Eur J Vasc Surg 8, 567-573 (1994)

Raynaud's Phenomenon and Cold Stress Testing: A New Approach

S a d h a n a Naidu 2, Paul A. B a s k e r v i l l e 1, David E. Goss 3 and V. Colin R o b e r t s 2 Department of 1Vascular Surgery and aDepartment of Medical Engineering and Physics, King's College Hospital, Denmark Hill London SE5 9RS, U.K. and 3Vascular Laboratory, Department of Medical Engineering and Physics, King's College Hospital (Dulwich), East Dulwich Grove SE22 8PT, U.K. There are a number of methods of evaluating digital blood flow in the vascular laboratory but none fulfills the criteria of providing a quick and reproducible diagnostic test for Raynaud's phenomenon. We present our experience with the use of high frequency ultrasound to provide direct real time imaging of the digital arteries. Using this method and a standardised cold challenge test, consisting of exposure of the hand to a temperature of lOC for 5 minutes, it is possible to distinguish patients with Raynaud's phenomenon from normal controls on the basis of extent of digital artery closure. The mean fall in digital artery diameter on cold challenge, expressed as a percentage of the original diameter, was 92.4% (s.D. = 16.4, S.E.M. = 2.1) in patients with Raynaud's phenomenon as against 8.7% (s.D. = 11.5, sx.M. = 2.5) in a group of normal volunteers. Using a 45% fall in digital artery diameter as the diagnostic cut-off point, the test has a specificity of 100% and a sensitivity of 96.6% in differentiating patients with Raynaud's phenomenon from controls. It is suggested that the test could be used as objective confirmation of a clinical diagnosis and to assess the efficacy of therapeutic interventions. Key Words: Raynaud's phenomenon; Digital blood flow; High frequency ultrasound; Digital arteries; Cold challenge.

is now considered to form the basis of the typical Raynaud's attack. 9'm It has been demonstrated to The diagnosis of Raynaud's phenomenon is largely occur using diverse methods such as digital plebased on clinical criteria, often aided by question- thysmography,11 digit systolic pressures, 4"12laser Dopnaires seeking information on relevant risk factorsJ "2 pler flowmetry13 and more recentl~ high frequency One of the main problems in evaluating digital blood ultrasound. 14 The present report details our experiflow in patients with Raynaud's phenomenon has ence with the use of high frequency ultrasound in been the episodic nature of the symptoms and signs. characterising digital artery responses to a standarDifferent methods have been used to provoke an dised cold stress in patients with Raynaud's phenomeattack in a laboratory setting. These have included non and in a group of normal controls. local cooling of the hand or the digits by exposure to cold air, cold water or the use of digital cuffs perfused with cold water, 3'4's and general body cooling using Subjects and Methods water perfusable blankets 6 or through exposure to low ambient temperatures. 7 Having provoked a vasospastic attack, the second problem that faces the The patient group consisted of 60 patients, 40 with investigator is the measurement and quantification of primary Raynaud's Phenomenon (RP) and 20 patients with secondary RP from the vascular clinic at King's the digital arterial constriction. The "critical closing phenomenon" or spastic College Hospital. The diagnosis was based on history closure of the digital arteries in response to pro- and clinical criteriaJ The control group consisted of 22 gressive cooling was first proposed by Burton in 1951.s normal volunteers with no history of cold sensitivit~ Although initially a subject of considerable debate, it of which 18 were women and four were men (ratio 4.5:1), with a mean age of 45.2 years (range 21 to 71 years). The patient group comprised 46 women and 14 Please address all correspondence to: David Goss, Vascular Laborator~ Department of Medical Engineering & Physics, King's men (ratio 3.3:1), with a mean age of 48.9 years (range College Hospital (Dulwich),East Dulwich Grove, SE228PT,U.K. 15 to 79 years). Forty of the patients were classified as 0950-821X/94/050567+07 $08"00/0 1994 W. B. Saunders CompanyLtd.

Introduction

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having p r i m a r y RP and the remaining 20 as secondary RP (see Table 1 for subject characteristics). The subjects were rested for 15 minutes in a thermally neutral environment maintained at a temperature of 25C. The test was p e r f o r m e d b y placing the h a n d on a specially constructed perspex positioning rig, with the middle finger resting on the horizontal support bar (Fig. 1). Measurements were m a d e using the Dermascan A high frequency ultrasound system (Cortex Technology, Diastron Ltd. Hampshire). The equipment uses a 20 Mhz transducer probe which has a captive water bath at the front end to serve as the coupling medium. A screen displays the reflected A line ultrasound echoes in real time and a foot switch enables the display to be frozen. Measurement cursors can be positioned on screen and allow for instantaneous readouts of distances between echoes of interest. Echoes originating from the digital artery walls are recognised b y their pulsatile m o v e m e n t s and their separation b y an echo free interval representing blood within the artery. The probe can be positioned perpendicular to the long axis of the digital arter)~ at any point on the circumference of the finger and fixed in place b y means of a clamp attached to the perspex rig. The clamp enables the probe to be positioned against the finger with m i n i m u m pressure, thereby avoiding errors due to distortion of the tissues b y u n d u e pressure. The most accurate estimate of digital artery diameter is obtained with the probe perpendicular to the long axis of the digital artery (Fig. 1). The middle finger was chosen as the representative finger as most of our subjects in the patient group had bilateral and symmetrical s y m p t o m s and for accurate comparison in the control group. H o w e v e r the technique can be equally well applied to any of the

Table 1. Subject characteristics

Age, years (range) Controls Patients with Raynaud's Phenomenon Primary Raynaud's Secondary Raynaud's Systemic Sclerosis Rheum. Arthritis SLE Peripheral Vasc. Disease Vibration White Finger Cervical Ribs (bilateral) Beta blockers 45.2 (21-71) 48.9 (15-79)

Male 4 14

Female Total 18 46 22 60

46 (15-75) 54.8 (35-79) 49.9 (43-62) 53 (39-58) 53 70 (61-79) 57.5 (48-64) 46 62

6 8 1 --2 4 -1

34 12 6 4 1 --1 --

40 20 7 4 1 2 4 1 1

fingers, including the thumb, unless fixed deformities of the fingers do not allow the probe to be placed as described. Two sets of digital artery measurements were taken for each subject. A baseline digital artery diameter (DAD) record was m a d e at r o o m temperature. Following this, a standardised cold challenge was administered consisting of immersion of the h a n d in cold water at a temperature of 10C for 5 minutes. Both hands were assessed and four observations were taken with each set of measurements. A m e a n value of digital artery diameter was then calculated from the observations from both hands in each subject. Results are expressed as m e a n DAD (S.D. and S.E.M.) and digital artery responses to cold stress are expressed as percentage decrease in baseline DAD. The differences between the groups were analysed for statistical significance using the Mann-Whitney U test.

Results

Fig. 1. Measurement of digital artery diameter; finger positioned on the perspex rig with probe held in place by clamp. Eur J Vasc Surg Vol 8, September 1994

The digital artery diameters and their changes in response to cold stress were recorded in 60 patients with Raynaud's p h e n o m e n o n and 22 normal controls. The baseline DADs at r o o m temperature (Table 2) were slightly higher in the control group (1.18 m m S.D. = 0.17 ram) as compared to the patient group (1.06

Raynaud's Phenomenon and Cold Stress Testing

569

Table 2. Digital Artery Diameters and changes with cold stress

p values (Mann-Whitney U Test) (*significant) Patients with Primary RP (n = 40) 1.08 S.D. = 0.27 S.E.M. = 0.04 Patients with Controls Secondary RP v s . (n = 20) Patients 1.03 0.01" S.D. = 0.23 S.E.M. = 0.05 0.10 S.D. = 0.23 S.E.M. = 0.05 91.3 S.D. = 19.2 S.E.M. = 4.3 <0.001" Primary RP
VS.

Primary RP Secondary RP
VS, VS.

Controls (n = 22) Baseline DAD at room temperature (ram) DAD after cold stress (ram) Percent drop in DAD

Patients (n = 60)

Secondary RP all patients 0.94 0.97

all patients 0.95

1.18 1.06 S.D. = 0.17 S.D. = 0.26 S.E.M. = 0.04 S.E.M. = 0.03

1.07 0.09 0.09 S.D. = 0.15 S.D. = 0.21 S.D. = 0.20 S.E.M. = 0.03 S.E.M. = 0.03 S.E.M. = 0.03 8.7 S.D. = 11.5 S.E.M. = 2.5 92.4 S.D. = 16.4 S.E.M. = 2.1 92.9 S.D. = 15.1 S.E.M. = 2.4

0.99

0.99

0.99

< 0.001"

0.96

0.98

0.96

m m S.D. = 0.26 m m ) . T h i s d i f f e r e n c e w a s s i g n i f i c a n t (Mann-Whitney U test: p < 0.05, 95% c o n f i d e n c e i n t e r v a l s : 0.03 m m , 0.23 m m ) . T h e r e w e r e n o s i g nificant differences between patients with primary R a y n a u d ' s (1.08 m m S.D. = 0.27 m m ) a n d t h o s e w i t h s e c o n d a r y R a y n a u d ' s (1.03 m m S.D. = 0.23 m m ) . F o l l o w i n g t h e s t a n d a r d i s e d c o l d stress, D A D i n t h e c o n t r o l g r o u p f e l l to a m e a n o f 1.07 m m (S.D. = 0.15 m m ) , r e p r e s e n t i n g a fall of 8.7% (S.D. = 11.5%) of t h e baseline diameter. In the patient group the mean DAD a f t e r c o l d s t r e s s w a s 0.09 m m (S.D. = 0.21 r a m ) , r e p r e s e n t i n g a m e a n fall of 92.4% (S.D. = 16.4%) o f t h e

b a s e l i n e v a l u e s . T h e D A D r e s p o n s e s to c o l d s t r e s s in t h e t w o g r o u p s a r e i l l u s t r a t e d i n Fig. 2. T h e d i f f e r e n c e between the responses of the control group and the p a t i e n t g r o u p i n t e r m s of b o t h t h e D A D m e a s u r e d a f t e r t h e c o l d s t r e s s a n d t h e p e r c e n t fall, w a s h i g h l y s i g n i f i c a n t (p < 0.0001, 95% c o n f i d e n c e i n t e r v a l s : 0.96 m m , 1.05 m m a n d - 9 4 . 5 % , - 8 2 . 2 % r e s p e c t i v e l y ) . A m o n g t h e p a t i e n t s , s i m i l a r d e g r e e s of v a s o s p a s m were seen in the two subgroups of primary and s e c o n d a r y RP, ( m e a n d e c r e a s e in D A D 92.8% S.D. -15.1% a n d 91.3% S.D. = 19.2% r e s p e c t i v e l y ) w i t h m e a n D A D s of 0.09 m m (S.D. = 0.20 m m ) i n t h e f o r m e r a n d

Diameter (ram) 2.5 Controls (n:22) Patients with RP

(n:60)

1.5

- -

1 -

0.5

(0.5)
Room Temp. Cold Stress Room Temp. Cold Stress
=

Fig. 2. Digital artery diameter (DAD) responses to cold stress. Vertical bars indicate mean + S.D.*

p value 0.01;** = p value < 0.001.

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Table 3. I n f l u e n c e o f s e x o n D A D r e s p o n s e s to c o l d stress

Controls (n = 22) Men (n = 4) Baseline DAD at room temperature (ram) DAD after cold stress (mm) Percent drop in DAD Women (n = 18)

Patients with RP (n = 60) Men (n = 14) Women (n = 46)

p values (Mann-Whitney U test) (* significant) Controls Pts. with RP Controls men Cntrl. women men vs. men vs. vs. men vs. women women women with RP with RP 0.009* 0.87 0.002*

1.16 1.18 1.22 S.D. = 0.20 S.D. = 0.17 S.D. = 0.30 S.E.M. = 0.10 S.E.M. = 0.04 S.E.M. = 0.08 1.18 1.04 0.18 S.D. = 0.14 S.D. = 0.15 S.D. = 0.32 S.E.M. = 0.07 S.E.M. = 0.03 S.E.M. = 0.08 -3.4t 11.4 S.D. = 14.7 S.D. = 9.1 S.E.M. = 7.4 S.E.M. = 2.2 87.9 S.D. = 21.5 S.E.M. = 5.8

1.01 0.76 S.D. = 0.22 S.E.M. = 0.03 0.07 S.D. = 0.16 S.E.M. = 0.02 93.7 S.D. = 14.6 S.E.M. = 2.2 0.12

0.44

0.003*

< 0.0001"

0.07

0.49

0.003*

< 0.0001"

(~- mean change after cold stress was an increase in DAD)

0.10 m m (S.D. = 0.22 m m ) in t h e latter. T h e c o l d stress r e s p o n s e s of t h e t w o g r o u p s w e r e n o t s i g n i f i c a n t l y d i f f e r e n t f r o m e a c h o t h e r a n d a l s o d i d n o t differ f r o m t h o s e of t h e w h o l e p a t i e n t g r o u p (p > 0.05). While the control and patient groups were fairly w e l l m a t c h e d for age, t h e r e w a s a l a r g e r p r o p o r t i o n of w o m e n in t h e p a t i e n t g r o u p . T h e r e f o r e a f u r t h e r s u b g r o u p a n a l y s i s w a s p e r f o r m e d to a s s e s s t h e influe n c e of sex o n t h e d i g i t a l a r t e r y r e s p o n s e s (Table 3). T h e r e w a s n o d i f f e r e n c e b e t w e e n t h e D A D s of m e n a n d w o m e n i n t h e c o n t r o l g r o u p ; e i t h e r at r o o m t e m p e r a t u r e o r f o l l o w i n g a c o l d stress (p > 0.05). H o w e v e r in t h e p a t i e n t g r o u p , w o m e n a p p e a r e d to h a v e a s i g n i f i c a n t l y s m a l l e r b a s e l i n e D A D as c o m p a r e d to m e n w i t h R P (1.01 m m S.D. -- 0.22 as a g a i n s t 1.22 m m S.D. = 0.18 m m ; p < 0.01). This d i f f e r e n c e d i s a p p e a r e d w h e n t h e r e s p o n s e s to c o l d stress w e r e c o m p a r e d , w i t h m e a n D A D s of 0.18 m m (S.D. = 0.32 m m ) r e f l e c t i n g a 87.9% (S.D. = 21.5%) fall in b a s e l i n e D A D in m e n a n d m e a n D A D s of 0.07 m m (S.D. = 0.16 r a m ) r e f l e c t i n g a fall of 93.7% (S.D. = 14.6%) of b a s e l i n e v a l u e s in w o m e n (p > 0.05). T h e b a s e l i n e D A D s of m e n w i t h R P d i d n o t d i f f e r s i g n i f i c a n t l y f r o m e i t h e r m e n o r w o m e n c o n t r o l s (p > 0.05); h o w e v e r b a s e l i n e D A D s of w o m e n w i t h R P w e r e s i g n i f i c a n t l y l o w e r t h a n b o t h m e n a n d w o m e n controls. I n a n a t t e m p t to a s s e s s t h e i n f l u e n c e of t h e b a s i c disease process on the baseline DAD, the differences between patients with primary and secondary Raynaud's phenomenon were analysed. While the two g r o u p s d i d n o t differ s i g n i f i c a n t l y as a w h o l e , c e r t a i n d i f f e r e n c e s b e c a m e a p p a r e n t w h e n t h e sexes w e r e s e p a r a t e d (Fig. 3) B o t h m e n a n d w o m e n w i t h s e c o n d a r y RP h a d s m a l l e r b a s e l i n e D A D s (1.1 m m , S.D. = 0.16 m m a n d 0.98 m m , S.D. = 0.27 m m r e s p e c t i v e l y ) as compared with men and women with primary RP Eur J Vasc Surg Vol 8, September 199.4

(1.38 m m , S.D. = 0.39 a n d 1.02 m m , S.D. = 0.21 m m r e s p e c t i v e l y ) . W h e n s u b j e c t e d to s t a t i s t i c a l a n a l y s i s h o w e v e r , it a p p e a r e d t h a t w o m e n w i t h p r i m a r y a n d s e c o n d a r y RP h a d s i g n i f i c a n t l y s m a l l e r b a s e l i n e D A D s w h e n c o m p a r e d to m e n w i t h p r i m a r y RP (p < 0.05), b u t n o t w h e n c o m p a r e d to m e n w i t h s e c o n d a r y RP. A l t h o u g h m e n w i t h s e c o n d a r y RP h a d s m a l l e r m e a n D A D s t h a n t h o s e w i t h p r i m a r y RP this d i f f e r e n c e w a s n o t s i g n i f i c a n t (p > 0.05). C o m p l e t e c l o s u r e of t h e d i g i t a l a r t e r y in r e s p o n s e to c o l d stress w a s s e e n in 48 p a t i e n t s (80%), w i t h n o p u l s a t i l e s i g n a l d e t e c t e d o n s c a n n i n g . This w a s a c c o m p a n i e d b y s y m p t o m s a n d c o l o u r c h a n g e s t y p i c a l of t h e R a y n a u d ' s attack. Of t h e r e m a i n d e r , 11 p a t i e n t s (18.3%) h a d s y m p t o m s s i m i l a r to t h o s e t h a t o c c u r r e d d u r i n g a n attack, a l t h o u g h t h e i r m e a n D A D d e c r e a s e w a s 61.8%. T h e c o l d stress test d i d n o t p r o v o k e symptoms in only one patient. His mean DAD d e c r e a s e w a s 36.2%. C o m p l e t e c l o s u r e of t h e d i g i t a l a r t e r y as a c o l d stress r e s p o n s e s e e m e d as l i k e l y to o c c u r in p a t i e n t s w i t h p r i m a r y R a y n a u d ' s (80%) as in t h o s e w i t h s e c o n d a r y R a y n a u d ' s (80%). I n n o n e of t h e s u b j e c t s of t h e c o n t r o l g r o u p w a s t h e D A D d e c r e a s e g r e a t e r t h a n 40%. A n i n t e r e s t i n g f i n d i n g t h a t w a s o b s e r v e d in t h i s g r o u p w a s t h a t t w o c o n t r o l s h a d a n e t i n c r e a s e i n d i g i t a l a r t e r y d i a m e t e r in r e s p o n s e to c o l d stress ( m e a n i n c r e a s e 15%). W h e n w e s t u d i e d t h e c o l d stress r e s p o n s e s of t h e t w o g r o u p s in t e r m s of a p e r c e n t a g e d e c r e a s e in D A D a clear separation between the two groups was e v i d e n t at t h e l e v e l of a 35% d e c r e a s e in D A D . H o w e v e r i n o r d e r to i n c r e a s e t h e a p p l i c a b i l i t y of t h e s e l e c t e d cutoff p o i n t w e p l o t t e d t h e c o l d s t r e s s r e s p o n s e o f 11 c o n t r o l s a n d 30 p a t i e n t s (50% of e a c h g r o u p ) , s e l e c t e d i n a r a n d o m f a s h i o n (Fig. 4). F r o m t h i s g r a p h , a c u t o f f p o i n t c o u l d b e o b t a i n e d at a 45%

Raynaud's Phenomenon and Cold Stress Testing

Baseline D A D in cms

571

4
I a p<0.05 I P<0.05~I

o
Men I

0
Men (n:8)
I

(n:6) Primary RP

Women (n:34)
1

Women (n:12)
I

Secondary RP

Fig. 3. Comparison of baseline DAD according to sex and etiology of RP. Vertical bars indicate mean _+S.D. Only significant p values are shown.

+40 +20 0 20 40 60 80 100 120

Percent change in DAD

Controls (n:ll)

Patients (n:30)

Controls (n:l 1)

Patients (n:30)

O O O O

oo
/x /X /X A

Z~26)

Fig. 4. Derivation of the diagnostic cutoff point. The left half of the figure represents the percentage drop in DAD following cold stress in 50% of randomly selected controls and patients. The remaining data is plotted on the right half of the figure.

d e c r e a s e in D A D t h a t s e p a r a t e d t h e c o n t r o l s f r o m t h e p a t i e n t s . W h e n this cutoff w a s a p p l i e d to t h e r e m a i n i n g d a t a , it y i e l d e d a d i a g n o s t i c s p e c i f i c i t y of 100% a n d a s e n s i t i v i t y of 96.6% i n d i s t i n g u i s h i n g t h e t w o groups.

Discussion
D u r i n g a t y p i c a l R a y n a u d ' s attack, t h e r e is c o m p l e t e 9.15 16 cessation of blood flow in the digital arteries." ' H o w e v e r it h a s b e e n difficult to q u a n t i t a t e this Eur J Vasc Surg Vol 8, September 1994

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response with most available methods. Singh et al., 17 in a group of patients with Raynaud's phenomenon demonstrated that progressive cooling of the fingers caused digital vasospasm that was essentially complete in all patients at temperatures below 16C. The clinical severity of the disease was found to correlate with the temperature at which this critical closure occurred. Practical difficulties were encountered with progressive finger cooling to determine the point of digital vasospasm. Stepwise cooling of the hands with repeated immersion in cold water with several estimates of the digital artery diameters is required. We therefore evolved the concept of a standardised cold challenge, consisting of exposure of the hand for a standard length of time to a temperature at which digital vasospasm is known to be complete in most patients with Raynaud's phenomenon. Standardising the cold stress has also allowed for comparison with normal controls in whom the technique of progressive cooling does not have an end point as they do not exhibit complete vasospasm in response to cold. The cold stress test was successful in reproducing typical symptoms in 80% of patients. This was confirmed on DAD estimation which demonstrated 100% decrease or total digital arterial shut off. One observation of interest was the fact that 18.3% of the patients still had symptoms and signs of the typical Raynaud's attack, even without complete digital artery closure (mean DAD decrease 61.8%). We attempted therefore, to relate the degree of vasospasm to the severity of the patients' clinical symptoms. However, although the patients whose DAD decreases were in the range of 40% to 50%, did admit to being only moderately symptomatic with their Raynaud's, there were several patients with such symptoms in the group who had total arterial shutdown. In the patients who showed incomplete digital vasospasm it is possible that prolonging the duration of exposure to the cold stress may convert the response to the complete digital arterial shut off characteristic of the majority of patients. The baseline digital artery diameters were significantly smaller in the patient group as compared to the control group (mean DAD: 1.06 mm as against 1.18 mm; p < 0.05). When the results of the subgroup analysis by sex were studied, it became apparent that this difference was largely contributed by women with RP who had a mean baseline DAD of 1.01 mm. In contrast men with RP had a mean baseline DAD of 1.22 mm which was not significantly different either from men or women controls (p > 0.05). It may be argued that a smaller baseline DAD might predispose the vessel to complete or near complete vasoconstriction in response to cold. However there was no Eur J VascSurg Vol 8, September 1994.

difference between the cold stress responses of men and women patients (p = 0.43). Baseline DADs were smaller in patients with secondary RP (1.03 mm S.D. = 0.23) as compared to those with primary RP (1.08 mm S.D. = 0.27). This difference however was not statistically significant (p > 0.05). Significant comparisons emerged only on further subgroup analysis for sex when baseline DADs of men with primary RP were found to be greater than women with either primary or secondary RP. It would seem therefore that the smaller baseline DADs observed in the patient group were more directly related to the sex of the patient than the nature of the disease process. Smaller baseline DADs in women with secondary RP might be easily explained considering the effects of connective tissue disease on digital arterial anatomy; especially as this group consisted almost entirely of patients with connective tissue disease (11/12), 50% of whom had scleroderma. However the same observation in women with primary RP does seem to suggest a possible hormonally mediated baseline vasoconstriction, existing even at room temperature. In our study group, patients with secondary Raynaud's constituted 33% of the total with a preponderance of women (ratio 3:2). Perhaps the differences between the two groups may be highlighted by further studies that include more patients, especially more men, with secondary RP. The diagnosis of Raynaud's phenomenon will to a large extent remain clinical. However the characterisation of the digital artery response to a cold stress in terms of a percentage drop from baseline values does allow the separation of the patient group from normal controls. By randomly selecting 50% of the data from controls and from patients, it was possible to plot percentage drop in baseline DADs. From this graph a cutoff point of 45% was derived which separated the responses of the control group from those of the patient group. When this cutoff was applied as a diagnostic test to the rest of the data, it was possible to distinguish the patients from the controls with a specificity of 100% and a sensitivity of 96.3%. The less than 100% sensitivity was accounted for by the single patient with 36% decrease in baseline DAD on cold stress, who felt that the cold stress test had not provoked a typical Raynaud's "attack". While reemphasising that the diagnosis of Raynaud's will remain clinical we suggest that the method of measuring digital artery diameters using high frequency ultrasound together with a standardised cold stress test offers a direct, reproducible and noninvasive means of assessing the extent of vasospasm that occurs in response to a cold challenge. The method also provides a useful objective parameter

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against which to compare the effects of various therapeutic interventions.

Acknowledgements
The authors would like to acknowledge the generous assistance given by the Raynaud's and Scleroderma Association.

References
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Accepted 24 January 1994

Eur J Vasc Surg Vol 8, September 1994