Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.
BACKGROUNDThis is a rare cause of an axillary artery aneurysm in a young patient and brings together dermatology, rheumatology and vascular surgery.
CASE PRESENTATIONA man in his late 20s presented with a painless swelling in his left axilla. He also had a long history of nocturnal sweating with no history of weight loss or fatigue. On examination, there was a large, well circumscribed lump measuring 3 × 2.5 cm within the apex of the left axilla. The mass was pulsatile, fi rm and non-tender. General examination was otherwise unremarkable; in particular, there were neither skin lesions nor palpable lymphadenopathy.
INVESTIGATIONSBiochemical and haematological investigations were normal apart from a mildly raised eosinophil count of 0.5 × 10 9 /l (upper limit of normal 0.4 × 10 9 /l).Doppler ultrasound confi rmed a 2.9 cm long × 1.8 cm wide aneurysm of the distal axillary artery with evidence of an irregular thrombus present within.
DIFFERENTIAL DIAGNOSISAngiolymphoid hyperplasia with eosinophilia (ALHE) has been known by a variety of different names, such as epithelioid haemangioma, pseudopyogenic granuloma, infl ammatory angiomatous nodule, papular angioplasia, subcutaneous angioblastic lymphoid hyperplasia with eosinophilia and lymphofolliculosis, intravenous atypical vascular proliferation and histiocytoid haemangioma. 1 This extensive list of nomenclature refl ects the spectral variation in microscopic presentations of ALHE encountered by past investigators and, not least, the divided opinion as to whether the pathogenesis of the lesion is truly neoplastic or a reactive phenomenon.There has been controversy over the exact relationship between Kimura's disease (KD) and ALHE, where the two terms have been used interchangeably in many articles. KD was fi rst described by Chinese authors Kimm and Szeto 2 in 1937 and later made widely recognised by Kimura in 1947. KD is a chronic infl ammatory disease of unknown aetiology usually presenting as solitary or multiple subcutaneous nodules in the head and neck region, often involving the parotid or submandibular salivary glands. KD is associated with regional lymphadenopathy; this may become generalised in longstanding disease, 3 and systemic eosinophilia with raised IgE levels. It is most prevalent in Asians with 85% of cases occurring in males.Although KD has been thought to be integral to the spectrum of ALHE in the past, histological features show that these conditions represent two separate disease entities. 4 KD is characterised by lymphoid nodules with germinal centres which may extend from the dermis to the underlying fascia and muscles. Lesions show a distinct eosinophilic infi ltrate with microabscesses. Vascular proliferation is not always present; however, when seen, there are many canalised capillaries lined by fl at endothelial cells. Systemic eosinophilia is almost always present, seen in approximately 98% of cases in comparison to 20% in ALHE. 5 In contrast to KD, ALHE lesions are superfi cial containing blood vessels of varying luminal sizes, some of w...
In claudicants with arteriosclerosis obliterans admitted for vascular surgery, Buerger's test was compared with other indicators of lower limb ischaemia. Rest pain, gangrene, trophic changes, and chronic erythromelia were significantly commoner and more distal pulses were absent in Buerger positive limbs. Doppler and transcutaneous oxygen pressures and indices were significantly lower in Buerger positive legs. Significantly more occlusions were noted on arteriography in arteries distal to the adductor hiatus in the Buerger positive group. Buerger's test is a useful adjunct to routine peripheral vascular assessment and, if positive, suggests more severe ischaemia with distal limb artery involvement.
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