BACKGROUND: Symptomatic carotid disease due to thromboembolism has been associated with acute plaque instability and intraplaque haemorrhage. These features may be influenced by the fragility and position of plaque neovessels. The purpose of this study was, therefore, to determine whether any association existed between neovessel density, position, morphology and thromboembolic sequelae. METHODS: Carotid endarterectomy (CEA) samples were collected from 15 asymptomatic patients with greater than 80 per cent stenosis and from 13 patients with greater than 80 per cent stenosis and symptoms within 30 days of CEA. Groups were matched for sex, age, risk factors and plaque size. Samples were stained with haematoxylin and eosin, and Van Gieson stains. An endothelial-specific antibody to CD31 was used for immunohistochemistry. Plaques were assessed for histological characteristics while neovessels were counted and characterized by size, site and shape. RESULTS: There were more neovessels in plaques (P < 0.00001) and fibrous caps (P < 0.0001) from symptomatic than asymptomatic patients. Symptomatic plaque neovessels were larger in size (P< 0.004) and more irregular in shape. There was a significant increase in plaque necrosis and rupture in symptomatic plaques. Plaque haemorrhage and rupture were associated with more neovessels within the plaque (P < 0.02, P < 0. 001) and fibrous cap (P < 0.05, P < 0.004). Patients with preoperative or intraoperative embolization had more plaque and fibrous cap neovessels (P < 0.03, P < 0.001). CONCLUSION: Symptomatic carotid disease is associated with increased neovascularization within the atherosclerotic plaque and fibrous cap; these vessels appear larger in size, more irregular in shape and may contribute to plaque instability and onset of thromboembolic events.

Surgeons must quote their own results and be aware that a high operative risk reduces long-term benefit. Accordingly, in those centres with a higher operative death/stroke rate, some "lower risk" patients should probably be considered for best medical therapy alone. It is hoped that pooling of the ECST and NASCET databases will enable more definitive guidelines to be developed regarding who benefits most from CEA.

In patients with venous ulceration and isolated superficial venous incompetence, superficial venous surgery can produce ulcer healing in the majority of patients without the need for perforator surgery, postoperative compression bandaging or skin grafting.

Saphenous vein disconnection improves venous function and heals venous ulcers without compression bandaging if the deep veins are normal. This procedure under local anaesthetic may be particularly suitable for elderly patients, but long saphenous vein stripping should be added in young patients.

had developed a duodenal ulcer, one a gastric ulcer, one a combined duodenal and gastric ulcer, and one was found to have radiological evidence of achalasia of the cardia. These patients were referred for surgical treatment, with excellent results in all except the patient with achalasia. Of the four remaining patients, further radiological investigation had shown renal disease in -two, but with no evidence of gastrointestinal disease, and two were again found to have no abnormality.When the radiological diagnosis for the 1964 barium-meal study was compared with the follow-up diagnosis six years later it changed in eight cases. Six, as indicated above, developed upper gastointestinal lesions, and two were found to have renal disease. None of these patients experienced gastrointestinal haemorrhage or perforation during the period of follow-up. Six had died, but in none was the recorded cause of death attributable to a lesion in the upper gastrointestinal tract. DiscussionAn increasing number of patients with dyspepsia are referred for radiological investigations by their general practitioners because a peptic ulcer is suspected. In this series few (3 5%) of those patients with a normal finding on barium-meal examination in 1964 were later found to have a peptic ulcer. Most showed appreciable symptomatic improvement, 65 (76%) claiming to have little or no dyspepsia when questioned in 1970. Fifteen patients claimed there had been no change in their symptoms. The five patients shown by the questionnaire to have deteriorated symptomatically were reinvestigated, and in two a positive diagnosis was obtained.Similar groups of patients studied over an extended period have shown a much higher incidence of peptic ulceration in follow-up. In a group of 174 hospital patients who were followed for 27 years, 40 % were shown to have a peptic ulcer at subsequent investigations (Krag, 1965). Brummer and Hakkinen (1959) followed 102 patients over a six-year period and found that 12 had developed a peptic ulcer. Barfred (1959) followed 235 patients over a 10-year period, and 30% developed a peptic ulcer during this time.The lower incidence of peptic ulcer in our study may be related to two factors. Firstly, all of the present patients were referred directly from general practitioners, whereas the reports referred to above all dealt with a hospital population. Secondly, a longer follow-up period would possibly have given a higher incidence of the subsequent development of peptic ulceration. We believe that this would be unlikely as 76% of the present patients were virtually symptomless six years later.If we assume that "x-ray-negative dyspepsia" represents a separate disease entity then its prognosis is more favourable than for peptic ulcer, most patients showing appreciable improvement with time. If further investigations are reserved only for those patients who show a deterioration symptomatically then the burden of repeated reinvestigations both for the radiological services and the patients will be eased, so reducing unnecessa...