Common Femoral Endarterectomy Research Articles

The specificities of the common femoral artery anatomy, calcification and endovascular treatment.

Atherosclerotic lesions of the femoral artery bifurcation are one of the most complex lesion subsets commonly encountered in peripheral artery disease. Common femoral endarterectomy remains the standard of care in this location due to the bulky, eccentric, heavily calcified nature of the plaques, the frequent involvement of the femoral bifurcation, and the risk of compromising future femoral approaches. Recent studies have reported high rates of technical success and low rates of complications with endovascular treatment of the femoral artery bifurcation. This is related to improvements of endovascular equipment and the technical skills of operators. The aim of this manuscript was to provide a comprehensive review of the peculiarities of common femoral artery anatomy, calcification and treatment.

Morbidity and mortality of common femoral endarterectomy: Presented at the Forty-seventh Annual Meeting of the Midwestern Vascular Society, Minneapolis, Minnesota, September 7-9, 2023.

Morbidity and mortality of common femoral endarterectomy: Presented at the Forty-seventh Annual Meeting of the Midwestern Vascular Society, Minneapolis, Minnesota, September 7-9, 2023.

Management of common femoral artery occlusive disease: the current gap in the evidence and future perspectives.

The common femoral artery (CFA) is the most common site affected by peripheral artery disease. Due its various anatomical and morphological features, common femoral endarterectomy has long since been the preferred treatment option. However, there are complications associated with common femoral endarterectomy including, but not limited to, surgical site infections, hematoma formation, bleeding, and nerve injury. Unfortunately, this has been further complicated by the ageing population and increasing epidemic of obesity and diabetes mellitus. Within vascular surgery, there has been a rise in use of endovascular techniques for peripheral artery disease. Endovascular repair of the CFA is safe and feasible. One clear advantage is that they can be performed under local or regional anesthesia, thus reducing morbidity. This narrative review seeks to describe the current gap in the evidence and future perspectives in the management of common femoral artery occlusive disease.

The natural history of isolated common femoral endarterectomy for chronic limb-threatening ischemia

ObjectiveOcclusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated endarterectomy of the common femoral artery (CFE) is highly effective. As CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to report and assess the natural history of selected patients with CLTI treated with isolated CFE (without concomitant infrainguinal revascularization). MethodsConsecutive CFE performed in a large, urban hospital for CLTI between 2014-2021 were reviewed. Patient characteristics, limb, and anatomic stages using the Wound, Ischemia, foot Infection (WIfI) and Global Anatomic Staging Systems (GLASS) were tabulated. Limb-specific and survival-related endpoints were analyzed. Results58 patients presenting with CLTI underwent isolated CFE (mean age 74±10 years; 62% male, 90% current or prior smoker). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% GLASS 3). After a median follow-up of 17 months (range 10-29 months), vascular reintervention was required in 7 patients (12%). One patient (2%) required major limb amputation after presentation in WIfI stage 4 (W3I3fI0). Indeed, WIfI stage 4 was a significant univariate predictor of the need for subsequent infrainguinal bypass (p=0.034). ConclusionsIsolated CFE as primary therapy in highly selected patients with CLTI was safe and effective. Index limb stage is predictive of the need for associated infrainguinal revascularization in this complex population.

Morbidity and mortality of common femoral endarterectomy

ObjectiveCommon femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. MethodsConsecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. ResultsA total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). ConclusionsAlthough commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.

Observational Study on the Risk of Surgical Site Infection in Patients Undergoing Common Femoral Endarterectomy in Conjunction With an Endovascular Procedure Compared With Common Femoral Endarterectomy Alone

A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence of hybrid revascularisation (HR) compared with common femoral endarterectomy (CFEA) alone. This was a retrospective review of consecutive patients who underwent CFEA or HR alongside CFEA between 2017 and 2021 including one year of follow up. The primary outcome was SSI incidence. Secondary outcomes included length of surgery, duration of admission, further revascularisation surgery, limb salvage, and death. Differences in outcomes were assessed with the Student's unpaired t test, chi square test, and Fisher's exact test. A total of 157 groin incisions from 155 patients were included: 78 had CFEA procedures and 79 had HR procedures. No statistical difference was found between groups for age, sex, and indication for surgery. Surgical site infection occurred in five of the CFEA patients (6%) compared with seven of the HR patients (9%) (p= 0.77). The HR procedures took significantly longer, with an average of 299 minutes compared with 220 minutes for CFEA (p < 0.001). No statistically significant difference was identified for length of admission: median stay five days for CFEA vs. four days for HR (p= 0.44). Major amputation was performed within one year in five of the CFEA procedures (6%) and five of the HR procedures (6%) (p= 1.0). Further revascularisation surgery was attempted in two patients in the HR group and six patients in the CFEA group (p=. 17). No statistically significant difference was found in the one year mortality rate: eight CFEA (10%) and seven HR (9%) (p= 0.77). Patients who underwent HR alongside CFEA did not have a statistically significantly increased incidence of SSI, despite increased surgical time. Using HR techniques enabled patients to have multilevel disease treated in one stage without an increased incidence of SSI.

Common Femoral Endarterectomy with Retrograde Iliac Stenting: Creating the Optimal Transition Point

Common Femoral Endarterectomy with Retrograde Iliac Stenting: Creating the Optimal Transition Point

WTP1.11 The impact of the Covid-19 pandemic on discharge practices following vascular surgery

Abstract Introduction Standard operating procedures and patient pathways in healthcare have been greatly influenced by the Covid-19 pandemic. The aim of this study is to understand the impact of changes in discharge practices by comparing hospital length of stay and rates of failed discharge in selected common vascular procedures in the pre-Covid-19 and post-Covid-19 periods. Methods A single consultant surgeon’s logbook at a major vascular hub was used to identify all patients who underwent common vascular procedures in the pre-Covid-19 period (January to December 2017), and post-Covid-19 period (January 2021 to August 2022). Basic demographic data was recorded, as well as post-operative length of stay (LOS), failed discharge rates (re-admission within 24-hours) and re-admission within 30-days of the index procedure. Results 65 cases were identified in the pre-Covid-19 period. 71 cases identified in the Post-covid-19 period. For each of the surgical procedures, patient demographics were comparable. There has been a reduction in the median post- operative LOS for each of the surgical procedures. Common femoral endarterectomy from 3-days to 2-days, femoral-popliteal bypass from 10-days to 5-days, major limb amputation from 29-days to 18-days, endovascular aneurysm repair from 4-days to 2-days and fenestrated endovascular aneurysm repair from 4-days to 2- days. There were no recorded failed discharges. There was no increase in re-admission at 30-days. Conclusion We have demonstrated a reduction in the median duration of hospital stay in the post-Covid-19 period, without an increase in any readmissions. Early mobilisation and a prompt discharge policy is thought to be relevant.

Isolated Common Femoral Endarterectomy (without Infrainguinal Bypass) for the Treatment of Chronic Limb-threatening Ischemia

Isolated Common Femoral Endarterectomy (without Infrainguinal Bypass) for the Treatment of Chronic Limb-threatening Ischemia

Feasibility of patchless proximal profundoplasty and common femoral endarterectomy.

Typical repair of common femoral artery (CFA) occlusive disease involves surgical endarterectomy followed by patch closure; however, prosthetic materials may become infected. In addition, in our institution, we have experienced an increased incidence of severe patch-related restenosis. We describe a technique for CFA endarterectomy and patchless proximal profundoplasty, and evaluate its feasibility. We performed a single-centre retrospective cohort study of patients who, between July 1, 2020, and June 30, 2021, underwent a procedure that consisted of transection of the superficial femoral artery (SFA) off the femoral bifurcation in a bevelled manner, eversion endarterectomy of the SFA, remote-type endarterectomy of the CFA, direct visualization of the end point in the profunda femoris artery (PFA) with a longitudinal arteriotomy extension if needed and reimplantation of the SFA "hood" as a patch. We collected clinical information and outcomes from the patients' charts. Ten patients who underwent a patchless profundoplasty procedure during the study period were identified. Indications for repair included tissue loss (3 patients), rest pain (2 patients), claudication (3 patients) and establishing access for other procedures (2 patients). Profunda femoris artery arteriotomy extensions were used in 5 cases. Six cases included simultaneous iliac or infrainguinal revascularization. All cases were technically successful. There was 1 intraoperative complication of remote tibial balloon angioplasty tear. The mean follow-up time was 199 (range 29-381) days. There were no surgical site infections. All patients were asymptomatic, with patent CFAs, at last follow-up. There was 1 case of surgical site restenosis and 1 reintervention for remote stenosis. The average increase in ankle and toe brachial indices was 44% and 75%, respectively. One patient was readmitted for gastrointestinal bleeding. One patient died from an acute myocardial infarction, on postoperative day 34. The patchless profundoplasty technique is feasible and results in autologous anatomic repair of CFA disease without the need for vein, and allows direct visualization and tacking sutures of the proximal PFA. This technique may replace the ubiquitous vascular procedure of patch arterioplasty of the CFA, depending on the anatomic configuration.

Management of lower limb ischaemia using hybrid techniques: a single-centre experience

Introduction: Modern vascular surgery combines procedures with both open and endovascular techniques, with these hybrid procedures becoming part of routine arterial surgery. Hybrid procedures have been established in this centre with access to a hybrid suite since 2014. The aim of this study was to characterise patients undergoing hybrid procedures including an open groin dissection plus an endovascular component. Methods: A retrospective review of operation notes, electronic health records and radiology software for patients undergoing hybrid revascularisation for critical limb threatening ischaemia (CLTI) or intermittent claudication (IC) between January 2017 and December 2021 was performed. Any open groin surgical procedure including common femoral endarterectomy and/or lower limb bypass plus any endovascular procedure were recorded. Primary outcomes were recorded as stent patency, a composite of tissue healing or symptom resolution, and wound complications including surgical site infections. Secondary outcomes were length of stay, rate of readmission and mortality at 30 days. Results: A total of 98 patients (77 men) of median age 73 years (IQR 68–78) underwent a hybrid procedure during this period. Treatment was for CLTI in 66% of the patients and for IC in 34%. The median length of stay was 5 days. Overall graft and stent patency was 85%. The overall rate of tissue healing and symptom resolution was 92%. The surgical site infection rate was 14% (14/98) and mortality at 30 days was 2%. Conclusion: Hybrid revascularisation is safe and effective in treating CLTI and IC with an acceptable risk of surgical site infections. Our short-term results suggest that hybrid revascularisation should be considered in patients with multilevel disease.

Outcomes of Isolated Endarterectomy and Patch Angioplasty of the Common Femoral Artery According to Current Inclusion Criteria for Endovascular Treatment.

This study aimed to evaluate the outcomes of isolated common femoral endarterectomy with patch angioplasty (IFEA) in the endovascular era. In 2012-2022, 189 limbs underwent femoral endarterectomy with patch angioplasty. Of them, 45 IFEAs were included. We evaluated safety based on early complications; efficacy with primary patency (PP) and reintervention, above-ankle amputation, or stenosis (RAS)-free survival. We also evaluated lesion characteristics and outcomes according to the inclusion criteria (IC) of vascular mimetic implant-common femoral artery (VMI-CFA) stenting trial. Forty-one patients were male, and 30 IFEAs were required for claudication. No cases of early mortality occurred. Ten limbs (22%) developed local/nonvascular complications (hematoma, 3; lymphocele, 5; wound infection, 2), of which 8 resolved spontaneously. The overall PP and secondary patency rates were 100% at 1 year and 87% and 97% at 3 years, respectively. Twenty-one lesions (47%) did not meet the IC. The PP within the IC was 100% at 1 and 3 years, and the PP outside the IC was 100% at 1 year and 73% at 3 years (P=0.068). The overall RAS-free survival rates were 91% at 1 year and 81% at 3 years. All cases of RAS occurred in lesions outside the IC. The multivariate analysis showed that dialysis was associated with poor RAS-free survival (adjusted odds ratio, 8.56; 95% confidence interval, 1.9-35.5; P=0.005). The recent VMI-CFA trial results should be interpreted with caution. IFEA is a low-risk and durable procedure; however, careful follow-up is warranted in patients undergoing dialysis.

Long-Term Outcomes following Common Femoral Endarterectomy.

Thromboendarterectomy of the common femoral artery (CFA) for occlusive disease is a crucial procedure in vascular surgery. As an outcome reference for emerging endovascular procedures and new devices, we need more robust evidence of the outcome of this gold standard technique. The purpose of this study was to report 10-year results after femoral endarterectomy (FEA). A retrospective review of medical records at our institution identified eighty consecutive patients (91 limbs) who underwent FEA for CFA lesions. Indications for FEA included 50 limbs (55%) for intermittent claudication (IC) and 39 limbs (43%) with chronic limb-threatening ischemia (CLTI). Two limbs (2%) underwent FEA to prevent hemodynamic steal during extra-anatomical bypass. Adjunctive procedures included endovascular therapy in 32%. CFAs were closed with patch angioplasty in 44%. With a mean follow-up period of 39 months, the survival rates at 3 and 8 years were 85% and 77%, respectively. Limb salvage rates were 92% and 87%. Primary patencies were 98% and 84%. Freedom from target lesion revascularization was 95% at 3 years and 91% at 8 years. Our findings support the durability of FEA, with comparable long-term procedural results in CLTI patients as well as IC patients. Since the FEA is a gate maneuver for hybrid revascularization in CLTI patients, our findings support a strategy combining open and endovascular approaches. Femoral endarterectomy remains a durable solution for common femoral occlusive disease in IC and CLTI in the era of endovascular therapy.

Patchless Proximal Profundoplasty and Common Femoral Endarterectomy

Patchless Proximal Profundoplasty and Common Femoral Endarterectomy

Society for Vascular Surgery appropriate use criteria for management of intermittent claudication

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term “inappropriate” was replaced with the phrase “risk outweighs benefit.” The term “appropriate” was also replaced with “benefit outweighs risk.” The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

A Novel Angiography Scoring System Predicts Improvement After Isolated Common Femoral Endarterectomy With Profundaplasty

Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, between-group t-tests, Pearson correlations, and linear regression were used. Clinical Outcomes 88% of patients (n=22) had clinical improvement at 30 days; the remaining 12% of patients (n=3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 ± 0.21 at 30 days, and by 0.06 ± 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of ≥2.6 was strongly associated with 6-month clinical improvement (64% of those ≥ 2.6 improved, versus 15% of those <2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r=0.73, P = 0.01) and 6 months (r=0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of ≥1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. This institutional angiography scoring system successfully predicts clinical improvement following CFEP. Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months.Future validation studies will investigate these outcomes in a larger population, and over a longer period.

Retrograde Endovascular With Intimal Re-Entry Through Endarterectomy: The REWIRE Technique

ObjectiveHybrid lower extremity revascularization has been well described, typically consisting of common femoral endarterectomy (CFE) followed by direct patch puncture and endovascular treatment of any distal disease. We describe a modified technique that obviates the need for endovascular re-entry and simplifies treatment at the proximal and distal endpoints. MethodsThe REWIRE technique begins with retrograde arterial access via a patent tibial, pedal or femoropopliteal vessel. The diseased segment is crossed in the subintimal plane. Once the wire reaches the common femoral artery (CFA), the vessel is surgically exposed. Arteriotomy is performed and the wire is externalized during standard CFE. With through-wire access achieved, a sheath is inserted and the distal disease is treated. The proximal extent of the endovascular revascularization is incorporated into a standard CFE with patch angioplasty. ResultsSeven patients with chronic limb-threatening ischemia were treated with this approach, all with long segment occlusions of the SFA and significant CFA disease. The SFA disease was stented and bovine pericardial patch was used for CFE in all. Technical success was achieved in all patients. There were no complications related to the retrograde puncture site, which was controlled with manual pressure (4) or excluded with a covered stent (3). Thirty-Day freedom from major adverse limb events was 100%. ConclusionsThe REWIRE technique is an effective approach to hybrid revascularization involving the CFA. By crossing the occluded segment in a retrograde fashion and surgically externalizing the wire during CFE, the proximal and distal endpoints can be addressed with ease, the profunda femoris is protected under direct visualization, and the need for endovascular re-entry is eliminated.

Common Femoral Artery Stenting: Computed Tomography Angiography Based Long-Term Patency.

Despite considerable morbid-mortality rates, common femoral endarterectomy is still considered the gold standard for atherosclerotic common femoral artery (CFA) disease. The aim of this study was to demonstrate computed tomography angiography based long-term patency after CFA stent placement and to analyze associated risk factors for restenosis. A retrospective and observational study was carried out in consecutive patients treated with endovascular stent placement in CFA lesions. A clinical follow-up and imaging study was performed using MD-CTA to assess different degrees of in stent restenosis (ISR) and primary, assisted, and secondary patency rates. In a 5-year period, 35 extremities were treated in 33 patients with self-expandable nitinol stents. The technical success was 100% without complications related to the procedure. The mean follow-up (FU) was 32.2 months, and 8 limbs were lost. The degree of CFA stenosis was reduced from 79.69 ± 26.47% to 11.23 ± 24.53%. ISR < 20%, 20-70%, and ≥ 70% was evident in 15 (55.6%), 9 (33.3%), and 3 (11.1%) limbs, respectively. Estimated primary, assisted, and secondary patency was 79.5, 96.3, and 96.3%, respectively, after 24 months and 79.5, 96.3, and 96.3%, respectively after 60 months, with a freedom of clinical driven target lesion revascularisation rate of 87.8%. Endovascular treatment with self-expandable nitinol stents in CFA lesions had a high technical success rate and was related to few complications. A mild form of intimal hyperplasia was observed in a considerable number of cases. However, long-term patency was high; therefore, CFA stent placement might be a suitable therapeutic alternative in selected patients.

The Use of a Vascular Surgery Operative Cost Sheet to Increase Surgeon Financial Awareness and Decrease Operative Cost

Operative expenses compose one-third of the rising health care costs in the United States. Therefore, novel strategies for mitigating cost in the vascular surgery space are warranted. Our institution implemented a cost reduction strategy in 2017 by simply showing surgeons the costs of their implants and disposable supplies at the end of each case in order to increase surgeon financial awareness and reduce costs. We performed a retrospective analysis of recorded supply and implant costs for vascular procedures from 2015 to 2018 at a single institution. Total operative cost was defined as the accumulated implant and supply cost during a procedure. We assessed total implant and disposable supply cost, supply cost alone, and cost per time. Cost was analyzed over two periods: the 24 months prior (PRE) to the tool implementation and 24 months following (POST) with a 1-month washout. Medians and interquartile ranges were calculated for each parameter and compared using the Mann-Whitney U test. We analyzed a total of 1372 procedures performed over the time period studied. Total supply and implant cost (–17.5%; P = .008), supply cost (–1.99%; P = .049) and cost per minute (–28.24%; P = .015) all saw significant reductions across the composite of open procedures from the PRE to POST time point (Table). Largest supply cost reductions were seen in common femoral artery endarterectomy (–42%; P < .001). The total operative cost/time was most significantly reduced for carotid endarterectomy (–8.89%; P = .001), abdominal aortic aneurysm repair (–16.21; P = .019), carotid-subclavian bypass (–9.94%; P = .032), and common femoral endarterectomy (–41.16%; P = .06), with nonsignificant cost reductions in arteriovenous grafting and rib resection. Relative price increases of 31%, 8%, and 3% were calculated for temporal artery biopsy, vein transposition, and distal bypass, respectively. The composite of all endovascular procedures saw large implant cost increases with minimal change in supply cost. We demonstrate that a low-cost, highly implemenTable cost sheet is effective at reducing cost in vascular surgery. Further investigations should assess how and why surgeons choose supplies and implants in order to target further intraoperative cost savings.TableCost trends before and after implementation of a cost sheet across multiple vascular surgery proceduresProcedureTotal operative cost (supply + implant), $Supply cost, $Total cost/time (supply + implant), $/minutePREPOST% ΔP valuePREPOST% ΔP valuePREPOST% ΔP valueCarotid endarterectomy504.3 (411.5-664)452.6 (409.5-525.7)–10.25.012250.3 (238.5-277)249.1 (235-276.1)–0.45.35344.86 (4.05-6.09)4.43 (3.77-5.25)–8.89.001AAA repair1686 (1268-2041)1399 (1257-1717)–17.01.037542.5 (432-602.5)536.8 (456.6-621.8)–1.052.81857.59 (5.67-9.49)6.36 (1.65-8.13)–16.21.019Carotid-subclavian bypass681 (609.1-805.4)682.6 (641-771.6)0.23.953272.3 (245.8-385.7)259.9 (245.1-290)–4.54.36155.49 (4.52-6.36)4.85 (1.39-5.76)–9.94.032Common femoral endarterectomy3102 (1107-5232)971.3 (532.5-4309)–68.69.0107662.4 (441.3-886.1)382.8 (237.8-566.8)–42.21<.000114.35 (6.32-14.35)8.45 (3.81-8.45)–41.16.061Arteriovenous graft181.8 (130.8-189.2)183.3 (123.8-223.1)0.822.5425113.8 (108.3-132.4)112.5 (106.7-125.9)1.0865.54112.07 (1.39-10.57)1.70 (1.48-2.67)–17.65.14Rib resection119.7 (115.8-124.6)116.6 (112.2-149.2)–2.577.8662120.3 (117.8-123)114.6 (109.7-138.3)–4.738.05621.46 (1.25-2.06)1.39 (1.02-2.11)–4.46.56Temporal artery biopsy45.25 ( 34.41-73.4)90.26 (47.84-121.4)99.49.000345.25 (34.41-73.4)90.55 (48.17-121.4)100.01.00041.38 (0.79-1.79)1.81 (1.25-3.05)30.92.0099Upper extremity vein transposition181.9 (125.1-249)187.7 (132.2-269.2)3.16.5116127.2 (113-145.7)114.9 (101.3-121.1)–9.669.00081.89 (1.02-2.84)2.05 (1.39-2.56)8.68.53Distal bypass831.7 (491.8-2315)767.6 (480-2987)–7.69.8428308.8 (244.9-382.6)377.9 (242.4-572)22.36.08172.64 (1.87-7.98)2.72 (1.59-8.29)3.26.94All endovascular (EVAR + TEVAR)17653 (12890-24376)22524 (15366-29092)27.59.00022031 (1581-2588)2022 (1559-2597)0.437.8103180.3 (11.4-262.1)163.2 (97.84-271.4)–9.48.6396All open549 (275.1-1115)452.7 (209.3-782.4)–17.54.0078250.3 (141.1-411.1)245.3 (121.5-343.2)1.99.04935.237 (2.039-11.03)3.758 (1.86-7.241)–28.24.015AAA, Abdominal aortic aneurysm; EVAR, endovascular aneurysm repair; POST, the 24 months following tool implementation; PRE, The 24 months prior to the tool implementation; TEVAR, thoracic endovascular aneurysm repair.Values are median (interquartile range). Open table in a new tab

Covid-19 and Regional Anaesthesia: Use of Ultrasound guided Popliteal Sciatic Nerve Blocks for Emergency Forefoot Amputation in a High Risk Deaf and Mute Covid-19 Contact Patient

Vol 6 | Issue 3 | September-December 2020 | Page 08-10 | Maria Alexandra Tsoutsou, Shiv Kumar Singh Author: Maria Alexandra Tsoutsou [1], Shiv Kumar Singh [1] [1] Department of Anaesthesia, Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, United Kingdom. Address of Correspondence Dr. Maria Alexandra Tsoutsou, Clinical Fellow in Perioperative medicine and Anaesthesia, Royal Liverpool University Hospital, Prescot St, Liverpool L7 8XP, United Kingdom. E-mail: maria.tsoutsou@nhs.net Covid-19 and Regional Anaesthesia: Use of Ultrasound guided Popliteal Sciatic Nerve Blocks for Emergency Forefoot Amputation in a High Risk Deaf and Mute Covid-19 Contact Patient Abstract Introduction: COVID-19 has brought in the foreground the benefits of regional anaesthetic techniques as the preferred method of anaesthesia when possible. While there are many case reports of peripheral nerve blocks successfully used during the pandemic, to our knowledge this is the first case report of the use of regional anaesthesia for peripheral limb surgery for high risk deaf and mute COVID-19 contact patient and challenges one encounters in patients with this disability. Case Presentation: A 65-year-old man presented as an emergency with critical left lower limb ischaemia. Initially, a left common femoral and profunda femoris endarterectomy were performed under general anaesthesia that led to unplanned admission to the HDU for vasopressor support due to persistent hypotension. Following the initial procedure, his symptoms failed to improve, with ongoing forefoot pain and signs of infection. The decision was made to proceed to a forefoot debridement that was successfully performed under peripheral nerve block and patient discharged back to the ward without any peri-op complications. Conclusion: In this case report we describe the use of regional techniques to facilitate the emergency procedure with a view to minimising risk to the patient with a previous history of requiring prolonged vasopressor support and unplanned HDU admission after general anaesthesia. His status as a COVID-19 bay contact and as a high risk deaf and mute patient where communication is an issue make this an interesting case. Keywords: COVID-19; Regional anaesthesia; Forefoot amputation; Contact positive; Deaf and mute.