The distribution o f carotid plaque ultrasound appearance has been evaluated using duplex ultraround in symptomatic and asymptomatic patients. There were I34 patients with unilateral carotid territory *yiiiptoiiis who subsequently underwent endarterectomy of the symptomatic carotid bifurcation. and 92 asyii,ploiii;itic patients. Both carotid bifurcations in all patients were examined. thus providing three groups ol' vcssels lor study: (i) asymptomatic vessels in asymptomatic patients 01 = 184): (ii) asyniptoniatic vessels in symptomatic patients ( n = 134); and (iii) asymptomatic contralateral vessels in symptomatic patients 01 = 1341.ultrasound appearances were classified as types I -4. This classification has previously k e n compared prospectively with endarterectomy specimen pathology where the more echolucent type I and 2 lesion\ correlated well with the presence of intraplaque haemorrhage or ulceration.In the symptomatic arteries, type I and 2 lesions were predominant. whereas in the asymptomatic paticntr the most comnion lesions were types 3 and 4. This difference was statistically significant ( P < 0.01 ). Evalu;ition of the asymptomatic contralateral vessel in the symptomatic patients showed a pattern ol' plaque lypc distribution between the other two groups.
The incidence of distal ischaemia following aortic reconstruction may be as high as 25%, despite the use of systemic heparin. As anticoagulation may be associated with excessive operative blood loss, a retrospective study was performed to assess the prevalence of these problems, in a consecutive series, during a 30‐month period. Evaluation of reconstruction was possible in 161 patients with aneurysm and 38 patients with occlusive disease. The incidence of vessel occlusion was 21% in the occlusive and 4% in the aneurysm group (P < 0.05). Four of seven patients who had major vessel occlusion had serious complications. and there were two resultant deaths. These problems occurred despite the administration of heparin. Blood loss and operating time were quantitated in the patients who had resection for aortic aneurysm. Both were significantly longer in patients who received heparin (P < 0.05) and the differences were maintained when patients were stratified according to increments in dose or operating time, and according to whether woven tube or bifurcation grafts were performed.
It was concluded that aneurysm surgery, in the absence of distal occlusive disease, could be safely performed without the use of systemic heparin, but surgery for occlusive disease still requires heparinization.
This study, while confirming significant risk for asymptomatic patients with critical stenosis or echolucent plaque, demonstrates the importance of contralateral disease and the absence of orderly progression from minimal disease through high-grade stenosis to symptomatic cerebral ischemia. TIA and stroke commonly occur in association with abrupt, unpredictable, quantum changes in carotid artery disease.
Conducting an audit of surgical practice contributed to an improvement in outcomes for dialysis-dependant patients. Establishing an arteriovenous fistula in a greater proportion of cases before initiating renal replacement therapy may further address the problem of dialysis access insufficiency.
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