Objectives: Ankle brachial pressure index (ABPI) is limited for diabetic patients. This can have costly impacts upon patient's quality of life along with healthcare budgets, with diabetic care equating to approximately 10% of NHS expenditure.11 We aimed to determine whether ultrasound waveform parameters are an alternative for quantifying lower extremity peripheral arterial disease (PAD) where ABPI is unreliable. Design: This was a prospective, observational study. Waveform parameters, systolic rise time (SRT), maximal systolic acceleration (AccMax) and peak systolic velocity (PSV) were recorded at ankle and compared to the ABPI and an aorta-ankle duplex ultrasound scan (DUS) as gold standard. Setting: Measurements were obtained by a Clinical Vascular Scientist at the Royal Free Hospital. Participants: Participants (≥18yrs) with known PAD, but without previous vascular intervention were allocated to non-diabetic control ( n = 24) and diabetic test groups ( n = 22). Outcome measures: The primary outcome measure was the correlation of novel ultrasound derived indices to PAD severity. The secondary outcome was the efficacy of this correlation in the diabetic population. Results: AccMax was most powerful in detecting PAD in both groups when compared to ABPI in the controls ( r = 0.805; p < 0.01) and to DUS in control and test groups ( r = −0.633 to −0.643; p < 0.01). In the test group, PSV did not consistently quantify PAD. SRT measurements were inconclusive throughout. Conclusion: AccMax is a rapid alternative tool for diagnosing PAD in diabetic patients. With further research, this simple test may prove useful for monitoring PAD progression in patients unsuitable for ABPI, reducing the need for lengthy repeat duplex scans.

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The presentation of symptomatic inferior vena cava (IVC) occlusion is variable, and no clear guidance exists on indications for invasive treatment. We describe the first documented case in the literature of IVC occlusion and venous congestion of the spine with associated neurological symptoms, successfully treated with endovascular IVC reconstruction. Case report A 31 year-old male presented with a long history of reduced sensation and motor function in his lower limbs upon waking every morning, lasting 30-50 minutes during which he was unable to ambulate. He was involved in a severe road traffic accident as a child, and was born prematurely requiring prolonged neonatal hospitalisation. Both duplex ultrasonography and magnetic resonance venography identified an occlusion of the IVC, with patent common femoral and iliac veins draining into large spinal collaterals. No other cause was identified for his symptoms. After appropriate multidisciplinary team discussion and patient counselling, the patient proceeded to have endovenous recanalization of his IVC and common iliac veins with dedicated venous stents. Post-operatively, the patient reported an immediate resolution of neurological symptoms, with an improvement in quality of life questionnaire scores and with stent patency at 9-month follow up. Conclusion IVC occlusion with symptomatic spinal venous congestion is a rare condition which may be successfully treated with endovascular iliocaval recanalization, although long-term outcomes of this treatment are still unknown.

Objective: The life expectancy in PAH is very less, and only symptomatic treatment is available. Patients with pulmonary hypertension are mostly diagnosed with co-existing vitamin D deficiency. In PAH, there is an increase in the level and expression of PDE 5 enzyme that results in increased degradation of cGMP but there is also a simultaneous decrease in the activation of cGMP due to a subsequent decrease in eNOS mediated nitric oxide synthesis. Thus, limiting the efficacy of sildenafil as monotherapy in the treatment of PAH. Furthermore, vitamin D deficiency is also associated with reduced expression of eNOS mediated NO synthesis, which further decreases cGMP synthesis thus increasing disease severity. Hence, this study was undertaken to study the combined effect of sildenafil and vitamin D therapy in monocrotaline-induced PAH in rats.Design and method: Rats were fed on a vitamin D deficient diet with exposure to filtered fluorescent light to induce vitamin D deficiency. PAH was induced by a single s.c. injection of MCT 50 mg/kg. Rats were divided into 6 groups: Control, MCT, MCT+Sildenafil, MCT+Vitamin D, MCT+Vitamin D+Sildenafil and MCT+L-NAME+Vitamin D+Sildenafil. Haemodynamic, echocardiographic, histopathological and biochemical parameters were analysed. The expression and level of eNOS was done using immunohistochemistry and western blot. Results:The effect of the vitamin D sildenafil combination group was significantly higher than the vitamin D and sildenafil treated alone groups. This protective effect of vitamin D sildenafil combination in PAH is attenuated when administered with L-NAME (20 mg/kg). Furthermore, the administration of MCT reduced the expression of eNOS, which was significantly reversed by the treatment with vitamin D sildenafil combination compared to vitamin D and sildenafil alone. Conclusion:The effect of vitamin D in the treatment of PAH is comparable to sildenafil alone and is further improved when given in combination with sildenafil. Moreover, if pulmonary hypertension is accompanied by vitamin D deficiency it results in increased disease severity of PAH. Thus, sildenafil when combined with vitamin D may exert a synergistic effect in amelioration of symptoms and disease severity in patients of pulmonary hypertension.