (20.5-31.3) min compared with 40 (34.5-45.5) min it took for RGS (p=0.02). Pain score for VNUS was 1.7 (0.2-4), significantly lower than that for RGS 3.8 (0.6-6.3) (p=0.02). Bruise score for VNUS was 1.7 (0.4-4.4), and that for RGS was 5.2 (2.6-7) (p=0.03). All LSVs were sealed by VNUS at duplex follow up. Three legs in the RGS group and two in the VNUS group had a minor complication. CONCLUSIONS: VNUS caused less pain and bruising and was performed more quickly than RGS. VNUS should be considered the treatment of choice for recurrent long saphenous varicose veins.

Adult↗
PubMed2003

The endovascular management of ruptured abdominal aortic aneurysms.

Endovascular aneurysm repair (EVAR) is a controversial technique, which remains the subject of a number of prospective randomised trials. Although questions remain regarding its long-term durability objective evidence exists which demonstrates its reduced physiological impact compared with conventional open repair. If this technique could be used in patients with ruptured abdominal aortic aneurysm (AAA) it may reduce the high peri-operative mortality. A review of the literature identified a limited experience with EVAR of ruptured AAA. Only a small number of case series with selected patients exist. The majority of patients were haemodynamically stable. However, the selective use of aortic occlusion balloons allowed successful endovascular management in a small number of unstable cases. All investigators had access to an "off the shelf" endovascular stent-graft (EVG). Per-operative mortality ranged from 9 to 45% and may reflect increasing experience and patient selection. A number of patients who underwent successful EVAR were turned down for open repair. A number of important lessons have been learned from these studies but questions remain regarding patient suitability and staffing issues. If these difficulties can be surmounted then the technique may offer an alternative to open repair.

Aortic Aneurysm, Abdominal↗
PubMed2002

The results of subintimal angioplasty in a district general hospital.

OBJECTIVES AND DESIGN: we report a prospective study to determine if subintimal angioplasty can be performed in non-teaching centres and to establish its learning curve. MATERIALS AND METHODS: subintimal angioplasty was performed on 50 limbs in 46 patients (34 male) with a median age of 72 years (range 45-93 years). Indication was critical limb ischaemia (27 limbs) or intermittent claudication (23 limbs). Occlusions were located in the superficial femoral artery in 44 limbs, popliteal artery in 4 limbs and the peroneal artery in two limbs. At a median of 7.9 months patients had colour duplex imaging of the vessels that underwent angioplasty to assess vessel patency. RESULTS: primary technical success was achieved in 39 cases (78%). Primary technical success was greater in the second group of 25 consecutive limbs to undergo angioplasty at 92% (23 cases) compared with the first 25 consecutive limbs at 64% (16 cases). At 6 months the overall vessel patency rate on duplex imaging was 57%, improving to 64% in the group having a primarily successful procedure. The equivalent rate of symptomatic improvement was 59 and 66% respectively. Complications occurred in five procedures, most were minor, but a single fatality was directly attributable to the procedure. CONCLUSION: subintimal angioplasty can reasonably be performed outside major teaching institutions. There is a short learning curve associated with the procedure.

Aged↗
PubMed2000

Variation of method for measurement of brachial artery pressure significantly affects ankle-brachial pressure index values.

BACKGROUND: Mmeasurement of ankle brachial pressure indices (ABPI) is important in the assessment of patients with peripheral vascular disease. METHODS: Thirty-one hospitals with a vascular surgeon were selected at random. A telephone questionnaire was completed to assess the method used for the measurement of ABPI. Following the survey, 14 patients with peripheral vascular disease had their ABPI measurement done by two observers, a pre-registration house officer and a clinical nurse practitioner. Observers were blinded to their own and each other's results. Brachial systolic pressures were obtained using a DINAMAP(TM)(Critikon, Tampa, U.S.A.) automated blood pressure monitor, the Korotkoff method (12 cm cuff, parallel wrap) and an 8 MHz Doppler probe (Huntleigh) and sphygmomanometer. Ankle systolic pressures were obtained using the Doppler probe. The results were analysed using the Wilcoxon signed rank test. RESULTS: The survey demonstrated that at the majority of centres with vascular laboratories the brachial artery systolic pressures were measured using a Doppler probe. In contrast, at centres where the house officers performed the routine measurements, over 60% used the Korotkoff method to obtain this reading. One in four nurse practitioners used the Korotkoff method. When the ABPI values were calculated, the DINAMAP produced significantly higher median values than the Korotkoff (0.79 vs 0.72, p=0.003) and Doppler methods (0.79 vs 0.70, p<0.0001). The nurse had a higher median ABPI value of 0.76 compared with the doctor (0.71, p=0.01). CONCLUSION: This study shows that measurement of ABPI varies in different vascular units. The technique for ABPI measurement should be standardised.

Aged↗
PubMed1999

Peripheral thrombolysis for acute-onset claudication. Thrombolysis Study Group.

BACKGROUND: The aim of this study was to determine the outcome of patients who presented with sudden onset of incapacitating claudication of less than 2 weeks' duration and who were treated with peripheral arterial thrombolysis. METHODS: The database of the Thrombolysis Study Group was searched retrospectively for patients who received thrombolysis for acute-onset claudication. Some 108 patients (65 men, median age 69 (range 29-94) years) were treated with intra-arterial tissue plasminogen activator at 14 hospitals. The median duration of symptoms was 72 h (range from 2 h to 2 weeks). There were 52 graft and 56 native vessel arterial occlusions. RESULTS: The immediate outcome of thrombolysis for native vessel arterial occlusion was thrombus clearance in 50 patients (89 per cent) and failed lysis in six (11 per cent). Thirty-six patients (64 per cent) had a secondary radiological or surgical procedure carried out after lysis. After 30 days four patients (7 per cent) had a major amputation, eight (14 per cent) had died, 38 (68 per cent) were symptom free and seven (12 per cent) continued to have claudication. Three patients (5 per cent) suffered a major haemorrhage. The immediate outcome of thrombolysis for graft occlusion was thrombus clearance in 48 patients (92 per cent) and failed lysis in four (8 per cent); 27 patients (52 per cent) had a secondary procedure. After 30 days four patients (8 per cent) had a major amputation, seven (13 per cent) had died, 32 (62 per cent) were symptom free and nine (17 per cent) had persistent claudication. Three patients (6 per cent) suffered a major haemorrhage. CONCLUSION: Patients who presented with acute onset of incapacitating claudication had an outcome similar to that after thrombolysis for critical ischaemia. It is recommended that patients who present in this way should be observed and treated with thrombolysis only if they progress to critical ischaemia. Presented to the Association of Surgeons of Great Britain and Ireland, Edinburgh, UK, May 1998, and published in abstract form as Br J Surg 1998; 85(Suppl 1): 24

Adult↗
PubMed1999

Enterolith ileus complicating jejunal diverticulosis.

Small intestinal obstruction caused by enteroliths originating in jejunal diverticula is rare. We present our experience with three elderly female patients who were successfully treated for this condition. The diagnosis, in all three cases, was made on laparotomy. Two patients underwent enterolithotomy while the third, who had a acutely inflamed jejunal diverticulum, had a jejunal resection.

Aged↗
PubMed1998

Management of acute leg ischaemia in the elderly.

BACKGROUND: Peripheral thrombolysis is advocated by some as the best initial treatment for acute leg ischaemia; but this may not be true for elderly patients. This study reviewed the management of acute leg ischaemia in patients aged over 75 years. METHODS: Over a 5-year interval, 91 events of acute leg ischaemia in 84 patients were managed in a single district general hospital according to a local protocol. There were 60 women and 24 men of median age 81 (range 75-100) years. Fifteen patients were too elderly and infirm for active treatment and received anticoagulation alone. Some 76 events (84 per cent) occurred in patients suitable for active therapy: 33 were managed by initial surgery and 43 by peripheral thrombolysis with tissue plasminogen activator. RESULTS: Overall outcome after 30 days was limb salvage in 48 (53 per cent), amputation in five (5 per cent) and death in 38 (42 per cent). In actively treated patients the corresponding values were 43 (57 per cent), four (5 per cent) and 29 (38 per cent). Initial successful revascularization was more likely following surgery (29 of 33 versus 25 of 43 events with thrombolysis, P < 0.01), but the 30-day outcome was similar in the actively treated groups owing to subsequent morbidity and mortality. CONCLUSION: A group of patients (mostly women) with emboli could be identified, using clinical criteria, who had a high chance of successful revascularization following embolectomy. Late outcome remained poor due to associated co-morbid conditions. Thrombolysis is associated with substantial risk in the elderly, and with high complication rates.

Aged↗
PubMed1998

Early results of a randomized trial of rifampicin-bonded Dacron grafts for extra-anatomic vascular reconstruction. Joint Vascular Research Group.

BACKGROUND: The aim of this study was to determine whether the routine use of an antibiotic-bonded gelatin-coated Dacron graft could reduce the incidence of prosthetic graft infection. Extra-anatomic grafts were chosen for study as they have the highest risk of graft infection. This paper reports early results up to 1 month after surgery. METHODS: This multicentre study involved 14 vascular units in the UK. A total of 257 patients underwent extra-anatomic bypass. Patients were randomized to rifampicin bonding (1 mg/ml rifampicin soak for 15 min before graft insertion) or a control group. Routine three-dose antibiotic prophylaxis was administered to patients in both groups. RESULTS: There were 178 men and 79 women of median age 69 (range 43-92) years. Rifampicin-bonded (n=123) and control (n=134) groups were well matched for clinical details, risk factors and operative techniques. No side-effects were noted from rifampicin bonding. Only one patient (in the control group) developed a graft infection and this proved fatal. There were no significant differences between bonded and unbonded grafts in terms of perioperative mortality rate (9 and 5 per cent respectively), median hospital stay (10 days for both groups), total infective complications (15 and 21 per cent respectively) or need for postoperative antibiotics (13 and 18 per cent respectively). CONCLUSION: Early results from this study have not identified any significant advantage in the routine use of rifampicin bonding, but the rate of graft infection was very low (0.4 per cent). Gelatin coating alone may provide protection against infection. Definitive recommendations about the role of antibiotic bonding cannot be made until longer follow-up becomes available.

Aged↗
PubMed1997

Mechanism of late prosthetic vascular graft infection.

This study was a retrospective analysis of 41 patients with late prosthetic graft infections (> 30 days after operation) from six hospitals in the south-west of England. The 41 patients had a median age of 66 years and generally accepted risk factors for infection were documented in 19 patients preoperatively. Thirteen patients had postoperative wound complications and three had early reoperation at the site of subsequent infection. The median time between index operation and symptoms of infection was 10 (range 1-224) months. Abscess (46%) was the most common presentation followed by false aneurysm (20%) and graft thrombosis (20%). All patients had reoperations (median two per patient, range one to seven). Seven (17%) patients died and 10 (24%) required a major amputation. Bacteria were isolated from retrieved grafts in 23/41 patients (high virulence 14, low virulence nine) and the most frequent organism was coagulase-negative Staphylococcus epidermidis (nine patients). In the majority of cases the aetiology of the late infections in this series was consistent with bacterial implantation at the index operation, but in four cases bacteraemia or intraperitoneal spread was more likely. Dental-type antibiotic prophylaxis would not have prevented any of the infections in this study. Aggressive treatment of recognized sources of infection in patients with vascular grafts is imperative.

Aged↗
PubMed1997

Acute leg ischaemia in Gloucestershire.

BACKGROUND: Acute leg ischaemia is both life threatening and limb threatening. This audit was designed to determine the incidence and outcome of acute leg ischaemia in a single county. METHODS: Using multisource data collection for a 1-year interval in 1994 all patients with acute leg ischaemia were identified prospectively using hospital and general practice records in the county of Gloucestershire, population 540,000. RESULTS: Seventy-seven patients with 84 events of acute leg ischaemia were identified, giving an incidence of one per 7000 per year rising to one per 6000 per year when bypass graft occlusions were included. All but four patients were treated in hospital. Sixteen of 80 hospital events involved conservative treatment; after 30 days nine patients had died and two required amputation. The remaining five patients had borderline ischaemic rest pain and accepted their symptoms without intervention. Sixty-four of 80 events were managed by either primary surgery and angioplasty (n = 31) or thrombolysis (n = 33). The 30-day outcome in patients treated actively was: limb salvage in 50 (78 per cent), amputation in four (6 per cent) and death in ten (16 per cent). CONCLUSION: In Gloucestershire almost all cases of acute leg ischaemia are managed by, or discussed with vascular surgeons. A flexible integrated policy of surgery and peripheral thrombolysis has resulted in a limb salvage rate of 78 per cent in patients suitable for active treatment.

Acute Disease↗
PubMed1997

Prospective randomized trial of high-dose bolus versus low-dose tissue plasminogen activator infusion in the management of acute limb ischaemia. Thrombolysis Study Group.

INTRODUCTION: Accelerated thrombolysis with high-dose bolus tissue plasminogen activator (tPA) may enable patients with more severe acute leg ischaemia to be treated without recourse to surgery. This study was a randomized comparison of two thrombolytic regimens. METHODS: One hundred patients with acute leg ischaemia of less than 30 days' duration were randomized to receive either high-dose bolus tPA (three doses of 5 mg over 30 min, then 3.5 mg/h for up to 4 h, then 0.5-1.0 mg/h) or conventional low-dose tPA (0.5-1.0 mg/h). The groups were well matched for age, cardiovascular risk factors, duration and severity of ischaemia, site, cause and length of arterial occlusion. RESULTS: The median duration of infusion in the high-dose group was 4.0 (range 0.25-46) h compared with 20 (range 2-46) h for low-dose infusion (P < 0.0001). Successful thrombolysis was achieved in 45 of 49 high-dose and 39 of 44 low-dose infusions but significantly more adjunctive procedures were required following high-dose bolus infusion (26 versus 16 patients) (P = 0.002). Thirty days after treatment was commenced, limb salvage was achieved in 39 of 49 patients in the high-dose group compared with 37 of 44 who had a low-dose infusion of tPA. Six and two patients respectively required amputation. Four patients in the high-dose group and five in the low-dose group died. Three patients in each group suffered a major haemorrhage and one in the low-dose group had a stroke. CONCLUSION: High-dose bolus therapy significantly accelerated thrombolysis with tPA without compromising outcome. Some 50 per cent of patients were treated within 4 h enabling thrombolysis to be used as primary therapy for patients with acute critical ischaemia.

Acute Disease↗
PubMed1996

Management cost of acute limb ischaemia.

The cost of attempting limb salvage in patients who presented with acute lower limb ischaemia was recorded prospectively for 20 months. Seventy-five patients were admitted during the study; 45 were treated primarily by radiological intervention and 18 had primary surgery. The remainder were treated conservatively. Patients who had primary surgery required fewer visits to the operating theatre than those who had primary thrombolysis, but there was no difference in the total time that the theatre or radiology suite was occupied: median 2.3 (10th centile range 1.5-5.0) h and 3.0 (2.0-5.0) h respectively. Median (range) cost of disposables for performing surgery was Pounds 82 (58-169) and for thrombolysis was Pounds 407 (252-596). When the costs of using the theatre or radiology suite were included, the costs of both treatments were similar: surgery Pounds 683 (309-1438) and lysis Pounds 861 (611-1244). Median (10th centile range) inpatient stay for surgical patients was 9 (3-18) days and for those having thrombolysis 11 (2-29) days. Median (10th centile range) costs for bed occupancy were similar in both groups: surgery Pounds 2497 (643-9115) and lysis Pounds 2189 (902-6020). Mean cost for attempting limb salvage by surgery was Pounds 3429 (1094-10065) compared with Pounds 3230 (1543-8353) for thrombolysis.

Acute Disease↗
PubMed1996

Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein.

OBJECTIVES: To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery. DESIGN: Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up. MATERIALS AND METHODS: One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning. RESULTS: Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, chi 2). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins. CONCLUSIONS: Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.

Adult↗
PubMed1996

Aspirin increases tissue oedema after skeletal muscle ischaemia and reperfusion.

PURPOSE: Skeletal muscle ischaemia reperfusion syndrome affects patients following lower limb revascularisation. Aspirin has the potential to attenuate these effects. METHODS: Using an established model of hind limb tourniquet ischaemia, the effects of oral and intravenous aspirin administration were observed after 6 h of ischaemia and 18 h reperfusion. Samples were obtained and analysed for muscle viability and oedema, and lung neutrophil infiltration. RESULTS: Aspirin, when compared to placebo and controls, significantly increased muscle interstitial oedema when given orally and intravenously. It had no effect on tissue viability or lung neutrophil infiltration. CONCLUSION: Aspirin increases tissue oedema after ischaemia and reperfusion but has no effect on tissue viability. Although its mechanism of action has not been clarified, aspirin may influence the no-reflow component of ischaemia-reperfusion syndrome.

Administration, Oral↗