Background-Carotid angiographic plaque surface morphology is a powerful risk factor for stroke and systemic vascular risk. However, the underlying pathology is unclear, and a better understanding is required both to evaluate other forms of carotid imaging and to develop new treatments. Previous studies comparing angiographic plaque surface morphology with pathology have been small and unblinded, and the vast majority assessed only the crude macroscopic appearance of the plaque. We performed the first large study comparing angiographic surface morphology with detailed histology. Methods and Results-Carotid plaque surface morphology was classified as ulcerated, irregular, or smooth on 128 conventional selective carotid artery angiograms from consecutive patients undergoing endarterectomy for severe symptomatic stenosis. Blinded angiographic assessments were compared with 10 histological features recorded on detailed microscopy of the plaque using reproducible semiquantitative scales. Angiographic ulceration was associated with plaque rupture (Pϭ0.001), intraplaque hemorrhage (Pϭ0.001), large lipid core (Pϭ0.005), less fibrous tissue (Pϭ0.003), and increased instability overall (Pϭ0.001). For example, angiographically ulcerated plaques were much more likely than smooth plaques to be ruptured (ORϭ15.4, 95% CIϭ2.7 to 87.3, PϽ0.001), show a large lipid core (ORϭ26.7, 95% CIϭ2.6 to 270, PϽ0.001) or a large hemorrhage (ORϭ17.0, 95% CIϭ2.0 to 147, Pϭ0.02). The equivalent odds ratios for angiographically irregular versus smooth plaque were 6.3 (1.3 to 31, Pϭ0.02), 6.7 (1.5 to 30, Pϭ0.008), and 9.2 (1.1 to 77, Pϭ0.02), respectively. Conclusions-In contrast to previous studies based on macroscopic assessment, we found very strong associations between detailed histology and carotid angiographic plaque surface morphology. Plaque surface morphology on carotid angiography is a highly sensitive marker of plaque instability. Studies of the predictive value of MR-and CT-based lumen contrast plaque surface imaging are required.

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Ultrasound guided percutaneous thrombin injection has recently been described for the treatment of iatrogenic femoral pseudoaneurysms. Patient selection and technical aspects of this technique are still evolving and safety data, particularly after coronary intervention, remains limited. The percutaneous thrombin injection of femoral artery pseudoaneurysms in 13 consecutive patients, most of whom were receiving antiplatelet/anticoagulant treatment (aspirin 11, heparin 4, clopidogrel 6), is reported. Thrombin (1000 U/ml) was injected over several seconds until Doppler colour flow within the cavity ceased. The median dose of thrombin injected was 800 U (range 200-1000 U) and the treatment was successful in all cases without complication. In one case, thrombus was visualised within the arterial lumen immediately after thrombin injection, but this dissolved spontaneously within five minutes without evidence of embolisation. In contrast to ultrasound guided compression, percutaneous thrombin injection of femoral pseudoaneurysms is a rapid, well tolerated, and successful technique even in patients receiving antiplatelet/anticoagulant treatment. (Heart 2001;85:e5) Keywords: ultrasound guided percutaneous thrombin injection; iatrogenic femoral artery pseudoaneurysm Iatrogenic femoral artery pseudoaneurysms occur following 0.2-0.5% of diagnostic angiography cases and in up to 8% of coronary interventions.

The CIA in the presence of an AAA expands over time. CIA > 16 mm are more likely to increase. Routine duplex examination of a CIA less than 16 mm may not be necessary when following up AAA. These data may be used to aid planning and intervention during AAA repair.

Perioperative complications from carotid endarterectomy (CEA) are the main drawbacks of the procedure. The aim of this study was to assess the complication rates in patients undergoing CEA under general anesthesia (GA) or regional anesthesia (local anesthesia [LA]) at our institution. Patients undergoing CEA at our regional vascular unit between 2000 and 2004 were included. Data were collated retrospectively from a prospective database. Follow-up was up to 62 months. In all, 383 endarterectomies were performed, 260 of which were under LA. Outcome measures included 30-day death (2.1%), stroke (1.8%), and combined stroke and death (2.8%). A 30-day incidence of stroke, death, and combined stroke and death was lower in the LA group. Incidence of myocardial infarction and transient ischemic attacks, and annual mortality were higher in the LA group. No significant difference was found between the 2 groups. In a unit where CEA is preferentially performed under LA, anesthesia technique failed to significantly influence outcome.

There is some disagreement about whether the first rib should be excised in the presence of a cervical rib for the relief of the thoracic outlet compression syndrome (TOCS). Over a 14-year period (1975-1988) 58 patients have undergone surgery for TOCS. Forty-four patients (76 per cent) had vascular symptoms, 28 (48 per cent) with a neurological component; 11 (19 per cent) had only neurological symptoms. Thirty-six patients (62 per cent) had the first rib excised; 19 (33 per cent) had a cervical rib excised; two (3 per cent) had a division of fibrous bands; and one patient had a large transverse process resected. Follow-up details were available on 53 patients (91 per cent). Overall 38 (72 per cent) were cured of their symptoms, 11 (21 per cent) had a significant improvement, and four (8 per cent) showed no improvement. There was no significant difference between the results following excision of a cervical rib or of a first rib in terms of relief of symptoms. In patients with TOCS who have a cervical rib, excision of the cervical rib alone without excision of the first rib would appear to be an appropriate treatment.

Background Population breast screening services in England were suspended in March 2020 due to the COVID-19 pandemic. Here, we estimate the number of breast cancers whose detection may be delayed because of the suspension, and the potential impact on cancer deaths over 10 years. Methods We estimated the number and length of screening delays from observed NHS Breast Screening System data. We then estimated additional breast cancer deaths from three routes: asymptomatic tumours progressing to symptomatically diagnosed disease, invasive tumours which remain screen-detected but at a later date, and ductal carcinoma in situ (DCIS) progressing to invasive disease by detection. We took progression rates, prognostic characteristics, and survival rates from published sources. Results We estimated that 1,489,237 women had screening delayed by around 2–7 months between July 2020 and June 2021, leaving 745,277 outstanding screens. Depending on how quickly this backlog is cleared, around 2500–4100 cancers would shift from screen-detected to symptomatic cancers, resulting in 148–452 additional breast cancer deaths. There would be an additional 164–222 screen-detected tumour deaths, and 71–97 deaths from DCIS that progresses to invasive cancer. Conclusions An estimated 148–687 additional breast cancer deaths may occur as a result of the pandemic-related disruptions. The impact depends on how quickly screening services catch up with delays.