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P A Gaines

Publications and source records attributed to P A Gaines.

At least 19 recordsLinked to original sources
PubMed2006

The evidence for carotid stenting versus carotid endarterectomy in symptomatic patients.

Large randomized trials have demonstrated the value of surgical intervention for symptomatic carotid artery disease in stroke prevention. More recently trials have also demonstrated benefit in asymptomatic patients. However, the benefit of surgery comes with significant burden in terms of a risk of both stroke at the time of procedure and other complications. Less invasive endovascular techniques might reduce this complication rate whilst proving as effective as surgery. At the time of writing conclusive evidence is still being sought but a Cochrane meta-analysis has indicated that with the current knowledge based on randomised trials the neuro-embolic complication rate at 30 days is equivalent between the two therapies. Endovascular techniques have fewer non-neuroembolic complications.

Blood Vessel Prosthesis↗
PubMed2005

Safety of arch aortography for assessment of carotid arteries.

PURPOSE: To retrospectively review the safety of arch aortography and compare complication rates with published figures for selective catheter angiography. METHODS: The medical records of patients undergoing arch aortography over the last 3 years (n=311; 180 male, 131 female; mean+/-SD age 71.0+/-9.2 years, range 42-90 years) were retrospectively reviewed. Any peri-procedural (0-48 h) complications were recorded. A certified neurologist (MSR/GSV) classified all questionable neurological events. RESULTS: There were no focal neurological events or deaths (n=0; 0%; CI: 0-0.96%). Non-focal neurological events included mild disorientation (n=2; 0.6%; CI: 0.176-2.31) and unequal pupils (n=1; 0.3%; CI: 0.056-1.79%). Cardiovascular events included symptomatic hypotension (n=4; 1.3%; CI: 0.50-3.25%), angina (n=1; 0.3%; CI: 0.056-1.79%) and arrhythmia (n=4; 1.3%; CI: 0.50-3.25). There were 27 minor access site complications (8.7%; CI: 6.0-12.3). None of these complications extended hospital stay. None of the arch angiograms had to be followed by selective carotid angiography. CONCLUSION: Arch aortography appears to have a lower neurological complication rate than selective carotid angiography.

Adult↗
PubMed2005

A multicentre evaluation of the Medtronic AVE Flexible Iliac Bridge Stent in the iliac arteries (the first study).

PURPOSE: To investigate the short term and 6 month outcomes of a recently introduced iliac stent (the Medtronic AVE Flexible Iliac Bridge Stent). METHOD: One hundred and sixteen patients, 122 limbs from 6 European sites with atherosclerotic occlusive disease were included if they either had a full occlusion or there was a residual gradient >10 mmHg following PTA. Clinical, haemodynamic and Duplex outcomes were recorded to 6 months. RESULTS: After stent placement there was no residual stenosis >30 and 8.1% of segments had a residual resting gradient of >10 mmHg. There were three local complications and three deaths at 30 days. Primary patency at 30 days and 6 months was 94.1 and 82.7%. Marked clinical improvement occurred in 87.6 and 86.2% at 30 days and 6 months. CONCLUSION: The Medtronic AVE iliac stent has good 30 day and 6 months outcomes supporting the effective use of this device in occlusive disease.

Adult↗
PubMed2005

The benefits of combined anti-platelet treatment in carotid artery stenting.

OBJECTIVE: To assess the benefits of a combined anti-platelet regime of aspirin and clopidogrel in carotid artery stenting. METHODS: A randomised controlled trial was performed comparing aspirin and 24-h heparin with aspirin and clopidogrel for patients undergoing carotid artery stenting. Outcome measures included 30-day bleeding and neurological complications and 30-day stenosis rates. RESULTS: Bleeding complications (groin haematoma or excessive bleeding at the groin site) occurred in 17% of the heparin and 9% of the clopidogrel group (p=0.35; n.s). The neurological complication rate in the 24-h heparin group was 25% compared to 0% in the clopidogrel group (p=0.02). The 30-day 50-100% stenosis rates were 26% in the heparin group and 5% in the clopidogrel group (p=0.10; n.s). CONCLUSIONS: The dual anti-platelet regime has a significant impact on reducing adverse neurological outcomes without an additional increase in bleeding complications. This study was terminated prematurely due to an unacceptable level of complications in the heparin arm of the trial.

Aged↗
PubMed2005

Endoluminal repair of anastomotic false popliteal aneurysm using the Wallgraft endoprosthesis.

The aim of this study was to present the endoluminal repair of a false anastomotic popliteal aneurysm on a previous polytetrafluoroethylene (PTFE) above knee bypass using a Wallgraft endoprosthesis. A 53-year-old man who underwent a left femoro-popliteal above knee PTFE bypass 13 years before was admitted with a painful pulsatile mass in the above knee area. Nine months previously he developed sudden pain around the knee extending to the foot associated with coldness and numbness after he was handling some fishing gear in a crouching position for about 1 hour, but this episode spontaneously resolved. Duplex scanning and angiography revealed a 3 x 2.5 cm false aneurysm, which was successfully treated by deploying a Wallgraft endoprosthesis as the patient declined surgical repair. The graft was detected as being occluded on the 3-month follow-up but no further action was taken because the patient experienced only non-limiting claudication and he refused again surgical treatment. Endoluminal repair of perianastomotic false aneurysms in the popliteal artery with Wallgraft endoprosthesis seems feasible and safe, but until its durability is validated in larger series surgical repair remains the treatment of choice.

Aneurysm, False↗
PubMed2004

Is the endovascular treatment of carotid stenosis in high-risk patients really safer than carotid endarterectomy?

BACKGROUND: We assess the outcomes of patients who would have been considered at high-risk from carotid endarterectomy (CEA), who have undergone endovascular treatment. METHODS: High-risk patients were classed as those with occlusion of the contralateral internal carotid artery, recurrent stenosis following CEA, stenosis secondary to neck irradiation or treatment prior to coronary bypass surgery. RESULTS: 103 procedures fulfilled at least one inclusion criterion. 58.3% had symptomatic disease. The all stroke/death rate was 9.7%. The major disabling stroke/stroke-related death rate was 3.9%. 63 had a contralateral occlusion, 15 post-CEA, 17 post-radiation and 33 pre-coronary surgery. The major disabling stroke/stroke-related death rates for each subset were 4.8, 6.7, 0 and 0%, respectively. CONCLUSIONS: These results suggest that this category of patients is at high-risk of stroke regardless of method of carotid intervention.

Adult↗
PubMed2003

Effect of treatment of carotid artery stenosis on blood pressure: a comparison of hemodynamic disturbances after carotid endarterectomy and endovascular treatment.

BACKGROUND AND PURPOSE: Carotid intervention by carotid endarterectomy (CEA) or endovascular treatment may cause hemodynamic change. The immediate and long-term effects on blood pressure after these procedures were assessed. METHODS: Patients were randomized to CEA (n=49) or endovascular treatment (n=55) that comprised percutaneous transluminal angioplasty alone (n=31), balloon-expandable stent (n=13), or self-expandable stent (n=11). A baseline 24-hour ambulatory blood pressure recording was made before carotid intervention and repeated at 24 hours, 1 month, and 6 months after the procedure. RESULTS: In the first 24 hours after the procedure, episodes of hypotension occurred in 75% of the CEA group and 76% of the endovascular group; hypertension occurred in 11% and 13%, respectively. There was a significant fall in blood pressure at 1 hour after the procedure in both groups (24 and 16 mm Hg fall in CEA and endovascular groups, respectively), but this was only sustained in the endovascular group. The pattern of blood pressure response in the first 24 hours was significantly different (P<0.0001, ANCOVA). Systolic blood pressure was significantly lower at 1 and 6 months only in the surgical group (6 and 5 mm Hg fall, respectively). CONCLUSIONS: Both CEA and endovascular treatment have an effect on blood pressure stability, particularly within the first 24 hours after the procedure.

Aged↗
PubMed2003

Complications following carotid angioplasty and carotid stenting in patients with symptomatic carotid artery disease.

BACKGROUND: We review a single centre's experience of the endovascular treatment of carotid artery disease, present the 30-day and 1-year complication rates and assess whether changes in technique are associated with a change in clinical outcome. METHODS: Patients who underwent carotid angioplasty with or without stenting for symptomatic > or = 70% carotid artery stenosis secondary to atherosclerosis were included. 333 procedures were performed, i.e. angioplasty alone (86), stent without cerebral protection (150) and stent with cerebral protection (97). RESULTS: At 30 days, the total major disabling stroke and all death rate was 3.0%. For angioplasty alone, this was 2.3%, for stent without cerebral protection 4.0% and for stent with cerebral protection 2.1%. If non-stroke-related deaths were excluded, it was 2.3, 3.3 and 0%, respectively. After 30 days, the 1-year ipsilateral stroke rate was 0.8%. CONCLUSIONS: Carotid artery stenting, in particular with a cerebral protection device, is a safe alternative to carotid endarterectomy for the treatment of symptomatic high-grade carotid artery disease.

Aged↗
PubMed2002

Results of a European multicentre iliac stent trial with a flexible balloon expandable stent.

PURPOSE: to determine the 12 months success rate with a balloon expandable, flexible stainless steel stent in iliac artery obstructions. MATERIALS AND METHODS: one-hundred and twenty-six consecutive patients with iliac obstructive disease and who demonstrated an unsatisfactory angioplasty result with a post-dilatation gradient of at least 10 mmHg, or a primary occluded lesion were included in the study. Follow-up was by Doppler sonography, ankle pressures with and without exercise and clinical parameters. RESULTS: after stent placement, the mean percentage diameter stenosis decreased from 79 to 4%, with a mean intra-arterial pressure gradient of 3 mmHg. Primary stent patency was 94% at 6 months and 89% at 12 months. Primary clinical result at 6 months was 88% and at 12 months 81%. Primary assisted clinical result (after re-pta) at 6 and 12 months was 89 and 86%, respectively. The Ankle Brachial Index (ABI) after exercise at 1 month follow-up was reduced from 0.88 to 0.75, with minor deterioration at 6 months to 0.72, and at 12 months to 0.68. The 1, 6, and 12 months follow-up Piek Systolic Velocity (PSV) ratios across the stented lesions remained stable at a mean of 1.4, 1.6, and 1.6, respectively. However, respectively 44, 39 and 34% of the patients still experienced symptoms of claudication. CONCLUSIONS: the results presented here support the suggestion stenting to be an effective device in the treatment of iliac artery obstructive disease. This study also, confirms other study results concerning haemodynamic patency after iliac stenting on the indication of a 10 mmHg pressure gradient after pta and the discrepancy between good haemodynamic patency and clinical result.

Adult↗
PubMed2002

Mesenteric arterial ischaemia: diagnosis and therapeutic options.

Ischaemia of the bowel may arise from a number of causes affecting the arterial and venous compartments of the vascular tree. This article addresses the causes and consequences of arterial obstruction, which may compromise the supply of oxygenated blood to the bowel. These events may occur as an acute phenomenon, or they may present in a chronic fashion. The therapeutic options available to treat this condition are largely dependent on the mode of presentation and the amount of time that is available before irreversible damage occurs to the bowel integrity. In the acute phase, the viability of the bowel is in doubt, and this necessitates an open operative approach to assess the amount of bowel infarction which has already occurred. A variety of operative procedures are then available to limit this bowel loss and to secure the viability of the remaining bowel. In the more chronic phase there are alternative, less invasive procedures that may be appropriate for the patient, who may have suffered a prolonged period of undernourishment and dehydration. In such cases the immediate bowel viability is not in doubt, but the medium/long-term survival is compromised. Treatment options appropriate to each clinical scenario are discussed, along with the major technical issues associated with these treatments. A team approach to the most appropriate management plan is stressed, and the published outcomes reviewed.

Angiography↗
PubMed2001

Short-term (30-day) outcome of endovascular treatment of abdominal aortic aneurism: results from the prospective Registry of Endovascular Treatment of Abdominal Aortic Aneurism (RETA).

OBJECTIVES: to assess the early morbidity and mortality of a new treatment, the endovascular repair of abdominal aortic aneurysms, during its introduction into clinical practice. DESIGN: a prospective voluntary registry collecting demographic and risk factor data, details of aneurysm morphology, procedure performed, immediate and 30-day outcomes. SETTING: thirty-one U.K. centres performing endovascular repair submitted data. RESULTS: six hundred and eleven cases were registered in three years of data collection (January 1996 to December 1998). Four per cent of patients received an aortic tube device, 60% an aorto-bi-iliac device and 36% an aorto-uni-iliac device and a crossover graft (AUIC). Conversion to open repair was required in 5% of cases, with more conversions in the AUIC group (OR 2.9 (95% CI: 1.3-6.4)p=0.01). Post procedure complications occurred in 25% of cases. Unfit patients had significantly more complications than fit patients (35% vs 20% for fit patients (OR 1.8 (95% CI: 1.2-2.7)p=0.007)). At 30 days aneurysms were excluded in 90% of cases. Endoleaks were more common in larger aneurysms (2% if aneurysms were <6 cm in diameter vs 10% if >6 cm, OR 5.6 (95% CI: 2.1-14.9)p=0.0006). The overall mortality was 7% but was significantly higher for AUIC devices, (4% for combined aortic tube and bi-iliac devices (AT/BI) vs 12%, OR 2.6 (95% CI: 1.2-5.9 p=0.018)), and unfit patients (4% for fit patients vs 18%, OR 4.3 (95% CI: 2.0-9.5)p<0.001). CONCLUSIONS: endovascular repair is feasible with short-term outcomes comparable to those of conventional surgical repair. In unfit patients the possible benefit in life expectancy gain must be balanced against the morbidity and mortality of the procedure.

Adult↗
PubMed2001

Thoracic aortic stent grafts--early experience from two centres using commercially available devices.

OBJECTIVES: open surgical intervention for aneurysms of the distal arch and descending thoracic aorta is associated with high morbidity and mortality. Stent grafts offer an attractive alternative treatment for these aneurysms. The aim of this study was to assess the morbidity and mortality of endovascular treatment for these aneurysms with stent grafts. DESIGN, PATIENTS AND METHODS: a prospective observational study was performed of 37 consecutive patients treated from July 1997 to October 2000 (30 at Guy's and St. Thomas' and 7 at Sheffield). Indications included degenerative aneurysms (n=18), false aneurysm (5), acute dissection (4), aortic transection (4), aneurysm related to previous surgery for coarctation (3), chronic dissection (2) and traumatic dissection (1). Nineteen were performed as elective and 18 as non-elective procedures. RESULTS: three non-elective patients died in hospital (in-hospital and 30-day mortality 8%) and one suffered a stroke with spontaneous full recovery. No elective patient died. One patient with a persistent proximal endoleak required conversion to open repair at 6 weeks. Two patients with persistent flow into the sac at 24 h spontaneously thrombosed at subsequent 3 month follow-up. Two further patients developed new distal endoleaks at 3 months and required distal extension cuffs. One patient died at 28 months of aortic rupture. Serial CT scans had shown prolapse of the stent graft into the aneurysm sac and the patient died just before planned endovascular repair. No patient suffered paraplegia or renal failure. Intensive care facilities were only required for patients who needed them preoperatively. CONCLUSIONS: thoracic stent grafts can be performed with low morbidity and mortality. They offer a realistic alternative to open surgery. Long term follow up is required to assess their durability.

Aged↗
PubMed2000

[Interventional therapy of aortic isthmus stenosis with concomitant thoracic aortic aneurysm with a stent graft].

A 23 year old male presented with hypertension and a systolic murmur. ECG and echo revealed signs of left ventricular hypertrophy. Aortography showed aortic coarctation (delta p max. 40 mmHg) in combination with an aneurysm originating from the coarcted segment distal from the origin of the left subclavian artery. Coarctation and aneurysm were treated using direct placement of a stent graft and subsequent balloon dilatation. On final aortography, the outline of the stented segment was smooth with good stent apposition and the aneurysm entry was closed. The residual gradient was 10 mmHg (max). Six months later, the patient has no symptoms and a blood pressure of 120/80 mmHg on both arms.

Adult↗