Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program

OBJECTIVE

Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting.

METHODS

This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis).

RESULTS

Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot.

CONCLUSIONS

In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Arterial Blood Flow and Effects on Limb Tissue Perfusion During Endoshunting of the Common Iliac Artery in an Experimental Porcine Model

Objective

Temporary arterial shunting is an established method to prevent tissue ischaemia. Although less well established, shunting might also be achieved through endovascular and hybrid techniques, known as endoshunting. Endoshunting offers advantages, for example, enabling minimally invasive access and avoiding complete occlusion of the donor artery. In an ex vivo bench test, volume flow in various interconnected endoshunt systems has been tested previously. This study aimed to investigate the capacity of the best performing endoshunt system in vivo.

Methods

Six anaesthetised pigs had their common iliac arteries (CIAs) explored, with the left CIA serving as the experimental and the right CIA as the control. Mean arterial pressure, regional blood flow, endoshunt flow, and regional oxygen extraction and lactate production were recorded. Distal muscle perfusion was monitored using near infrared spectroscopy (NIRS). Each experiment involved baseline registration, cross clamping of the left CIA, a 120 minute endoshunt session, and restoration of native flow.

Results

During cross clamping, NIRS values on the experimental side reached the lowest measurable value. Following endoshunt activation, there were no NIRS value differences between the experimental and control extremities whereas the average arterial flow decreased in both the experimental (270-140 mL/min, p = .028) and control extremities (245-190 mL/min, p = .25), with a greater drop on the endoshunted side (48% vs. 22%, respectively). Lactate levels temporarily increased by 42% in the endoshunted limb on endoshunt activation but were normalised within an hour. Oxygen extraction remained constant at 55% on the control side but increased to 70% on the endoshunted side (p = .068).

Conclusion

In this animal model, a flow optimised endoshunt system appeared to provide sufficient blood flow and restored stable tissue perfusion. Although arterial flow was slightly lower and oxygen extraction slightly higher on the endoshunted side, the endoshunt seemed to deliver adequate perfusion to prevent significant ischaemia.

A Tubular Vena Cava Conduit Used to Lengthen a Kidney Transplant Renal Artery Injured During Organ Procurement

Introduction

Organ transplantation is limited by the supply of transplantable organs, and the supply of organs cannot meet the needs of patients on the waiting list. Ensuring transplantation of any procured organ is therefore mandatory. Organ injury, mostly to the organ's vasculature, can occur during multi-organ procurement, preventing subsequent transplantation. In such a context, vascular reconstructions of arterial or venous organ injuries can be useful.

Report

This report describes the case of an obese 64 year old female with a history of diabetic nephropathy who underwent a cadaveric kidney transplant (right kidney with one main renal artery, one inferior polar artery, one vein, and one ureter). The ex situ preparation of the graft revealed that the main renal artery was injured and cut close to the renal hilum (0.8 cm length, 6 mm diameter), not allowing graft implantation. In order to increase the length of the main renal artery, the donor inferior vena cava was used to create a tubular conduit, allowing subsequent graft implantation. Cold and warm ischaemic times were respectively 12 hours and 36 minutes, with immediate graft function. The patient was discharged on day 8 (serum creatinine level was 95 μmol/L). Twelve month follow up was uneventful (serum creatinine level was 108 μmol/L and duplex ultrasonography showed homogeneous blood flow throughout the graft).

Discussion

This case report highlights the possibility of overcoming an injured kidney graft artery by creating a tubular vena cava conduit in order to allow subsequent transplantation. Vascular reconstructions of organs injured during procurement should be considered.

A systematic review of frailty assessment tools used in vascular surgery research

OBJECTIVE

Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice.

METHODS

Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed.

RESULTS

Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population.

CONCLUSIONS

Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.

Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data

OBJECTIVE

To justify the up front risks of offering elective interventions for intermittent claudication (IC), patients should have reasonable life expectancy to derive durable clinical benefits. Open surgery for chronic limb threatening ischaemia (CLTI) is maximally beneficial in patients surviving ≥ 2 years. The aim was to assess long term survival after IC and CLTI interventions.

METHODS

In a retrospective cohort analysis, the Vascular Quality Initiative (VQI) registry from 1 January 2010 to 31 May 2021 was queried for peripheral vascular intervention (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for IC and CLTI across 286 US centres. VQI linkage to Medicare insurance claims provided five year survival data. Multivariable analysis identified factors associated with five year mortality.

RESULTS

There were 31 457 PVIs (44.7% IC, 55.3% CLTI), 7 978 IIBs (26.9% IC, 73.1% CLTI), and 2 149 SIBs (50.1% IC, 49.9% CLTI) recorded in the VQI. Among the PVI, IIB, and SIB cohorts, average ages were 75, 73, and 72 years, respectively. Respective five year mortality after PVI for IC and CLTI was 37.2% and 71.1%; after IIB for IC and CLTI it was 37.8% and 60%; and after SIB for IC and CLTI it was 33.8% and 53.8%. On multivariable analysis, across all procedures, end stage renal disease, CLTI, congestive heart failure, anaemia, chronic obstructive pulmonary disease, and prior amputation were independently associated with increased mortality. Pre-admission home living and pre-operative aspirin use were independently associated with decreased mortality.

CONCLUSION

Long term survival in Medicare patients undergoing interventions in VQI centres for peripheral arterial disease is poor. Two thirds of CLTI patients and over one third of IC patients were not alive at five years. Intervening for IC in patients with high mortality risk should be avoided. For CLTI patients identified with decreased survival likelihood, intervention durability may be less important than invasiveness. Pre-operative medical optimisation should always be undertaken.

The first meta-analysis research on the effects of endovenous laser ablation combined with sapheno-femoral junction high ligation of the great saphenous vein

Endovenous laser ablation (EVLA) is a common minimally invasive technique used to treat varicose veins. The most commonly used laser wavelengths for EVLA/EVLT of varicose veins are 810 nm and 1470 nm. The laser pulse frequency is typically set to continuous wave (CW) mode, with a pulse duration of a few milliseconds (ms) delivered in a radial mode. The energy delivered per pulse is typically set between 40 and 120 Joules, with a power setting of 10 to 30 watts and an intensity setting of 40 to 120 J/cm2. The controversy exists regarding the benefits of performing saphenofemoral junction (SFJ) ligation prior to EVLA to decrease the recurrence rate of varicose veins. This meta-analysis aims to investigate the effectiveness of combining EVLA with high ligation versus using EVLA alone in treating lower extremity varicose veins. We conducted a systematic search of four databases from their inception until July 1, 2022, for randomized controlled trials and prospective controlled trials evaluating the advantages and disadvantages of EVLA with or without high ligation for the treatment of lower extremity varicose veins. In analyzing binary data, rate difference (RD) is used, while odds ratio (OR) is used for evaluating the confidence interval (CI) of binary data. A P value of less than 0.05 is deemed statistically significant. Heterogeneity is assessed using the chi-square test. If the I2 statistic, which reflects statistical heterogeneity, is greater than 50%, a random-effects model should be used. In the absence of significant statistical heterogeneity, a fixed-effects model should be used if I2 is less than 50%. We used the Cochrane risk-of-bias tool to assess the quality of the studies and Review Manager 5.4 for the primary and secondary outcome analysis. The meta-analysis was conducted in accordance with the Cochrane Handbook. There were no significant differences in the rate of major complications (RR = 1.63; 95% CI, 0.40-6.69; P = 0.50) or in the frequency of minor complications (RR = 1.07, 95% CI, 0.87-1.31; P = 0.52) between the EVLA with high ligation (EVLA/HL) group and the EVLA group. However, the rate of vein occlusion was significantly lower in the EVLA group than in the EVLA/HL group (RR = 1.06; 95% CI, 1.03-1.09; P = 0.0004). Our meta-analysis indicates that combining EVLA with high ligation provides stable long-term clinical efficacy in treating varicose veins of the lower extremities, although it increases the invasiveness of the surgery. The use of EVLA alone may be less effective in preventing vein occlusion.

Below-Knee Prosthetic Bypass Is a Viable Option for Limb Salvage in Patients with Extensive Femoropopliteal Occlusive Disease

Purpose

This study aimed to (1) evaluate the outcomes of below-knee prosthetic bypass (BKPB) in the absence of the great saphenous vein, and (2) identify risk factors associated with these outcomes.

Materials and Methods

This study included 37 consecutive patients who underwent BKPB with or without distal modification between 2010 and 2022. We further assessed the following treatment outcomes: primary patency (PP), secondary patency (SP), limb salvage (LS), and amputation-free survival (AFS) rates. The risk factors for PP were also examined.

Results

Most patients (n=31) were male. In 32 (86.5%) patients, BKPBs were performed for chronic limb-threatening ischemia. At the time of initial admission, two (5.4%) early deaths and three (8.1%) major amputations were noted. At 1 year after BKPB, the overall PP, SP, LS, and AFS rates were 78%, 85%, 85%, and 70%, respectively; at 3 years, they were 58%, 70%, 80%, and 52%, respectively; and at 5 years, they were 35%, 58%, 62%, and 29%, respectively. Notably, PP was significantly lower in limbs with ≤1 patent tibial arteries than in limbs with ≥2 patent artery (hazard ratio [HR], 3.80; 95% confidence interval [CI], 1.14-12.69 for overall; and HR, 12.97; 95% CI, 2.15-78.08 for distal anastomosis to below-knee popliteal artery). However, the PP was unaffected by the distal modification.

Conclusion

BKPB is a viable option for LS in patients with extensive femoropopliteal disease. Tibial runoff was significantly correlated with patency; therefore, decision-making for BKPB and follow-up must involve careful evaluation of the outflow arteries.

Racial and ethnic differences in presentation severity and postoperative outcomes in vascular surgery

BACKGROUND

We assessed the effect of race and ethnicity on presentation severity and postoperative outcomes in those with abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral arterial disease (PAD), and type B aortic dissection (TBAD).

METHODS

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception until December 2020. Two reviewers independently selected randomized controlled trials and observational studies reporting race and/or ethnicity and presentation severity and/or postoperative outcomes for adult patients who had undergone major vascular procedures. They independently extracted the study data and assessed the risk of bias using the Newcastle-Ottawa scale. The meta-analysis used random effects models to derive the odds ratios (ORs) and risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). The primary outcome was presentation severity stratified by the proportion of patients with advanced disease, including ruptured vs nonruptured AAA, symptomatic vs asymptomatic CAS, chronic limb-threatening ischemia vs claudication, and complicated vs uncomplicated TBAD. The secondary outcomes included postoperative all-cause mortality and disease-specific outcomes.

RESULTS

A total of 81 studies met the inclusion criteria. Black (OR, 4.18; 95% CI, 1.31-13.26), Hispanic (OR, 2.01; 95% CI, 1.85-2.19), and Indigenous (OR, 1.97; 95% CI, 1.39-2.80) patients were more likely to present with ruptured AAAs than were White patients. Black and Hispanic patients had had higher symptomatic CAS (Black: OR, 1.20; 95% CI, 1.04-1.38; Hispanic: OR, 1.32; 95% CI, 1.20-1.45) and chronic limb-threatening ischemia (Black: OR, 1.67; 95% CI, 1.14-2.43; Hispanic: OR, 1.73; 95% CI 1.13-2.65) presentation rates. No study had evaluated the effect of race or ethnicity on complicated TBAD. All-cause mortality was higher for Black (RR, 1.23; 95% CI, 1.01-1.51), Hispanic (RR, 1.90; 95% CI, 1.57-2.31), and Indigenous (RR, 1.24; 95% CI, 1.12-1.37) patients after AAA repair. Postoperatively, Black (RR, 1.54; 95% CI, 1.19-2.00) and Hispanic (RR, 1.54; 95% CI, 1.31-1.81) patients were associated with stroke/transient ischemic attack after carotid revascularization and lower extremity amputation (RR, 1.90; 95% CI, 1.76-2.06; and RR, 1.69; 95% CI, 1.48-1.94, respectively).

CONCLUSIONS

Certain visible minorities were associated with higher morbidity and mortality across various vascular surgery presentations. Further research to understand the underpinnings is required.

Evaluating national guideline concordance of recurrent interventions after radiocephalic arteriovenous fistula creation

OBJECTIVE

Radiocephalic arteriovenous fistulas have been historically perceived as requiring multiple follow-up procedural interventions to achieve maturation and maintain patency. Recent clinical practice guidelines from the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) emphasize a patient-centered hemodialysis access strategy with new maximum targets for intervention rates, potentially conflicting with concomitant recommendations to prioritize autogenous forearm hemodialysis access creation. The present descriptive study seeks to assess whether radiocephalic fistulas can meet the KDOQI guideline benchmarks for interventions following access creation, and to elucidate clinical and anatomic characteristics associated with the timing and frequency of interventions following radiocephalic arteriovenous fistula creation.

METHODS

Prospective patient-level data from the multicenter PATENCY-1 and PATENCY-2 randomized trials, which enrolled patients undergoing new radiocephalic arteriovenous fistula creation, was analyzed (ClinicalTrials.govNCT02110901 and NCT02414841). The primary outcome was the rate of interventions at 1 year postoperatively. Incidence rates were calculated, and time to surgical or endovascular intervention following fistula creation was modeled using recurrent event extensions of the Cox proportional hazards model. Confidence intervals at the 95% level were calculated using nonparametric bootstrapping.

RESULTS

The cohort consisted of 914 patients; mean age was 57 years (standard deviation, 13 years), and 22% were female. Median follow-up was 707 days (interquartile range, 447-1066 days). The incidence of interventions per person-year was 1.04 (95% confidence interval [CI], 0.95-1.13) overall; 1.10 (95% CI, 0.98-1.21) before fistula use, and 0.96 (95% CI, 0.82-1.11) after fistula use. The most common interventions overall were balloon angioplasty (54.9% of all interventions), venous side-branch ligation (16.4%), and open revisions (eg, proximalization from snuffbox to wrist, 16.4%). The locations requiring balloon angioplasty included the juxta-anastomotic segment (51.7% of angioplasties), the outflow vein (29.2%), the inflow artery (14.8%), the central veins (3.8%), and the cephalic arch (0.5%). Common indications were to restore or maintain patency (75.6% of all interventions), assist maturation (14.9%), improve depth (4.4%), or improve augmentation (3.0%). In the multivariable regression analysis, female sex (adjusted hazard ratio [HR], 1.21; 95% CI, 1.05-1.45), diabetes (HR, 1.21; 95% CI, 1.01-1.46), and intraoperative vein diameter <3.0 mm (vs ≥4.0 mm: HR, 1.33; 95% CI, 1.02-1.66) were associated with earlier and more frequent interventions. Patients not on hemodialysis at the time of fistula creation underwent less frequent interventions (HR, 0.69; 95% CI, 0.59-0.81).

CONCLUSIONS

Patients with radiocephalic arteriovenous fistulas can expect to undergo one intervention, on average, in the first year after creation, which aligns with current KDOQI guidelines. Patients already requiring hemodialysis, female patients, patients with diabetes, and patients with intraoperative vein diameters <3.0 mm were at increased risk for repeated intervention. No subgroup exceeded guideline-suggested maximum thresholds for recurrent interventions. Overall, the results demonstrate that creation of radiocephalic arteriovenous fistula remains a guideline-concordant strategy when part of an end-stage kidney disease life-plan in appropriately selected patients.

Presenting limb severity is associated with long-term outcomes after infrainguinal revascularization for chronic limb-threatening ischemia

OBJECTIVE

The SVS Wound, Ischemia, foot Infection (WIfI) limb staging system was established to estimate risk of major amputation in chronic limb-threatening ischemia (CLTI) and better stratify outcomes comparisons. There is little data on treatment outcomes beyond 1 year based on presenting WIfI stage.

METHODS

This is a single-institution retrospective study of 413 patients who underwent infrainguinal revascularization for CLTI (2011-2021) with data available for WIfI staging. Patient characteristics and outcomes were gathered from the electronic medical record. Data were analyzed based on presenting WIfI stage and initial treatment received at our center.

RESULTS

Presenting WIfI stages were 1 to 2 (23%), 3 (27%), and 4 (50%). Index revascularization approach was endoluminal (59%), autogenous vein bypass (29%), or non-autogenous bypass (13%). Operative mortality within 30 days was 2.9% and was not associated with WIfI stage or revascularization approach. Median limb follow-up time was 502 days (interquartile range [IQR], 112-1256 days), and median survival follow-up time was 932 days (IQR, 343-1770 days). Major amputation or death occurred in 19% and 46% of patients at median times of 119 days (IQR, 28-314 days) and 739 days (IQR, 204-1475 days), respectively. WIfI stage was independently associated with major amputation (P = .001), as was initial revascularization approach (P = .01). In a Cox proportional hazards model, factors independently associated with major amputation were male sex (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.04-2.0; P = .03), diabetes (HR, 1.8; 95% CI, 1.3-2.5; P = .001), WIfI stage 4 (HR, 2.3; 95% CI, 1.5-3.5; P < .001), and non-autogenous bypass (HR, 2.9; 95% CI, 2.1-4.2; P < .001). In a Cox proportional hazards model for mortality, independently associated factors were age (HR, 1.04; 95% CI, 1.02-1.05; P < .001), end-stage renal disease (HR, 2.8; 95% CI, 1.9-4.0; P < .001), congestive heart failure (HR, 1.9; 95% CI, 1.4-2.5; P < .001), chronic obstructive pulmonary disease (HR, 1.5; 95% CI, 1.1-2.1; P = .02), and WIfI stage 4 (HR, 1.6; 95% CI, 1.04-2.2; P = .03). Among those presenting with WIfI stage 4 limbs, Kaplan-Meier estimated rates of freedom from major amputation or death at 2 years were 71% ± 3.7% and 68% ± 3.5%, respectively. In an inverse propensity weighted Cox proportional hazards model, non-white race (HR, 1.5; 95% CI, 1.01-2.2; P = .047), diabetes (HR, 2.0; 95% CI, 1.2-3.3; P = .008), Global Anatomic Staging System infrapopliteal grade (HR, 1.2; 95% CI, 1.05-1.3; P = .005), non-autogenous bypass (HR, 3.2; 95% CI, 1.9-5.3; P < .001), and endoluminal revascularization (HR, 2.6; 95% CI, 1.6-4.3; P < .001) were independently associated with major amputation in the WIfI stage 4 subgroup.

CONCLUSIONS

Presenting WIfI stage is strongly associated with long-term risks of major amputation and death following infrainguinal revascularization for CLTI and should be used to stratify outcomes comparisons. Effective revascularization is critical in WIfI stage 4 disease, and autogenous vein bypass provides durable long-term limb preservation.

Management of Takayasu arteritis

This review overviews the challenges in the assessment of disease activity, damage, and therapy of Takayasu arteritis (TAK). Recently developed disease activity scores for TAK are more useful for follow-up visits and require validation of cut-offs for active disease. A validated damage score for TAK is lacking. Computed tomography angiography (CTA), magnetic resonance angiography (MRA), and ultrasound enable the evaluation of vascular anatomy and arterial wall characteristics of TAK. 18-fluorodeoxyglucose (18-FDG) positron emission tomography (PET) visualizes arterial wall metabolic activity and complements the information provided by circulating C-reactive protein (CRP) levels. ESR and CRP alone moderately reflect TAK disease activity. TAK is corticosteroid-responsive but relapses upon tapering corticosteroids. Conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs) are the first-line maintenance agents, and tumor necrosis factor-alpha inhibitors, tocilizumab, or tofacitinib are second-line agents for TAK. Revascularization procedures for TAK should be used judiciously during periods of inactive disease.

Incidence and risk factors for pressure injuries in patients who have undergone vascular operations: a scoping review

BACKGROUND

Patients who have undergone vascular operations are thought to be at an increased risk for developing pressure injuries; however, the extent to which pressure injuries occur in this population is not clear. This scoping review sought to summarize what is known about the incidence of pressure injuries, and the risk factors for the development of pressure injuries in patients who have undergone vascular operations. MAIN: An initial search identified 2564 articles, and 9 English language studies were included. Results showed that due to study design limitations in the available literature preventing hospital-acquired and present on admission pressure injuries to be distinguished, it is difficult to ascertain the incidence rate of pressure injuries in this population.

CONCLUSION

Certain vascular procedures were found to be higher risk for the development of pressure injuries such as major amputations and lower extremity bypass surgery. In addition to procedural risk factors, patient factors were identified that may be associated with the development of pressure injuries in the vascular population, and these in the authors' view deserve further exploration. Overall, this scoping review identified an area ripe for future research, the results of which would have implications for wound care in healthcare institutions and at home.

Evaluation of the ICD-10 system in coding revascularisation procedures in patients with peripheral arterial disease in England: A retrospective cohort study using national administrative and clinical databases

BACKGROUND

Many studies evaluating care in hospitals in England use the Hospital Episode Statistics (HES) administrative database. The aim of this study was to explore whether the International Classification of Diseases 10th Revision (ICD-10) system used by HES supported the evaluation of care received by patients with peripheral arterial disease (PAD) who had revascularisation.

METHODS

This retrospective cohort study used records on patients who had revascularisation for PAD between 1st January 2017 and 31st December 2019 in England, collected prospectively in the National Vascular Registry (NVR) and linked to HES. Patients were excluded if their NVR record did not have a match in HES, due to lack of consent or different admission and procedure dates. Agreement between different presentations of PAD recorded in the NVR and the ICD-10 diagnostic codes recorded in HES was evaluated using the unweighted Kappa statistic and sensitivity and specificity. Agreement between the NVR and HES was also assessed for gender, age, comorbidities, mode of admission, and procedure type and side.

FINDINGS

In total, 20,603 patients who had 24,621 admissions were included in the study. Agreement between NVR and HES on patient gender (Kappa = 0.98), age (Kappa = 0.98), mode of admission (Kappa = 0.80), and procedure type and side (Kappa = 0.92 and 0.87, respectively) was excellent. When all diagnostic fields in HES were explored, substantial agreement was observed for chronic ischaemia with tissue loss (Kappa = 0.63), but it was lower for chronic ischaemia without tissue loss (Kappa = 0.32) and acute limb ischaemia (Kappa = 0.15). Agreement on comorbidities was mixed; excellent for diabetes (Kappa = 0.82), moderate for chronic lung disease (Kappa = 0.56), chronic kidney disease (Kappa = 0.56), and ischaemic heart disease (Kappa = 0.45) and fair for chronic heart failure (Kappa = 0.35).

INTERPRETATION

The diagnostic ICD-10 codes currently used in HES cannot accurately differentiate between stages of PAD. Therefore, studies using HES to examine patterns of care and outcomes for patients with PAD are likely to suffer from misclassification bias. Adopting an extended ICD-10 system or the ICD-11 version released to the World Health Organisation member states in 2022, may overcome this problem.

FUNDING

Healthcare Quality Improvement Partnership (HQIP).

Readmissions Following Arteriovenous Access Creation for Haemodialysis in a French National Database

OBJECTIVE

There is a lack of large real world data on arteriovenous (AV) access results. This study aimed to describe the required hospital care during the first year following creation of AV access.

METHODS

Data from all adult patients who underwent creation of AV access performed in 2017 in a public or private facility were collected through the French national hospitalisation database. Patients were classified into two groups ("de novo" and "secondary") according to their history of prior AV access creation. The primary outcome was the proportion of patients with at least one hospital readmission related to the AV access recorded during the first 12 post-operative months.

RESULTS

In 2017, 10 476 adult patients underwent AV access creation in France, including 8 690 (83%) de novo creations. An AV fistula was created for 92% of the patients (95% de novo vs. 78% secondary; p < .001). During the first 12 post-operative months, 6 591 (63%) patients recorded at least one related readmission (68% secondary vs. 62% de novo; p < .001). A total of 5 557 (53%) recorded a readmission for surgical/interventional procedure and 2 852 (27%) were observed with a readmission for medical complications. The mean (± standard deviation) number of related readmissions at 12 months was 1.4 ± 1.6 per patient (1.7 ± 1.9 secondary vs. 1.3 ± 1.5 de novo; p < .001). Patients with an AV graft were more frequently readmitted than those with an AV fistula (1.8 ± 2 vs. 1.3 ± 1.5 readmission; p < .001).

CONCLUSION

This study highlights the high frequency of readmissions during the first 12 months following creation of AV access, particularly in patients who had already undergone creation of a previous AV access or had an AV graft implanted. Further research should focus on tailoring AV access strategies to improve patient quality of life and decrease the healthcare cost burden.

Optimisation of Volume Flow Rates when Using Endovascular Shunting Techniques: An Experimental Study in Different Bench Flow Circuits

Objective

Acute tissue ischaemia may arise due to arterial emergencies or during more complex vascular procedures and may be mitigated by temporary shunting techniques.
Endovascular shunting (ES) techniques enable percutaneous access and shunting from the donor artery without the need to completely interrupt the arterial flow in the donor artery. An endoshunt system may also cover longer distances than most conventional shunts. The aim was to investigate and optimise the flow rates in different endovascular shunt systems.

Methods

Step 1: The flow capacity of different ES configurations was compared with the flow capacity of a 9 Fr Pruitt-Inahara shunt (PIS). An intravenous bag with 0.9% NaCl, pressurised to 90 mmHg, was connected simultaneously to a PIS and to one of the tested ES configurations. The two shunt systems were then opened at the same time.
The delivered fluid volumes from the shunt systems were collected and measured. The volume flow rate was subsequently calculated.
Steps 2 and 3: Within a heart lung machine circuit, pressure-flow charts were constructed for the individual ES components and for the fully connected optimised endoshunt systems. The flow rate was increased in steps of 40-50 mL/min while monitoring the driving pressure, enabling the creation and comparison of the pressure-flow charts for the individually tested components. In total, seven individual inflow and outflow potential ES components were investigated with inflow and outflow diameters ranging from 6 to 15 Fr.

Results

ES systems based on standard donor introducers led to substantially lower volume flow than the corresponding PIS volume flow, whereas ES systems based on dedicated 6 or 8 Fr dialysis access introducers (Prelude Short Sheet, Merit Medical) matched PIS flow rates. The introduction of 30 cm long ¼'' perfusion tubing within the ES system did not affect volume flow for any of the tested ES configurations.

Conclusion

Endoshunting techniques can match PIS volume flow rates over short and long distances. The achieved ES flow rate is highly dependent on the components used within the ES system.

Editor's Choice - Sex Differences in Response to Administration of Heparin During Non-Cardiac Arterial Procedures

OBJECTIVE

Females are more prone to complications during non-cardiac arterial procedures (NCAPs) than males. The current study investigated the difference in the effect of peri-procedural prophylactic heparin in males and females, using the activated clotting time (ACT). This was a retrospective analysis of a prospective multicentre cohort study.

METHODS

All patients undergoing elective NCAP using heparin and ACT measurements between January 2016 and March 2020 were included. Two heparin dosage protocols were used: weight based dosing of 100 IU/kg (international units per kilogram) or a bolus of 5 000 IU. The primary outcome was the anticoagulatory effect of heparin after five minutes, measured by ACT. Secondary outcomes were the effect of heparin after 30 minutes, bleeding complications, and arterial thromboembolic complications (ATECs).

RESULTS

A total of 778 patients were included; 26% were female. After 100 IU/kg (n = 300), females more often reached longer ACT (< 200 seconds: 22% vs. 25%, p = .62; 200 - 250 seconds: 41% vs. 53%, p = .058; 251 - 280 seconds, 26% vs. 15%, p = .030). The mean ACT after 100 IU/kg heparin was 233 seconds (95% confidence interval [CI] 224 - 243) for females and 226 seconds (95% CI 221 - 231) for males (p = .057). After a bolus of 5 000 IU of heparin (n = 411), females reached significantly higher levels of anticoagulation than males (mean ACT 204 seconds vs. 190 seconds: p ≤ .001; ACT < 200 seconds: 44% vs. 66%; p < .001; ACT 200 - 250 seconds: 47% vs. 30%, p = .001; ACT 251 - 280 seconds: 7.8% vs. 2.3%, p = .009). Thirty minutes after heparin administration, 58% of all patients had an ACT < 200 seconds. ATECs did not differ between females and males (6.9% vs. 5.1%, p = .33) but bleeding complications were higher in females (27% vs. 16%, p = .001).

CONCLUSION

Heparin leads to significantly longer ACT in females during NCAP. Further research is needed to investigate whether individually based heparin protocols lead to fewer bleeding complications and lower incidence of ATECs.

Patient Transfer with Kocher Forceps on the Axillary Artery: A Rare Case of Ongoing Iatrogenic Vascular Injury

Iatrogenic trauma of the axillary artery by non-vascular surgeons can occur during various general surgical procedures such as resection of soft tissue tumors or axillary lymph node clearance. Prompt recognition, appropriate initial management, and rapid transfer to a tertiary vascular surgery service, if needed, are key steps to ensuring patient safety. Here we present a case of iatrogenic axillary artery injury during the resection of a recurrent soft tissue tumor in a local hospital. The desperate application of a Kocher clamp on the bleeding axillary artery by the operating general surgeons controlled the bleeding but led to further arterial damage. The patient was transferred to our tertiary hospital, where the arterial injury was repaired using a vein interposition graft. Apart from the encountered intraoperative technical challenges, this case highlights the need for broader training of non-vascular specialist surgeons on the core principles of basic vascular surgical techniques and oncovascular surgery.

Editor's Choice - Post-operative Surveillance and Long Term Outcome after Endovascular Aortic Aneurysm Repair in Patients with an Initial Post-operative Computed Tomography Angiogram Without Abnormalities: the Multicentre Retrospective ODYSSEUS Study

OBJECTIVE

Lifelong imaging surveillance is recommended following endovascular aneurysm repair (EVAR). This study aimed to examine the association between adherence to post-operative surveillance and survival and secondary interventions in patients with an initial post-operative computed tomography angiogram (CTA) without abnormalities.

METHODS

All consecutive patients undergoing EVAR for intact abdominal aortic aneurysm (AAA) in 16 hospitals between 2007 and 2012 were identified retrospectively, with follow up until December 2018. Patients were included if the initial post-operative CTA showed no types I - III endoleak, kinking, infection, or limb occlusion. Discontinued follow up was defined as at least one 16 month period in which no imaging surveillance was performed. Primary outcomes were aneurysm related mortality and secondary interventions, and secondary outcome all cause mortality. Kaplan-Meier analysis was used to estimate survival, and Cox regression analyses to identify the association between independent variables and outcome. Sensitivity analyses were performed by varying the definition of continued yearly follow up. The study protocol was published (bmjopen-2019-033584).

RESULTS

1 596 patients (552 continued, 1 044 discontinued follow up) were included with a median (interquartile range) follow up of 89.1 months (52.6). Cumulative aneurysm related, overall, and intervention free survival was 99.4/94.8/96.1%, 98.5/72.9/85.9%, and 96.3/45.4/71.1% at 1, 5, and 10 years, respectively. American Society of Anesthesiologists (ASA) classification (ASA IV hazard ratio [HR] 3.810, 95% confidence interval [CI] 1.296 - 11.198), increase in AAA diameter (HR 3.299, 95% CI 1.408 - 7.729), and continued follow up (HR 3.611, 95% CI 1.780 - 7.323) were independently associated with aneurysm related mortality. The same variables and age (HR 1.063 per year, 95% CI 1.052 - 1.074) were significantly associated with all cause mortality. No difference in secondary interventions was observed between patients with continued vs. discontinued follow up (89/552; 16% vs. 136/1044; 13%; p = .091). Sensitivity analyses showed worse aneurysm related and overall survival in patients with continued follow up.

CONCLUSION

Discontinued follow up is not associated with poor outcomes. Future prospective studies are indicated to determine in which patients imaging follow up can be safely reduced.

Treating peripheral arterial occlusive disease and acute limb ischemia during a COVID-19 pandemic in 2020

Background

For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI).

Methods

A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics.

Results

In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018.

Conclusions

The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.

Torso vascular trauma

Vascular injury within the chest or abdomen represents a unique challenge to the pediatric general surgeon, as these life- or limb-threatening injuries are rare and may require emergent treatment. Vascular injury may present as life-threatening hemorrhage, or with critical ischemia from intimal injury, dissection, or thrombosis. Maintaining the skillset and requisite knowledge to address these injuries is of utmost importance for pediatric surgeons that care for injured children, particularly for surgeons practicing in freestanding children's hospitals that frequently do not have adult vascular surgery coverage. The purpose of this review is to provide an overview of torso vascular trauma, with a specific emphasis in rapid recognition of torso vascular injury as well as both open and endovascular management options. Specific injuries addressed include blunt and penetrating mediastinal vascular injury, subclavian injury, abdominal aortic and visceral segment injury, inferior vena cava injury, and pelvic vascular injury. Operative exposure, vascular repair techniques, and damage control options including preperitoneal packing for pelvic hemorrhage are discussed. The role and limitations of endovascular treatment of each of these injuries is discussed, including endovascular stent graft placement, angioembolization for pelvic hemorrhage, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in children.

In-patient care trends in peripheral artery disease in the German healthcare system over the past decade

OBJECTIVES

To analyze trends of in-hospital treatment of patients admitted due to peripheral artery disease (PAD) from 2009 to 2018 with special focus on comorbidities, revascularization procedures, resulting costs, and outcome.

METHODS

Using data from the research data center of the German Federal Statistical Office, we included all hospitalizations due to PAD Fontaine stage IIb or higher from 2009 to 2018. To analyze comorbidities, Elixhauser diagnostic groups and linear van Walraven score (vWS) were assessed.

RESULTS

A total of 1.8 million hospitalizations resulting in €10.3 billion in reimbursement costs were included. From 2009 to 2018, the absolute number of hospitalizations due to PAD increased by 13.3% (163,547 to 185,352). The average cost per hospitalization increased by 20.8% from €5,261 to €6,356. The overall in-hospital mortality decreased from 3.1 to 2.6%. Median vWS of all PAD cases increased by 3 points (2 to 5). The number of percutaneous transluminal angioplasties (PTA) increased by 43.9% while some surgical procedures such as bypasses and embolectomies decreased by 30.8% and 6.8%, respectively. Many revascularization procedures showed a disproportionate increase of those performed in vessels below the knee for example in PTA (+ 68.5%) or in endarterectomies (+ 38.8%).

CONCLUSIONS

This decade-long nationwide analysis shows a rising number of hospitalizations due to PAD with more comorbid patients resulting in increasing reimbursement costs. Interventions are shifting from surgical to endovascular approaches with a notable trend towards interventions in smaller vessels below the knee.

KEY POINTS

• The number of hospitalizations due to peripheral artery disease is rising and it is associated with increasing reimbursement costs. • Admitted patients are older and show an increasing number of comorbidities while overall in-hospital mortality is decreasing. • Revascularization procedures are shifting from surgical to endovascular approaches and show a trend towards intervention in smaller vessels below the knee. • Major amputations are decreasing while the number of minor amputations is increasing.

Low postoperative blood platelet count may be a risk factor for 3-year mortality in patients with acute type A aortic dissection

Background

Mortality and complications remain high after acute type A aortic dissection (ATAAD) open surgery and are associated with coagulation dysfunction. Platelets play an important role in the process of coagulation. This study explored the relationship between postoperative platelet counts and 3-year mortality after operation in patients with ATAAD undergoing open aortic repair surgery.

Methods

Patients with ATAAD who underwent Total Arch Replacement and Frozen Elephant Trunk in Fuwai Hospital from 2011 to 2015 were selected for this study. The perioperative data were collected and sorted through the electronic clinical case system. Multivariate Logistic regression was used to analyze the risk factors for death within three years after surgery.

Results

A total of 495 patients were included in the analysis. After correction for confounding factors, decreased postoperative platelet count remained an independent factor that was associated with lower mortality (OR = 0.918, 95% CI 0.853–0.988, P = 0.023).

Conclusions

The study indicated that decreased postoperative platelet count may lead to increased 3-year mortality, in patients with ATAAD who underwent open aortic repair surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01623-7.

What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons

INTRODUCTION

The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK.

METHODS

A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign.

RESULTS

Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF's 5-day 'admitted care' pathway is achievable, only 28.6% thought the 14-day 'non-admitted care' pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment.

CONCLUSIONS

The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an 'urgent' model of care may help to potentially overcome these challenges.

Arterial embolization of metal-on-metal hip arthroplasty-related pseudotumor material causing acute limb ischemia

We have described a complication of a pseudotumor secondary to metal-on-metal hip arthroplasty. The patient experienced acute limb ischemia after pseudotumor material had invaded and stenosed the external iliac artery and embolized distally. Multiple vascular surgery procedures were performed to revascularize the limb. The present report highlights the importance of involving vascular surgeons early in a limb-threatening presentation of a pseudotumor to achieve limb salvage.

Outcomes of Vascular Resection and Reconstruction in Extremity Soft Tissue Sarcoma and Bone Tumors

Purpose

This study aimed to evaluate and analyze the feasibility and the oncological and functional outcomes of limb salvage surgery in extremity soft tissue sarcomas (ESTS) and bone tumors invading vessels.

Materials and Methods

This single-center retrospective analysis included patients with ESTS encasing or invading major blood vessels that were treated by limb salvage surgery with vascular resection and reconstruction between January 1995 and December 2019. Patients with contiguous involvement of major blood vessels and nerves and patients requiring amputation were excluded from the study.

Results

A total of 24 vessels (14 arteries and 10 veins) in 14 patients were reconstructed. Ten (71.4%) patients underwent both arterial and venous reconstruction, and four (28.6%) underwent only arterial reconstruction. Reconstruction was performed with a reversed saphenous vein (RSV) graft in 12 patients and with a synthetic graft (SG) in the other 12 patients. At a median follow-up of 27 months, RSV grafts were patent in 10 of 12 (83.3%) vessels and SGs were patent in 6 of 12 (50.0%) vessels (log-rank test, P=0.083). Out of 14 arteries and 10 veins, 11 arteries and 5 veins were patent, respectively. No patient developed local recurrence, and 2 (14.3%) patients developed distant metastases. Limb salvage rate was 13/14 (92.9%). The mean Musculoskeletal Tumor Society score was 83.3%. The 5- and 10-year overall survival rates were 80% and 50%, respectively.

Conclusion

Limb salvage surgery in ESTS with vascular resection and reconstruction is feasible and provides favorable oncological and functional outcomes.

Reassessing the operative threshold for abdominal aortic aneurysm repair in the context of COVID-19

OBJECTIVE

The worldwide pandemic involving the novel respiratory syndrome (COVID-19) has forced health care systems to delay elective operations, including abdominal aortic aneurysm (AAA) repair, to conserve resources. This study provides a structured analysis of the decision to delay AAA repair and quantify the potential for harm.

METHODS

A decision tree was constructed modeling immediate repair of AAA relative to an initial nonoperative (delayed repair) approach. Risks of COVID-19 contraction and mortality, aneurysm rupture, and operative mortality were considered. A deterministic sensitivity analysis for a range of patient ages (50 to >80), probability of COVID-19 infection (0.01%-30%), aneurysm size (5.5 to >7 cm), and time horizons (3-9 months) was performed. Probabilistic sensitivity analyses were conducted for three representative ages (60, 70, and 80). Analyses were conducted for endovascular aortic aneurysm repair (EVAR) and open surgical repair (OSR).

RESULTS

Patients with aneurysms 7 cm or greater demonstrated a higher probability of survival when treated with immediate EVAR or OSR, compared with delayed repair, for patients under 80 years of age. When considering EVAR for aneurysms 5.5 to 6.9 cm, immediate repair had a higher probability of survival except in settings with a high probability of COVID-19 infection (10%-30%) and advanced age (70-85+ years). A nonoperative strategy maximized the probability of survival as patient age or operative risk increased. Probabilistic sensitivity analyses demonstrated that patients with large aneurysms (>7 cm) faced a 5.4% to 7.7% absolute increase in the probability of mortality with a delay of repair of 3 months. Young patients (60-70 years) with aneurysms 6 to 6.9 cm demonstrated an elevated risk of mortality (1.5%-1.9%) with a delay of 3 months. Those with aneurysms 5 to 5.9 cm demonstrated an increased survival with immediate repair in young patients (60); however, this was small in magnitude (0.2%-0.8%). The potential for harm increased as the length of surgical delay increased. For elderly patients requiring OSR, in the context of endemic COVID-19, delay of repair improves the probability of survival.

CONCLUSIONS

The decision to delay operative repair of AAA should consider both patient age and local COVID-19 prevalence in addition to aneurysm size. EVAR should be considered when possible due to a reduced risk of harm and lower resource utilization.

Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

OBJECTIVE

Vascular limb salvage services are recommended by the Global Vascular Guidelines to help improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study reports the 12 month outcomes for an outpatient based vascular limb salvage (VaLS) clinic.

METHODS

An analysis of a prospectively maintained database, involving all consecutive patients diagnosed with CLTI within the VaLS clinic from February 2018-February 2019, was undertaken. Data were compared with two comparator cohorts, identified from coding data: 1) patients managed prior to the clinic, between May 2017 and February 2018 (Pre-Clinic [PC]); and 2) patients managed outside of clinic, between February 2018 and February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan-Meier plots and adjusted Cox's proportional hazard models (aHR) were used to compare outcomes.

RESULTS

Five hundred and sixty-six patients (VaLS 158, AP 173, PC 235) were included (median age 74 years). Patients managed within the VaLS cohort were statistically significantly more likely to be free from major amputation (90.5%) compared with both the AP (82.1%, aHR 0.52, 95% confidence interval [CI] 0.28 - 0.98, p = .041) and the PC (80.0%; aHR 0.50, 95% CI 0.28 - 0.91, p = .022) cohorts at 12 months, after adjustment for age, disease severity, and presence of diabetes.

CONCLUSION

This study supports the recommendations of the Global Vascular Guidelines that vascular limb salvage clinics may improve the rate of major amputation. Furthermore, the study provides a reproducible service model that delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer term outcomes.

Development of three different decision support tools to support shared decision-making in vascular surgery

BACKGROUND

Shared decision-making (SDM) is known to improve quality of care. Particularly in vascular surgery treatment options are often preference-sensitive. Unfortunately, vascular surgeons infrequently apply SDM. Decision support tools (DSTs) have been shown to be helpful in SDM.

OBJECTIVE

This article describes the development process of three different DSTs to help vascular surgeons and patients apply SDM.

PATIENT INVOLVEMENT

Patients' information needs were obtained via focus group meetings. Fifty-two patients and eighteen vascular surgeons not involved in the development process evaluated the comprehensibility and usability of the DST-prototypes.

METHODS

A multidisciplinary steering group commissioned the development of the three DSTs according to international standards.

RESULTS

Digital decision aids and paper-based consultation cards and decision cards were developed for patients with an abdominal aortic aneurysm, carotid artery disease, intermittent claudication or varicose veins. Patients preferred the use of the decision aids followed by consultation cards, whereas vascular surgeons preferred to use decision cards followed by decision aids.

DISCUSSION

Decision aids, consultation cards and decision cards for four vascular diseases are now available to all vascular surgeons and patients in the Netherlands. The DSTs were well received by both surgeons and patients. English versions are also available.

Comparison of fibrin sealants in peripheral vascular surgery: A systematic review and network meta-analysis

Background

Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery.

Methods

A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed.

Results

Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%.

Conclusions

In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available.

•

Fibrin sealants can control perioperative bleeding, yet comparative evidence is limited.

•

This network meta-analysis compared fibrin sealants and compression in peripheral vascular surgery.

•

VISTASEAL and EVICEL had the highest probability of achieving hemostasis by 4 min.

•

These results show differences exist between fibrin sealants in peripheral vascular surgery.

[Operate, cancel, postpone or select?]

Gefäßchirurgische Zentren in Österreich (n = 15) wurden Mitte April 2020 mit erklärendem Begleitschreiben des Vorstands der Österreichischen Gesellschaft für Gefäßchirurgie (ÖGG) eingeladen, an einer Onlineumfrage über die Implikationen der COVID-19-Pandemie teilzunehmen. Insgesamt 12 Zentren (80 %) haben den Fragebogen ausgefüllt.

Alle Zentren waren mit positiv getesteten Patienten und 75 % auch mit positiv getesteten Mitarbeitern konfrontiert. Deutlich seltener war dies jedoch an den gefäßchirurgischen Abteilungen (positiv getestete Patienten in 25 %/Mitarbeiter in 33 %). Elektive Eingriffe wurden an allen Abteilungen entweder gestoppt (abgesagt oder verschoben) oder selektiv eingeschränkt. Dies betraf u. a. auch symptomfreie Patienten mit Karotisstenose, Aortenaneurysma kleiner 7 cm, peripherem Aneurysma, PAVK im Stadium II nach Fontaine oder Varikose. In allen Zentren wurden weiterhin uneingeschränkt gefäßchirurgische Notfälle behandelt. Uneinheitlich war das Vorgehen bei chronischen Ulzera, chronischer Mesenterialinsuffizienz, symptomfreiem Aortenaneurysma größer 7 cm und in der Shuntchirurgie.

Insgesamt war v. a. die zum Zeitpunkt der OP-Verschiebungen unklare Befristung der Maßnahmen problematisch, somit war auch das Risiko der abgesagten bzw. hinausgezögerten Behandlung nicht leicht abschätzbar. Für die Indikationen mit uneinheitlichem Vorgehen sollte unizentrisch und multizentrisch das Ergebnis der Patienten analysiert werden, auch hinsichtlich der mit der Verschiebung assoziierten psychologischen Belastung. Zudem bedürfen auch die aufgrund der COVID-19-Pandemie erfolgten Veränderungen im Alltag einer kritischen Auswertung, auch hinsichtlich demografischer und geografischer Unterschiede. Es ist anzunehmen, dass die Auswirkungen der COVID-19-Pandemie langfristig bedeutsam sind.

Improving shared decision-making in vascular surgery by implementing decision support tools: study protocol for the stepped-wedge cluster-randomised OVIDIUS trial

Background

Shared decision-making improves the quality of patient care. Unfortunately, shared decision-making is not yet common practice among vascular surgeons. Thus, decision support tools were developed to assist vascular surgeons and their patients in using shared decision-making. This trial aims to evaluate the effectiveness and implementation of decision support tools to improve shared decision-making during vascular surgical consultations in which a treatment decision is to be made.

Methods

The study design is a multicentre stepped-wedge cluster-randomised trial. Eligible patients are adult patients, visiting the outpatient clinic of a participating medical centre for whom several treatment options are feasible and who face a primary treatment decision for their abdominal aortic aneurysm, carotid artery disease, intermittent claudication, or varicose veins. Patients and vascular surgeons in the intervention group receive decision support tools that may help them adopt shared decision-making when making the final treatment decision. These decision support tools are decision aids, consultation cards, decision cards, and a practical training. Decision aids are informative websites that help patients become more aware of the pros and cons of the treatment options and their preferences regarding the treatment choice. Consultation cards with text or decision cards with images are used by vascular surgeons during consultation to determine which aspect of a treatment is most important to their patient. In the training vascular surgeons can practice shared decision-making with a patient actor, guided by a medical psychologist. This trial aims to include 502 vascular surgical patients to achieve a clinically relevant improvement in shared decision-making of 10 out of 100 points, using the 5-item OPTION instrument to score the audio-recordings of consultations.

Discussion

In the OVIDIUS trial the available decision support tools for vascular surgical patients are implemented in clinical practice. We will evaluate whether these tools actually improve shared decision-making in the consultation room. The stepped-wedge cluster-randomised study design will ensure that at the end of the study all participating centres have implemented at least some of the decision support tools and thereby a certain level of shared decision-making.

Trial registration

Netherlands Trial Registry, NTR6487. Registered 7 June 2017. URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6487

Self-reported health status and disease-specific quality of life one year after treatment for peripheral arterial disease in clinical practice

BACKGROUND

VascuQoL-6 (VQ-6) is a disease-specific quality of life (QoL) instrument validated for use in clinical practice and vascular registries before and after treatment for peripheral arterial disease (PAD). To improve future interpretation of self-reported outcome, an unselected cohort was followed through one year to provide observational data after both conservative and invasive treatment.

METHODS

Consecutive patients with intermittent claudication (IC) or critical limb ischemia (CLI) were included. All patients completed VQ-6 and Short Form-36 (SF-36), and were evaluated with ankle-brachial index (ABI) measurement pre- and post-exercise, a constant load treadmill test and clinical consultation at baseline and after one year. Change statistics and correlation analysis were used to describe self-reported outcome after conservative and invasive treatment for PAD.

RESULTS

One hundred seventy-one patients with peripheral arterial disease (PAD) were included, 70 (41%) female. 147 (86%) of the patients suffered from IC. 136 (80%) patients had one-year follow up, death, amputation and withdrawal were the major causes of loss to follow-up. Forty-eight patients (35%) evaluated their health to be unchanged compared to one year ago. There was a strong correlation between self-reported general health status based on SF-36 item 2 and VQ-6 summary score (Spearmans rho = - 0.536). Patients admitted to invasive intervention (endovascular or surgery) improved in all domains of SF-36, and in the physical component summary score (SF-36 PCS). Patients admitted to best medical treatment, smoking cessation and walking exercise (conservative group) improved only in the physical domains. There was significant improvement in VQ-6 summary score for both groups, mean 2.20 (95%CI 1.14-3.27) in the conservative group, 4.68 (95%CI 3.67-5.70) in the invasive group. VQ-6 sum score improved more than four points for 56% in the invasive group, 36% in the conservative group.

CONCLUSIONS

Treatment for symptomatic PAD, both invasive and conservative, improves self-reported health status and disease specific QoL after one year. Interpretation of patient-reported outcome measured with VQ-6 after surgery or endovascular treatment must be seen in light of the improvement from conservative treatment alone.

TRIAL REGISTRATION

ISRCTN14846962 (retrospectively registered).

Practice Pattern of Redo Varicocelectomy for Recurrent Varicocele according to Type of Initial Treatment: Retrospective Analysis of a United States-Based Insurance Claims Database

PURPOSE

The objective of this study was to investigate the type of redo varicocelectomy according to the initial surgery type using a large population of USA insurance data.

MATERIALS AND METHODS

This is a retrospective observational cohort study. Administrative claims data were extracted from the IBM® MarketScan Research Database. We included all newly diagnosed patients with varicocele from January 2007 to December 2014 using International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes. The treatment methods were identified by Current Procedural Terminology (CPT) code.

RESULTS

A total of 261,785 subjects were diagnosed with varicocele. Of these, a total of 19,800 (7.6%) patients underwent varicocele surgery. Inguinal, abdominal, laparoscopic, microsurgery, and embolization surgery were performed in 66%, 19%, 10%, 3%, and 2%, respectively, as initial treatment. A total of 340 patients (1.7%) underwent redo varicocele surgery. Inguinal, microscopic, embolization, abdominal, and laparoscopic surgery were used as the redo method in 43%, 25%, 16%, 8%, and 7%, respectively. The redo inguinal approach was the preferred method in patients who first underwent inguinal, abdominal, and laparoscopic surgery, but not in patients who underwent microscopic or embolization procedures. Most patients who initially underwent microscopic varicocelectomy or embolization underwent redo varicocelectomy using the same method.

CONCLUSIONS

Compared to the type of initial varicocelectomy, there were changes in the proportion of each type of surgical approach in redo operation procedures. While inguinal varicocelectomy is the most common method in redo operations, the number of microscopic varicocelectomy or embolization procedures is significantly increased in redo surgery.

The Relationship Between Operative Volume and Peri-operative Mortality After Non-elective Aortic Aneurysm Repair in Australia

OBJECTIVE

Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown.

METHODS

The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR).

RESULTS

Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67).

CONCLUSION

There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.

Cost-effectiveness of contrast-enhanced ultrasound for the detection of endovascular aneurysm repair-related endoleaks requiring treatment

OBJECTIVE

Follow-up after endovascular aneurysm repair is necessary to detect potentially life-threatening complications such as endoleaks. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) is often used as standard of care for follow-up. Contrast-enhanced ultrasound (CEUS) has been shown to be a viable and fast real-time nonionizing imaging modality with equivalent diagnostic accuracy while also being superior to color Doppler ultrasound. The aim of this cost-utility analysis was to evaluate the cost-effectiveness of this imaging method in comparison to others for the evaluation of endoleaks requiring treatment.

METHODS

A decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with CTA, MRA, CEUS, and color Doppler ultrasound. Model input parameters were obtained from recent literature. The applied sensitivity and specificity values amounted to 90.5% and 100.0% for CTA, 96.0% and 100.0% for MRA, 94.0% and 95.0% for CEUS, and 82.0% and 93.0% for color Doppler ultrasound. Probabilistic and deterministic sensitivity analysis was performed to estimate uncertainty of model results. To evaluate cost-effectiveness, incremental cost-effectiveness ratios were reported as a measure representing the economic value of a strategy compared with an alternative. The willingness to pay was set to $100,000/QALY.

RESULTS

In the base-case scenario for a willingness to pay of $100,000 per QALY, CEUS was the most cost-effective of the four diagnostic strategies with estimated costs of $17,383 and effectiveness of 9.770 QALYs. CTA was estimated to result in lifetime costs of $17,679 with an expected effectiveness of 9.768 QALYs, whereas color Doppler ultrasound showed expected costs of $17,287 with 9.763 QALYs. Expected costs and effectiveness of MRA amounted to $17,945 and 9.771 QALYs each. Base-case estimates of the incremental cost-effectiveness ratios for CEUS vs color Doppler ultrasound equaled $14,173.52/QALY.

CONCLUSIONS

CEUS is a cost-effective imaging method for the evaluation of therapy-requiring endoleaks in endovascular aneurysm repair surveillance.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms compared with open surgery: first experiences from a single institution

Purpose

The frequency of iatrogenic femoral artery pseudoaneurysm (FAP) diagnoses has recently increased due to the growing use of diagnostic and interventional procedures involving large diameter sheaths, as well as more potent anticoagulation procedures. In this study, we aimed to present our experience with ultrasound-guided thrombin injection (UGTI) in patients with iatrogenic FAP.

Methods

We studied patients with FAP who were under anticoagulant or antiplatelet therapies preoperatively, or who had received a loading dose during an interventional procedure. The outcomes of patients with FAP treated with UGTI were compared with those of patients who underwent open surgical repair for pseudoaneurysms.

Results

Among the 55 patients included in this study, 24 had UGTI while 31 had open surgery. The success rate was 95.8% when taking into consideration primary and secondary attempts. The mean duration of the procedure was shorter in patients with UGTI (10.1 ± 3.54 minutes) when compared with those who underwent open surgery (76.55 ± 26.74 minutes, P ≤ 0.001). In addition, the total complication frequency was significantly higher in the open surgery group (P = 0.005), as was their length of hospital stay (P < 0.001). Cost analysis showed significant differences between UGTI ($227.50 ± $82.90) and open surgery ($471.20 ± $437.60, P = 0.01).

Conclusion

We have found that UGTI is the safer and more effective choice of treatment in appropriate patients with FAP, as opposed to surgery.

Remote Ischaemic Preconditioning Attenuates Cardiac Biomarkers During Vascular Surgery: A Randomised Clinical Trial

OBJECTIVE

The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on preventing the leakage of cardiac damage biomarkers in patients undergoing vascular surgery.

METHODS

This is a randomised, sham-controlled, double-blinded, single-centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited non-consecutively. The RIPC protocol consisting of 4 cycles of 5 minutes of ischaemia, followed by 5 minutes of reperfusion, was applied. A RIPC or a sham procedure was performed noninvasively along with preparation for anaesthesia. High sensitivity troponin T level was measured preoperatively and 2, 8 and 24 hours after surgery and pro b-type natriuretic peptide was measured preoperatively and 24 hours after surgery.

RESULTS

There was significantly higher leakage of high sensitivity troponin T (peak change median 2 ng/L, IQR 0.9-6.2 ng/L vs 0.6 ng/L, IQR 0.7-2.1 ng/L, p = .0002) and pro b-type natriuretic peptide (change median 144 pg/mL, IQR 17-318 pg/mL vs 51 pg/mL, IQR 12-196 pg/mL, p = .02) in the sham group compared to the RIPC group.

CONCLUSION

RIPC reduces the leakage of high sensitivity troponin T and pro b-type natriuretic peptide. Therefore, it may offer cardioprotection in patients undergoing non-cardiac vascular surgery. The clinical significance of RIPC has to be evaluated in larger studies excluding the factors known to influence its effect.

Hybrid surgical and endovascular repair for anastomotic pseudoaneurysms after total arch replacement

An 83-year-old woman who had undergone total arch replacement for a thoracic aortic aneurysm seven years prior experienced concurrent rupture of second and third branch anastomotic pseudoaneurysms. A stent graft was initially deployed across the pseudoaneurysm from the third branch to the left subclavian artery. Following the left axillary and left carotid arterial bypass, the origin of the second branch was embolized with metallic coils. As a result, both anastomotic pseudoaneurysms were undetectable by both completion angiogram and postoperative CT. By combining surgical and endovascular procedures, ruptured anastomotic pseudoaneurysms after total arch replacement can be repaired without a risky resternotomy.

Effects of Cross-Clamping on Vascular Mechanics: Comparing Waveform Analysis With a Numerical Model

BACKGROUND

Immediate changes in vascular mechanics during aortic cross-clamping remain widely unknown. By using a numerical model of the arterial network, vascular compliance and resistance can be estimated and the time constant of pressure waves can be calculated and compared with results from the classic arterial waveform analysis.

METHODS

Experimental data were registered from continuous invasive radial artery pressure measurements from 11 patients undergoing vascular surgery. A stable set of beats were chosen immediately before and after each clamping event. Through the arterial waveform analysis, the time constant was calculated for each individual beat and for a mean beat of each condition as to compare with numerical simulations. Overall proportional changes in resistance and compliance during clamping and unclamping were calculated using the numerical model.

RESULTS

Arterial waveform analysis of individual beats indicated a significant 10% median reduction in the time constant after clamping, and a significant 17% median increase in the time constant after unclamping. There was a positive correlation between waveform analysis and numerical values of the time constant, which was moderate (ρ = 0.51; P = 0.01486) during clamping and strong (ρ = 0.77; P ≤ 0.0001) during unclamping. After clamping, there was a significant 16% increase in the mean resistance and a significant 23% decrease in the mean compliance. After unclamping, there was a significant 19% decrease in the mean resistance and a significant 56% increase in the mean compliance.

CONCLUSIONS

There are significant hemodynamic changes in vascular compliance and resistance during aortic clamping and unclamping. Numerical computer models can add information on the mechanisms of injury due to aortic clamping.

[Periinterventional management of acute endovascular stroke treatment]

Mechanical thrombectomy (MT) is more effective than standard medical treatment with or without intravenous thrombolysis alone for treating acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the anterior circulation. MT is therefore recommended in current international guidelines, and many acute-care hospitals and stroke centers will have to prepare for providing this treatment in an optimal way. Beside successful recanalization, management before, during, and after the intervention represents significant challenges. One unresolved matter is whether the choice of anesthetic strategy, including airway management, affects functional outcome. Based on current data, treatment under general anesthesia (GA)-respecting predefined safety criteria and contraindications-seem seems to be equivalent to treating the patient in conscious sedation (CS) and not necessarily disadvantageous. Aspects of periinterventional management of MT, including pragmatic recommendations concerning logistics, monitoring, postprocedural steps, and follow-up imaging, will be summarized in this overview.

Multispectrum Indocyanine Green Videography for Visualizing Brain Vascular Pathology

OBJECTIVE

Currently, neurosurgical vascular surgery frequently uses indocyanine green (ICG)-videography (VG) to evaluate the blood flow in brain vessels. Although ICG-VG delineates intravascular ICG fluorescence as a high-intensity signal in gray-scale with dark background, it is hard to identify anatomical structures, including vasculature or surgical devices simultaneously. This report developed combination of a near-infrared (NIR) camera with particular sensitivity and an optical filter to observe the blood-flow conditions and anatomical structures.

METHODS

To overcome the specific issues of ICG-VG, we applied a high-sensitivity camera with a 980-nm NIR component to delineate anatomical and fluorescence images, detecting signals between 830 and 1000 nm simultaneously during operation. We used a diluted ICG phantom to evaluate fluorescence signal changes by changing wavelength of the emission light. For clinical use, we used a high-sensitivity NIR camera with a high-pass filter on a surgical microscope. The new NIR system detected signals between 770 and 1000 nm, and the lighting system illuminated objects mainly at 980-nm wavelength. Both images with the blood flow and anatomical structures were projected to the smart glasses in real time.

RESULTS

In the phantom experiment, we found that the emission light with wide band widths (575-800 nm) evoked various intensities of ICG fluorescence. This new NIR system allowed us to observe ICG fluorescence and anatomical structures without image fusion or time-delay. The both information of anatomy and fluorescence was projected on wearable smart glasses. Furthermore, the new NIR system detected ICG-fluorescence signals for a longer duration than the original camera, which allowed us to achieve careful and detailed observation of more vasculature and fine vessels.

CONCLUSIONS

This study proposes a new NIR system and emphasizes simultaneous observation of anatomy and fluorescence signals during operation. It paves the way for further possibilities in the development of optical systems. To understand the natural phenomena and combination of different scientific and clinical fields, it might be important to understand and combine not only fluorescence, but also natural science, optics, and background pathology. This simple system would be available for neuroendoscope and robotic surgery.

Review of 20 years of vascular surgery research in Australasia: Defining future directions

Objectives

High-quality research is fundamental to the advancement of surgical practice. Currently, there is no quantitative assessment of the research output of vascular surgeons in Australia and New Zealand. By conducting this bibliometric analysis, we aim to provide an objective representation of the trends in vascular surgery and guide future research.

Methods

A list of all current vascular surgeons in Australia and New Zealand was compiled from the Royal Australasian College of Surgeons 'Find a Surgeon' website tool and correlated with the Australia and New Zealand Society for Vascular Surgery database. A Scopus search of each surgeon's author profile over the last 20 years was conducted.

Results

In total, 2120 articles were published by 208 Australasian vascular surgeons between 1998 and July 2018, with an overall increase in publications over time. Audits or case series were the most published type of study and only 8% of the publications were of high-level evidence. The most popular topics were thoracoabdominal aortic pathologies (24%), followed by peripheral arterial disease (15%). Chronological analysis illustrates an increasing volume of peripheral arterial disease research over time and there is a clear trend towards more endovascular and hybrid surgery publications. The top 10 (5%) highest publishing authors by h-index account for 41% of all publications and 49% of all citations and are also responsible for producing significantly more high-level evidence research.

Conclusion

Australasian vascular surgeons have made a significant contribution to medical research. However, the majority of these articles are of low-level evidence. In this time, there has been an increasing number of publications on endovascular and hybrid surgery in keeping with the trend in clinical practice. These areas, as well as research regarding peripheral arterial disease, show potential for high-evidence research in the future.

The Effect of Remote Ischaemic Preconditioning on Arterial Stiffness in Patients Undergoing Vascular Surgery: A Randomised Clinical Trial

OBJECTIVES

The main aim of this study was to evaluate the effect of remote ischaemic preconditioning (RIPC) on arterial stiffness in patients undergoing vascular surgery.

METHODS

This was a randomised, sham controlled, double blind, single centre study. Patients undergoing open abdominal aortic aneurysm repair, surgical lower limb revascularisation surgery or carotid endarterectomy were recruited. A RIPC or a sham procedure was performed, using a blood pressure cuff, along with preparation for anaesthesia. The RIPC protocol consisting of four cycles of 5 min of ischaemia, followed by 5 min of reperfusion was applied. Arterial stiffness and haemodynamic parameters were measured pre-operatively and 20-28 h after surgery. Two primary outcomes were selected: augmentation index and pulse wave velocity.

RESULTS

Ninety-eight patients were randomised. After dropouts 44 and 46 patients were included in the RIPC and sham groups, respectively. Both groups were comparable. There were no statistically significant differences in augmentation index (p = .8), augmentation index corrected for heart rate of 75 beats per minute (p = .8), pulse wave velocity (p = .7), large artery elasticity indices (p = .8), small artery elasticity indices (p = .6), or mean arterial pressure (p = .7) changes between the RIPC and sham groups. There occurred statistically significant (p ≤ .01) improvement in augmentation index (-5.8% vs. -5.5%), augmentation index corrected for a heart rate of 75 beats per minute (-2.5% vs. -2%), small artery elasticity indices (0.7 mL/mmHg × 100 vs. 0.9 mL/mmHg × 100), and mean arterial pressure post-operatively in both the RIPC and the sham groups (change median values in RIPC and sham groups, respectively).

CONCLUSIONS

RIPC had no significant effect on arterial stiffness, but there was significant improvement in arterial stiffness after surgery in both groups. Arterial stiffness and haemodynamics may be influenced by surgery or anaesthesia or oxidative stress or all factors combined. Further studies are needed to clarify these findings. CLINICALTRIALS.GOV: NCT02689414.

The relevance of low-fidelity virtual reality simulators compared with other learning methods in basic endovascular skills training

OBJECTIVE

The use of simulators has shown a profound impact on the development of both training and assessment of endovascular skills. Furthermore, there is evidence that simulator training is of great benefit for novice trainees. However, there are only a few simulators available geared specifically toward novice learners. Whereas research suggests that low-fidelity simulators could fill this gap, there are insufficient data available to determine the role of low-fidelity simulators in the training of endovascular skills.

METHODS

Medical students in their fifth year (N = 50) with no previous endovascular experience were randomized into three groups: conventional learning through a video podcast (group V; n = 12), low-fidelity simulation training with tablet-paired touch-gesture navigation (group A; n = 12), and low-fidelity simulation training with tablet-paired physical endovascular tool navigation (group S; n = 26). Within their respective groups, all students attended a 1-day class on basic endovascular skills. Questionnaire items for self-assessment before and after the class and assessment after the class of the participant's practical skills on a high-fidelity simulator were analyzed across all three groups as well as for each group separately using nonparametric tests.

RESULTS

All 50 participants completed the training. Participants in group S showed a significantly increased interest in working in interventional cardiology (P = .02) and vascular surgery (P = .03) after the class. Evaluation of the questionnaire items after the class showed that participants in group S rated their practical skills significantly higher after the class compared with those in group V and group A (P < .001 for pairwise comparison of all three groups, respectively), creating a significant trend across the three groups. However, analysis of the practical skills assessment for all three groups showed a significant difference between the groups only for choosing a guidewire (P = .045) and a significant trend in performance across the groups for choosing a guidewire and for positioning the guidewire in the vessel (P = .02 and P = .05, respectively). All other steps of the skills assessment showed no significant differences or a trend across the groups.

CONCLUSIONS

Low-fidelity simulation training, particularly with physical endovascular tool navigation, led to increased motivation in novice trainees. Whereas simulator training was associated with increased confidence of trainees in their skills, assessment of their practical skills showed no actual improvement in this study. Overall, low-fidelity simulation has the potential to benefit novice trainees, but possible risks of simulation training should be further evaluated.

Limitations of Vascular Quality Initiative-derived models to predict the outcomes of intervention for infrapopliteal limb-threatening ischemia

OBJECTIVE

The purpose of this study was to validate published Society for Vascular Surgery Vascular Quality Initiative (VQI) prediction models for patients with limb-threatening ischemia (LTI) undergoing open or endovascular revascularization for infrapopliteal occlusive disease.

METHODS

We sought to validate our prior VQI LTI models for major adverse limb events (MALEs) and amputation-free survival (AFS) in a VQI new cohort undergoing open or percutaneous interventions from September 2014 through August 2016. Receiver operating characteristic curves were generated including the C statistic, and the predicted vs actual outcomes were correlated. The Hosmer-Lemeshow (HL) statistic was calculated to determine goodness of fit, and the Tjur R² statistic was derived to demonstrate the degree to which the observed outcomes were accurately predicted by the models.

RESULTS

Of 15,576 open infrainguinal and 34,679 percutaneous interventions collected in the VQI during the 24-month interval, 8852 and 17,124, respectively, were performed for LTI, among which 4410 and 5116 specifically targeted the infrapopliteal vessels. MALEs and AFS were identified for 400 of 927 (43.1%) and 576 of 982 (58.7%) open procedures and 197 of 855 (23.0%) and 658 of 1115 (59.0%) percutaneous procedures, respectively. For open operation, the predictive ability of the model was poor for MALEs (C = 0.59; HL = 107; R² = 0.03) and only marginally better for AFS (C = 0.69; HL = 130; R² = 0.10). Similarly, for endovascular intervention, the model performed poorly for MALEs (C = 0.62; HL = 183; R² = 0.06) and slightly better for AFS (C = 0.68; HL = 68; R² = 0.11). Breaking AFS into its component determinants, the predictive ability of the open operation model for patient survival (C = 0.77; HL = 70; R² = 0.15) surpassed that for limb salvage (C = 0.64; HL = 54; R² = 0.05). For endovascular interventions, the survival model (C = 0.71; HL = 94; R² = 0.11) also outperformed the limb salvage model (C = 0.67; HL = 28; R² = 0.07). For both types of intervention, the actual MALE rate was lower and AFS was higher than predicted by the models.

CONCLUSIONS

The ability of reported VQI-derived models to accurately predict major outcomes for infrapopliteal LTI is limited and cannot be advocated for clinical decision-making at this time. Further study would be necessary to determine whether this is due to intraoperative and postoperative variables not accounted for in our models, absence of pertinent data points from the registry, or incomplete follow-up.

Preoperative beta blockade is associated with increased rates of 30-day major adverse cardiac events in critical limb ischemia patients undergoing infrainguinal revascularization

OBJECTIVE

The association between beta blockers and cardiovascular or limb-related outcomes after revascularization for critical limb ischemia (CLI) remains unclear. The objective of this study was to assess the impact of preoperative beta blockade on 30-day major adverse cardiac events (MACEs) and major adverse limb events (MALEs) in patients undergoing infrainguinal revascularization for CLI. We hypothesized that rates of MALEs and MACEs will be higher in patients not receiving preoperative beta blockade.

METHODS

The National Surgical Quality Improvement Program vascular targeted file for 2011 to 2014 identified patients receiving beta blockade and undergoing infrainguinal endovascular intervention and open bypass for CLI. Primary outcomes including 30-day MACE (stroke, myocardial infarction [MI], or death) and MALE (untreated loss of patency, reintervention, or amputation) were compared between patients taking and not taking preoperative beta blockers. Multivariate logistic regression identified independent predictors of MACEs and MALEs.

RESULTS

A total of 11,785 revascularizations were performed for CLI during the study period (7408 bypasses vs 4377 endovascular interventions). Preoperative beta blockers were used by 7365 patients, including 4541 (61.7%) in the open bypass cohort and 2824 (64.5%) in the endovascular group (P < .01). MACEs and MI were significantly higher in patients with preoperative beta blockers (MACEs, 5.8% vs 3.4% [P < .0001]; MI, 3.1% vs 1.8% [P < .0001]). After controlling for cardiac risk factors, beta blockers independently predicted MACEs (odds ratio [OR], 1.27; P = .03) and MI (OR, 1.36; P = .03) but not stroke (OR, 1.17; P = .58) or 30-day mortality (OR, 1.22; P = .19). Beta-blocker use did not have an effect on MALEs (OR, 0.99; P = .88).

CONCLUSIONS

In patients with CLI, preoperative beta blockade was an independent predictor of 30-day MI and MACEs after controlling for other cardiovascular risk factors. Beta blockers did not have an impact on short-term limb-related outcomes. The association between beta blockade and revascularization for CLI deserves further investigation.

ASL perfusion features and type of circle of Willis as imaging markers for cerebral hyperperfusion after carotid revascularization: a preliminary study

OBJECTIVES

Cerebral hyperperfusion (CH) could be a disastrous outcome causing complication after carotid revascularization if not managed properly and timely. The aim of this study was to investigate the association between preoperative arterial spin labelling (ASL) perfusion features and circle of Willis (CoW) pattern with CH.

METHODS

Forty-eight consecutive carotid stenosis patients who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) were enrolled. All patients had single post-labelling delay (PLD) ASL, territory-ASL, and 3-dimensional time-of-flight MR angiography (3D TOF MRA) within 2 weeks before surgery and within 3 days after surgery. Spatial coefficient of variation (CoV) of cerebral blood flow (CBF), whole brain, and territory perfusion volume ratio were calculated from ASL and territory-ASL. Postoperative CoW was classified into two groups based on patency of the first segment of the anterior cerebral arteries (A1) and anterior communicating artery (AcomA). ASL perfusion features, type of CoW, and clinical characteristics were analyzed between CH group and non-CH group to identify CH risk factors.

RESULTS

Higher CoV (p = 0.005) of CBF, lower whole brain perfusion volume ratio (p = 0.012), missing any of A1 or AcomA in CoW (p = 0.002 for postoperative MRA and p = 0.004 for preoperative MRA), and large artery stroke history (p = 0.028) were significantly associated with higher risk of CH. Two cases with cerebral hyperperfusion syndrome (CHS) were also discussed, and their perfusion and angiographic features were shown.

CONCLUSIONS

Single-PLD ASL and MRA might be useful and non-invasive imaging tools to identify patients with higher risk of CH after carotid revascularization.

KEY POINTS

• Cerebral hyperperfusion is a critical complication after carotid endarterectomy or carotid artery stenting. • ASL and MRA can be used to identify patients at higher risk of cerebral hyperperfusion • Pattern of circle of Willis, ASL perfusion features, and whole brain perfusion volume ratio are potential predicting markers for hyperperfusion after carotid revascularization.

Age-related presentation of acute type A aortic dissection

BACKGROUND

We evaluated the clinical and anatomic presentations of acute type A aortic dissection according to patient age.

METHODS

We retrospectively reviewed 235 consecutive patients who underwent acute type A dissection repair between January 2000 and December 2014. The influence of age on anatomical and clinical presentation, surgical management in the entire cohort and also after exclusion of patients with known connective tissue disorders was assessed using logistic regression.

RESULTS

Males presented with type A acute aortic dissection at a younger age than females. Acute onset with signs of myocardial ischemia, connective tissue disorders, or bicuspid aortic valve characterized the younger population. Extension to the coronary sinus(es) ( p = 0.0003), descending thoracic aorta ( p = 0.016), and abdominal aorta ( p = 0.029), and an intimal tear at the level of the aortic root ( p = 0.0017) correlated inversely with patient age. Similar findings were obtained after exclusion of patients with connective tissue disorders or a bicuspid aortic valve.

CONCLUSIONS

More frequent proximal and distal progression of the dissection flap occurs in younger patients with acute type A aortic dissection. Older age is associated with a lower probability of an intimal tear at the level of the sinus of Valsalva. These findings, associated with prognostic implications, account for the choice of more radical proximal procedures for repair of aortic dissection in younger patients.

Increased warm ischemia time during vessel harvest decreases the primary patency of cryopreserved conduits in patients undergoing lower extremity bypass

OBJECTIVE

Autologous vein is the preferred conduit for lower extremity bypass. However, it is often unavailable because of prior harvest or inadequate for bypass owing to insufficient caliber. Cryopreserved cadaveric vessels can be used as conduits for lower extremity revascularization when autogenous vein is not available and the use of prosthetic grafts is not appropriate. Many studies have shown that donor characteristics influence clinical outcomes in solid organ transplantation, but little is known regarding their impact in vascular surgery. The purpose of this study was to examine the effects donor variables have on patients undergoing lower extremity bypass with cryopreserved vessels.

METHODS

The tissue processing organization was queried for donor blood type, warm ischemia times (WITs), and serial numbers of cryopreserved vessels implanted at a single center from 2010 to 2016. The serial numbers were then matched with their respective patients using the institutional Clinical Data Repository and patient data were obtained from the Clinical Data Repository and chart review. Primary outcomes were primary patency of the bypass conduits and limb salvage. Time to loss of patency was evaluated using Kaplan-Meier methods and a Cox proportional hazards model determined risk-adjusted predictors of patency and limb salvage.

RESULTS

Sixty patients underwent lower extremity bypass with 65 cryopreserved vessels (23 superficial femoral arteries, 41 saphenous veins, 1 femoral vein). Thirty-eight procedures were reoperations. There were 21 inflow, 44 outflow, and 44 infrainguinal procedures. Preexisting comorbidities did not differ significantly between those who lost patency and those who did not. The mean WIT among the entire cohort was 892.3 ± 389.1 minutes (range, 158.0-1434.0 minutes). The median follow-up was 394 days. Kaplan-Meier analysis demonstrated an overall 1-year primary patency rate of 51%. Primary patency at 1 year was 67% and 41% for inflow and outflow procedures, respectively, and did not differ significantly between the two groups (P = .15). Donor-to-recipient ABO incompatibility was not associated with loss of primary patency. The 1-year amputation-free survival was 74%. Primary patency significantly decreased with each hourly increase in WIT on risk-adjusted analysis (hazard ratio, 1.1; P = .02).

CONCLUSIONS

Higher cryopreserved vessel WIT was associated with increased risk-adjusted loss of primary patency in this cohort. At 1 year, the overall primary patency was 51% and amputation-free survival was 74%. Vascular surgeons should be aware that WIT may affect outcomes for lower extremity bypass.