Tertiary Vascular Center Research Articles

Drug-Coated Balloons in Autologous Vein Peripheral-Distal Bypass Graft Maintenance: Advancements and Potential Impact.

Initial surgical revascularization has a recognized primary role in patients with critical limb-threatening ischemia with a high-quality great saphenous vein for conduit. However, approximately one-third of lower extremity vein grafts develop lesions threatening graft patency. Traditional treatments have limitations, highlighting the need for innovative solutions. The advantage of drug-coated balloons (DCBs) in treating native femoropopliteal occlusive disease is well established for its anti-restenotic features. This study evaluates the use of DCBs in maintaining the patency of autologous vein infrainguinal bypass grafts. This retrospective multicenter cohort study included consecutive patients who underwent DCB angioplasty of infrainguinal bypass vein graft stenoses from January 2010 to December 2022 in 4 tertiary Vascular Surgery referral Centers. The primary endpoints were assisted primary patency rate, amputation, and death. All endpoints were assessed at baseline, at 1, 3, and 6 months, and every 6 months after the procedure. Follow-up was mainly performed via duplex ultrasound, by hand of an experienced independent operator. In total, 296 patients received an endovascular procedure for primary patency loss of a pre-existing infrainguinal saphenous vein bypass graft. Of these, 86 cases (29%) were treated with a paclitaxel-coated balloon. The mean age of patients was 72 (67-75) years, most being males (62%, n=53). The median time from the primary revascularization to reintervention with DCB was 2.58 (95% confidence interval [CI]: 2.31-3.10) years. The DCB angioplasty involved the proximal anastomosis in 20%, the graft in 51%, the distal anastomosis in 33%, and the outflow region in 28% of cases. During a median follow-up of 5 years (3.93-7.01), a 69% assisted primary patency rate was recorded. Limb salvage was achieved in 100% of cases at 1 year and in 90% of cases at 3 years. Only 6 cases of major amputation were recorded in a median follow-up time of 10 years. Overall survival reached 84% at 5 years, calculated on a median follow-up of 9.4 (95% CI: 8.7-10.1) years. Results suggest that DCBs may have a transformative impact on vascular care, reducing the need for repeated reinterventions, and thus improving the quality of life for patients with peripheral bypass grafts. This study proposes a groundbreaking shift in the management of lower extremity vein graft lesions. By demonstrating the efficacy of drug-coated balloons (DCBs) in maintaining patency of infrainguinal vein bypass grafts, it offers clinicians a novel strategy to address a significant clinical challenge. Unlike traditional treatments with their limitations, DCBs present a promising alternative, potentially reducing the burden of repeated reinterventions. This innovation signifies a tangible improvement in patient outcomes, promising enhanced limb salvage rates and overall survival, thereby revolutionizing vascular care and enhancing the quality of life for individuals with peripheral bypass grafts.

Amputation-Free Survival, WIfI Stage, and GLASS Classifications in Distal Crural or Pedal Bypass for Chronic Limb-Threatening Ischemia.

Background: Chronic limb-threatening ischemia (CLTI) is a severe condition with high risks of amputation and mortality, especially in patients with distal crural or pedal artery disease. Despite advances in endovascular techniques, bypass surgery remains crucial for patients with CLTI. This study aimed to investigate amputation-free survival, Wound, Ischemia, and foot Infection (WIfI) staging, and Global Limb Anatomic Staging System (GLASS) classifications in patients undergoing distal crural or pedal bypass for CLTI. Methods: This retrospective study analyzed all patients who underwent distal crural or pedal bypass for CLTI in a tertiary vascular centre from January 2010 to December 2019. The data were collected from hospital records and preoperative imaging. WIfI stages and GLASS classifications were determined for each patient, and the primary endpoint was amputation-free survival. Secondary outcomes included bypass patency, 30-day morbidity, and mortality. Results: We identified 31 bypasses performed on 29 patients with a median age of 67 years (79% male). Preoperatively, 94% of limbs were staged GLASS III and 55% were classified WIfI stage 4. Failed endovascular revascularization preceded bypass surgery in 65% of the cases. Thirty-day mortality was 3% (n = 1) and 30-day major amputation rate was 10%. Primary patency was 87%, and secondary patency was 94% at 30 days. Median duration of follow-up for survival was 59 months with a mean follow-up index (FUI) of 0.99 ± 0.05, and for major amputation and bypass patency 54 months (mean FUI 0.9 ± 0.19 and 0.85 ± 0.28, respectively). At one year, amputation-free survival was 58%, decreasing to 45% at two years, 39% at three years, and 32% at five years. Most major amputations occurred in WIfI stage 4 patients, but 53% of WIfI stage 4 and 80% of WIfI stage 3 patients were alive without major amputation after one year. Conclusions: Distal crural and pedal bypasses are essential for limb salvage in high-risk CLTI patients, particularly those with failed prior revascularization. However, the procedure is associated with limited long-term amputation-free survival. WIfI and GLASS classifications are useful for stratifying risk and guiding treatment, but outcomes suggest the need for individualized care strategies. Further research into perioperative management and alternative interventions is warranted to improve long-term outcomes in this population.

Natural language processing realises the potential of electronic health records: identifying risk factors for disease progression and major adverse limb events in intermittent claudication

Abstract Background/Introduction Peripheral Arterial Disease (PAD) is a common pathology, affecting 4.5% of the UK population. Symptomatic PAD manifests as intermittent claudication (IC). Predictors of IC progression to Chronic-Limb-Threatening Ischaemia (CLTI) and complications including Major Adverse Limb Events (MALE), such as smoking history and diabetes, have been described previously in resource-intensive cohort studies. Novel Natural Language Processing (NLP) approaches transform routinely collected, unstructured health records into datasets for real-world analysis of PAD. Purpose This study leverages NLP based interrogation of electronic health records to efficiently identify risk factors for disease progression and MALE in patients presenting with IC. Methods A retrospective cohort study of patients with PAD at a large, tertiary vascular referral centre identified using the SNOMED terms of IC in the Medcat-NLP-AI toolkit. Demographics, Index of Multiple Deprivation (IMD), and indicators of disease progression, and revascularisation and amputation (MALE) were analysed using Kaplan-Meier survival and Cox Proportional-Hazards analysis. Results 5,027 patients (Mean age 73.7(61.8-85.6), Males 66.1% (n=2,781) were identified. Self-reported population ethnicity was 4.72% Asian, 15.5% Black, 79.7% White. All-cause mortality was 19.5% (n=979) after 10 years of follow-up, with 5.85% of patients progressing to CLTI (n=294). 2.32% of Asian patients, 5.78% of Black patients and 5.04% of White patients progressed to CLTI, respectively. 5.09% of Asian patients, 8.99% of Black patients, and 7.36% of White patients underwent amputation. Multivariate analysis of risk factors for progression to CLTI, demonstrated that diabetes (HR 2.36, 95%CI: 1.22 - 4.48, p = .01) and smoking history (HR 1.76, 95%CI: 1.19 - 2.59, p = .004) independently predicted progression. No risk factors for MALE reached significance. Conclusions Diabetes and smoking behaviour are well-described in the literature as risk factors for progression to CLTI. This study demonstrates the utility of NLP as a resource efficient, validated, methodological tool. Disparities in MALE may exist between patients within a universal healthcare system, although our sample size was insufficient to demonstrate statistical significance. A larger, multicentre analysis is warranted. NLP represents a valuable tool for efficiently identifying and analysing risk factors for PAD progression and holds potential to refine management algorithms.KM curves of CLTI-free survival (DM)

Outcomes of Nonagenarian Patients in Vascular Surgery Service in a Tertiary Institution.

With the world population growing and aging, nonagenarians have become a distinct patient cohort with specific characteristics that render the prediction of outcomes essential. We aimed to investigate the specific characteristics of this patient's cohort in a tertiary vascular center. Retrospective analysis was conducted for all consecutive patients 90 years and above referred or treated in the Department of Vascular Surgery between January 2017 and December 2022 for vascular pathologies. The main endpoint was to analyze the type of vascular services required for nonagenarians. Additional endpoints involved evaluation of treatment outcomes during the study period based on medical records. The analysis was patient-based. A total of 148 nonagenarians were included in the study. In all, 71 (48%) of the patients underwent surgery, whereas 77 (52%) had conservative treatment. Most of the patients were referred for peripheral arterial (PAD; 56, 37.8%) and aortic-related (39, 26.4%) diseases. Other pathologies encountered involved acute limb ischemia (ALI; 25, 16.9%), carotid diseases (12, 8.1%), renal/dialysis-related consultations (8, 5.4%), and referrals from other departments (12, 5.4%). Urgent interventions were performed in 27% of the cases. Indications for surgery included PAD Rutherford Stages IV, V, and VI; symptomatic and ruptured aortic aneurysms; ALI Rutherford Stages I, IIa, and IIb; symptomatic and near total occlusion asymptomatic carotid disease; and dialysis-related procedures for patients with chronic renal failure on regular hemodialysis. Perioperative complications were experienced in 22 patients (14.9%), the 30-day reintervention rate was 7.4%, and 30-day mortality was 4.7%. The overall length of hospital stay for operated patients was a median of 8 nights. The proportion of nonagenarians in the population is growing and so is their referral to vascular surgery. Satisfactory short-term treatment outcomes can be achieved in this highly selected cohort of patients. Thirty-day mortality is higher in patients undergoing urgent procedures. Follow-up mortality was higher in the operated nonagenarians as compared with those who were treated conservatively. Careful patient selection and thorough preparation are crucial to enhance clinical outcomes. Further research on therapy outcomes of nonagenarians will enable physicians to make better evidence-based approaches to individual patients and should be encouraged. The study highlights the growing need to manage vascular diseases in nonagenarians, emphasizing that age alone should not exclude patients from surgical interventions. By demonstrating acceptable short-term outcomes with careful patient selection, this research challenges the traditional bias against operating on the elderly. Clinicians should refine risk assessment and treatment plans, particularly when balancing surgical and conservative options. Comorbidities, rather than age, are key determinants of patient suitability, encouraging more individualized, evidence-based approaches in this expanding demographic.

Postdissection Abdominal Aorto-Iliac Aneurysm Open Repair: A Surgical Technique Description and Systematic Review of the Literature

BackgroundPost-dissection abdominal aortic aneurysms (pDAAA) may develop in up to 7% of patients affected by aortic dissection. However, there is no consensus on the optimal management. Different endovascular and open surgical techniques have been reported. This case-series describes the open surgical technique employed at a tertiary vascular surgery center to manage this complex pathology to allow future treatment of the visceral aorta if needed. A systematic review of the relevant literature on surgical and endovascular management of pDAAA was conducted. MethodConsecutive patients surgically treated at a single center for pDAAA metachronous to a Stanford type A or type B aortic dissection from January 2018 to March 2023 were retrospectively retrieved. The surgical technique we employed entails the use of large-diameter bifurcated grafts (≥ 9 mm branches) with longer main body, fenestration of the septum at renal arteries ostia and landing on a common femoral artery in case of small caliber iliac arteries (< 8 mm) to provide a suitable landing zone and access route for future endovascular thoracoabdominal repair in case of subsequent aneurysmal degeneration. The primary outcome was 30-day mortality. Secondary outcomes were major complications, late mortality, aortic-related mortality, and aortic-related reinterventions. Then, a systematic review of the literature until March 2023 was conducted. ResultsFive patients were included, all males with a mean age of 61 years. 30-day mortality was 0. One patient suffered from post-operative acute kidney injury and acute distress respiratory syndrome, and another one underwent repeat laparotomy for abdominal seroma. The mean follow-up was 44 months with no aortic-related reinterventions to date. One patient died from non-aortic-related causes 9 months after surgery. ConclusionsOpen repair of pDAAA appears to be an effective treatment in selected patients, with low mortality rates, and technical choices should consider future endovascular treatment of the thoracoabdominal aorta.

External Validation of Traditional and Modified Harborview Risk Scores for Ruptured Abdominal Aortic Aneurysm 30-day Mortality Prediction

A critical issue in the preoperative assessment of a patient with a ruptured abdominal aortic aneurysm (rAAA) is death risk prediction. The traditional and modified Harborview Risk Score (tHRS and mHRS) consider readily available variables to estimate 30-day mortality. The aim of the study was to validate tHRS and mHRS in a rAAA external population. Consecutive patients undergoing rAAA repair from January 2012 to January 2024 at a tertiary Vascular Surgery Center were retrospectively reviewed. The scores were calculated for each patient; receiver operating characteristic curves (ROC), area under the curve (AUC) with 95% confidence intervals (CIs) and calibration plots were built to evaluate discrimination and calibration. Furthermore, the relationship of mortality with score variables was updated running a multivariate logistic model, and then applied to one thousand bootstrap samples. One hundred and five patients treated for rAAA (97 males, 92.4%) were included in the study (77±8.5years). An endovascular repair (rEVAR) was performed in 35 patients (3 women, 80±9.0years) while an open repair (rOAR) in 70 patients (5 women, 75±8.0years). The 30-day mortality rate was 31.4%, (33/105), 25.7% (9/35), and 34.3% (24/70) for rEVAR and rOAR, respectively (p 0.5). Eight patients (7.6%) were on therapy with warfarin at the time of admission. AUC for tHRS was 0.56 while AUC for mHRS was 0.68 (DeLong test=0.29). The tHRS' calibration showed underestimation for patients with predicted mortality <25% and overestimation for the remaining; for mHRS, the predictions were well calibrated for patients with estimated mortality <40% with overprediction afterward. The model update demonstrated that the wider effects are due to the interaction between the HRS factors. tHRS and mHRS showed limited prediction capability with 30-day mortality overestimation in an external validation, raising many concerns about their extended and systematic application. Interaction between factors should be taken into account to enhance the score's performance, especially in high risk patients.

ThP8.8 - Role of Lymphoscintigraphy in Lymphoedema

Abstract Aim Lymphoscinigraphy (LSG) is a gold standard of investigation in patients with Lymphoedema, though not all patients with Lymphoedema are offered LSG and some who are offered decline to have the test. The aim of the present study was to do a clinico-radiological correlation of Lymphoscintigraphic findings. Methods All patients who underwent Lymphoscinti scans at a tertiary vascular centre over a 3 year period were included in the study. The technique was standardised and involved injection of a radioactive tracer in the Ist web space of both feet and uptake of the tracer at the groin at 2 hours was determined. Uptake less than 8% at 2 hours was considered abnormal. Clinical findings were compared with scan findings. Results 207 patients underwent LSG scans for suspected lower limb lymphoedema. 53 (26%) scans were normal. Of those with abnormal scans, 24 had mild lymphatic dysfunction (uptake 5-8%); 57 (28%) had moderate lymphatic dysfunction (uptake 2-5%) and 73 (35%) had severe lymphatic dysfunction with an uptake of &amp;lt;2%. Male to female ratio was 1:3. Median age at presentation was 60 years (range 3-89). Median BMI was 37Kg/m2 (range 17-71). Clinical profile based on the worst leg having moderate to severe Lymphatic dysfunction on LSG showed a 78-93% match between the leg affected and the LSG findings. This dropped to 29% in those with mild dysfunction. Conclusion Lymphoscintigraphy can objectively confirm and grade lymphoedema. It can be used to guide patients and their carers in following preventative measures to prevent complications.

Influence of balloon type and lesion location on outcomes following fistuloplasty.

There is limited evidence supporting the optimal use of fistuloplasty to maintain vascular access at various lesion sites, despite its critical role in facilitating renal replacement therapy and the overall high failure rates of arteriovenous fistulas (AVFs). This study aims to identify covariates affecting primary and secondary patency following fistuloplasty of native upper limb vascular access AVFs. This retrospective study included all patients who underwent fistuloplasty at a tertiary vascular centre over 4years. Baseline characteristics were recorded, and factors associated with primary and secondary patency rates were analysed. A total of 206 patients (88 male, 118 female) with a mean age of 68 (±14) years underwent fistuloplasty during the study period. The prevalence of diabetes, ischaemic heart disease and antiplatelet usage were 33%, 21% and 70%, respectively. The median number of fistuloplasties per access during the follow-up period was 2 [1-3]. Fistulas were classified as radiocephalic (65), brachiocephalic (102) and brachiobasilic transposition (39). Recurrent stenosis (RS) was identified in 60 patients who had previous fistuloplasty before the study period, while 146 patients had de novo stenoses (DNS). Stenosis location significantly differed between RS and DNS (p = .03), with DNS primarily being anastomotic and RS predominantly in central and mixed locations. Younger fistulas were more likely to have anastomotic stenoses compared to those older than 1year (p = .001). While no significant differences in primary patency (PP) were observed, secondary patency (SP) varied by stenosis location: Central 32 [13-42] months, Fistula vein 20 [12.5-35.5] months, Mixed 25 [13.5-37.5] months and Anastomotic 19 [7-29.5] months (p = .012). Stenosis location in AVFs is associated with the age and type of the fistula. Younger fistulas often fail due to anastomotic stenoses, which have lower secondary patency compared to stenoses at other sites. Preliminary data suggest that central stenoses, primarily occurring in older fistulas, exhibit better secondary patency following fistuloplasty than stenoses at other locations.

Treatment of symptomatic popliteal artery lesions: An obituary of the GORE® TIGRIS® vascular stent.

The popliteal artery is highly exposed to biomechanical stress, which is the primary factor associated with stent failure. However, information on the optimal endovascular treatment for the popliteal artery is lacking. To report the efficacy of the GORE® TIGRIS® Vascular Stent for the endovascular treatment of popliteal artery lesions. Retrospective analysis of all patients with symptoms of peripheral artery occlusive disease (PAD) and popliteal artery lesions who underwent implantation of a GORE® TIGRIS® Vascular Stent between August 2012 and August 2014 at a tertiary vascular centre. Between August 2012 and August 2014, 48 patients (32 men, aged 75±8 years) were treated with a GORE® TIGRIS® Vascular Stent. The technical success rate was 100%. At 12 months, the primary and secondary patency rates were 74% and 85%, respectively. During follow-up, no stent fracture was observed. No major amputations were performed. Our study showed that isolated popliteal artery lesions in patients with symptomatic PAD could easily be treated with the GORE® TIGRIS® Vascular Stent, as good short-term results were achieved at 12 months. Therefore, the discontinuation of this product removed a useful tool with a simple release mechanism from the endovascular armamentarium of vascular specialists.

AB078. SOH24AB_102. Rate of successful prosthetic rehabilitation post-major lower extremity amputation at tertiary vascular centre

AB078. SOH24AB_102. Rate of successful prosthetic rehabilitation post-major lower extremity amputation at tertiary vascular centre

O22: Postoperative Telemedicine is feasible and sustainable; a prospective life-cycle assessment approach to carbon footprint analysis

Abstract Introduction The NHS must provide a net zero service by 2045. Innovative strategies are required to quantify, evaluate and implement environmentally friendly interventions into practice. The study evaluates the feasibility and sustainability of remote post-operative follow-up using novel methodology. Methods Patients were reviewed remotely and face-to-face at 30 days post-operatively. A prospective life-cycle assessment(LCA) approach to carbon footprint analysis was used to calculate carbon emissions kgCO2e. Patient postcodes were applied to conversion factors to calculate travel emissions. Median(IQR) kgCO2e saved were presented. Carbon offsetting values are based on kgCO2e sequestered by a standardised UK variety tree. Results 31 participants(M:F 2.4, 66.7±11.7 years) were included. The median return distance for patient travel was 42.5km(7.2-58.7). Median reduction using remote follow-up was 41.2 kgCO2e(24.5-80.3) per patient(P&amp;lt;0.001). Using remote follow-up is equivalent to planting 1 tree for every 6.9 patients reviewed. Every readmission with SSI results in an additional 1219.93 kgCO2e. Discussion This model shows that the prospective LCA approach is achievable. Implementation of an asynchronous follow-up model is effective in substantially reducing the carbon footprint of a tertiary vascular surgical centre. Further work is needed to corroborate these findings on a larger scale and incorporate kgCO2e into cost analysis of SSI monitoring strategies.

Telemedicine for sustainable postoperative follow-up: a prospective pilot study evaluating the hybrid life-cycle assessment approach to carbon footprint analysis.

Surgical site infections (SSI) are the most common healthcare-associated infections; however, access to healthcare services, lack of patient awareness of signs, and inadequate wound surveillance can limit timely diagnosis. Telemedicine as a method for remote postoperative follow-up has been shown to improve healthcare efficiency without compromising clinical outcomes. Furthermore, telemedicine would reduce the carbon footprint of the National Health Service (NHS) through minimising patient travel, a significant contributor of carbon dioxide equivalent (CO2e) emissions. Adopting innovative approaches, such as telemedicine, could aid in the NHS Net-Zero target by 2045. This study aimed to provide a comprehensive analysis of the feasibility and sustainability of telemedicine postoperative follow-up for remote diagnosis of SSI. Patients who underwent a lower limb vascular procedure were reviewed remotely at 30 days following the surgery, with a combined outcome measure (photographs and Bluebelle Wound Healing Questionnaire). A hybrid life-cycle assessment approach to carbon footprint analysis was used. The kilograms of carbon dioxide equivalent (kgCO2e) associated with remote methods were mapped prospectively. A simple outpatient clinic review, i.e., no further investigations or management required, was modelled for comparison. The Department of Environment, Food, and Rural Affairs (DEFRA) conversion factors plus healthcare specific sources were used to ascertain kgCO2e. Patient postcodes were applied to conversion factors based upon mode of travel to calculate kgCO2e for patient travel. Total and median (interquartile range) carbon emissions saved were presented for both patients with and without SSI. Altogether 31 patients (M:F 2.4, ±11.7 years) were included. The median return distance for patient travel was 42.5 (7.2-58.7) km. Median reduction in emissions using remote follow-up was 41.2 (24.5-80.3) kgCO2e per patient (P < 0.001). The carbon offsetting value of remote follow-up is planting one tree for every 6.9 patients. Total carbon footprint of face-to-face follow-up was 2,895.3 kgCO2e, compared with 1,301.3 kgCO2e when using a remote-first approach (P < 0.001). Carbon emissions due to participants without SSI were 700.2 kgCO2e by the clinical method and 28.8 kgCO2e from the remote follow-up. This model shows that the hybrid life-cycle assessment approach is achievable and reproducible. Implementation of an asynchronous digital follow-up model is effective in substantially reducing the carbon footprint of a tertiary vascular surgical centre. Further work is needed to corroborate these findings on a larger scale, quantify the impact of telemedicine on patient's quality of life, and incorporate kgCO2e into the cost analysis of potential SSI monitoring strategies.

Long-term outcomes of major and minor lower limb amputation: eight-year retrospective analysis from a single tertiary referral centre

Objective: Lower limb amputation is increasingly common yet outcomes are historically poor, with high rates of short-term mortality, revisions and poor quality of life. This observational study evaluates outcomes from a high-volume tertiary vascular referral centre. Methods: Retrospective electronic case note review was performed to elicit all major and minor amputations performed between 03/11/2014 and 31/05/2022 for peripheral arterial disease and diabetic foot sepsis. Cases of amputation for trauma or chronic pain were not included. Results: A total of 1,566 amputations (865 major, 701 minor) were carried out in 1,237 patients during the study period. Mortality was significantly higher for patients undergoing major amputation compared with minor amputation at 30 days (7.9%, n=61/773 vs 1.0%, n=6/575; p&lt;0.0001) and at 1 year post-procedure (23.7%, n=183/773 vs 13.6%, n=78/575, p&lt;0.0001). Revision rates were significantly lower for major amputations than for minor amputations at 30 days (2.4%, n=19/799 vs 13.2%, n=91/691; p&lt;0.0001) and at 1 year post-procedure (10.0%, n=68/677 vs 26.3%, n=163/619, p&lt;0.0001). Of the patients with major amputation fitted with a prosthesis, there was no significant difference in the numbers of patients ambulating (p=0.19) or the mean ambulatory level (p=0.08) between above-knee and below-knee amputation at 6 months post-procedure. Conclusions: Both major and minor lower limb amputations are associated with a high risk of revision and mortality within 1 year which should be discussed explicitly as part of the informed consent process.

Patient-specific risk factors for reintervention following primary endovascular treatment of iliac artery disease

ObjectivePredictive models for reintervention may guide clinicians to optimize selection, education, and follow-up of patients undergoing endovascular iliac revascularization. Although the impact of lesion- and device-related characteristics on iliac restenosis and reintervention risk is well-defined, data on patient-specific risk factors are scarce and conflicting. This study aimed to explore the value of patient-related factors in predicting the need for clinically driven target-vessel revascularization (CD-TVR) in patients undergoing primary endovascular treatment of iliac artery disease. MethodsConsecutively enrolled patients undergoing endovascular revascularization for symptomatic iliac artery disease at a tertiary vascular referral center between January 2008 and June 2020 were retrospectively analyzed. Primary and secondary outcomes were CD-TVR occurrence within 24 months and time to CD-TVR, respectively. Patients who died or did not require CD-TVR within 24 months were censored at the date of death or at 730 days, respectively. Multiple imputation was used to account for missing data in primary analyses. ResultsA total of 1538 iliac interventions were performed in 1113 patients (26% females; 68 years). CD-TVR occurred in 108 limbs (74 patients; 7.0%) with a median time to CD-TVR of 246 days. On multivariable analysis, increasing age was associated with lower likelihood of CD-TVR (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.50-0.83; P = .001) and decreased risk of CD-TVR at any given time (hazard ratio [HR], 0.66; 95% CI, 0.52-0.84; P = .001). Similarly, a lower likelihood of CD-TVR (OR, 0.75; 95% CI, 0.59-0.95; P = .017) and decreased risk of CD-TVR at any given time (HR, 0.73; 95% CI, 0.58-0.93; P = .009) were observed with higher glomerular filtration rates. Lastly, revascularization of common vs external iliac artery disease was associated with lower likelihood of CD-TVR (OR, 0.48; 95% CI, 0.24-0.93; P = .030) and decreased risk of CD-TVR at any given time (HR, 0.48; 95% CI, 0.25-0.92; P = .027). No associations were observed between traditional cardiovascular risk factors (sex, hypertension, higher low-density lipoprotein cholesterol, higher hemoglobin A1c, smoking) and CD-TVR. ConclusionsIn this retrospective cohort study, younger age, impaired kidney function, and external iliac artery disease were associated with CD-TVR. Traditional markers of cardiovascular risk were not seen to predict reintervention.

Multicenter Comparison of Aortic Arch Aneurysms and Dissections Zone 0 Hybrid and Total Endovascular Repair.

Comparison of hybrid and total endovascular aortic arch repair at two tertiary vascular surgery centers. Consecutive patients undergoing hybrid (HG) or total endovascular (TEG) total aortic arch repair for aneurysms or dissections were included (2008-2022). Primary outcome measure was 30-day mortality. Secondary outcomes were major complications, technical success (defined as absence of surgical conversion/mortality, high-flow endoleaks or branch/limb occlusion), clinical success (defined as absence of disabling clinical sequelae), late and aortic-related mortality/reinterventions, freedom from endoleaks, aortic diameter growth > 5mm, graft migration and supra-aortic trunks (SAT) patency. In total, 30 patients were included, 17 in HG and 13 in TEG. TEG presented shorter intervention time (240.5 vs 341min, p = 0.01), median ICU stay (1 vs 4.5days, p < 0.01) and median length of stay (8 vs 17.5days, p < 0.01). No intraoperative deaths occurred. Technical success was 100%; clinical success was 70.6% in HG and 100% in TEG (p = 0.05). Thirty-day mortality was 13.3%, exclusively in HG (p = 0.11). Nine major complications occurred in 8 patients, 5 in HG and 3 in TEG (p = 0.99), among which five strokes, two in HG and three in TEG (p = 0.62). Late mortality was 38.5%, six patients in HG and four in TEG, p = 0.6. Two late aortic-related deaths occurred in HG (p = 0.9). Two aortic-related reinterventions, no graft migration or SAT occlusion was observed. Total endovascular repair seems to shorten operative times and provide higher clinical success compared with hybrid solutions, without significant 30-day mortality differences. The most common major complication is stroke.

Incidental Cardiovascular Abnormalities in the Abdominal Aortic Aneurysm (AAA) Surveillance Population During the AAA Get Fit Trial: A Case Series and Review of the Literature.

Background The prevalence of cardiovascular disease and incidence of major adverse cardiovascular events (MACEs) is very high among the abdominal aortic aneurysm (AAA) surveillance population. Formal assessments of and interventions to reduce cardiovascular risk are not a routine part of the surveillance programme at present. However, its potential importance is highlighted by incidental findings during the AAA Get Fit Trial, a randomised controlled trial which included baseline cardiopulmonary exercise testing (CPET). We speculate that CPET can act as an opportunistic screening programme to identify cardiovascular disease in AAA surveillance patients. Methods The AAA Get Fit Trial was a prospective, randomised controlled trial at a tertiary vascular centre, Manchester University NHS Foundation Trust, conducted between November 2017 and August 2019. Patients underwent CPET at baseline, 8, 16, 24 and 36 weeks as well as clinical history and examination and blood tests. We report on incidental cardiovascular abnormalities diagnosed during the trial. Results Of the 59 participants in the trial, four (6.8%) were identified to have abnormal findings suggestive of unstable cardiovascular disease. On subsequent further investigation, two patients were diagnosed and treated for severe coronary artery disease after abnormal ECG findings were noted during CPET. One patient was diagnosed with unstable angina after obtaining a detailed history on baseline assessment which was treated medically before going on to have a successful elective AAA repair. Conclusions There is a high incidence of MACEs among this high-risk population both pre and perioperatively. Identifying and treating cardiovascular disease among the AAA surveillance population must be a focus of the future AAA screening programme.

Fast-track surgery in a tertiary vascular surgery center

Fast-track surgery in a tertiary vascular surgery center

Post-operative transfusion is associated with infrainguinal bypass graft failure: contemporary Australian tertiary centre experience.

Peripheral arterial disease (PAD) is an increasingly prevalent and highly morbid pathology affecting the older population. Infra-inguinal bypass (IIB) surgery remains a robust revascularization option in these patients. This study aimed to identify modifiable predictors associated with graft patency and functional outcomes in contemporary Australian vascular surgical practice. A retrospective analysis of patients undergoing IIB between 2010 and 2020 at a tertiary vascular surgery centre in Australia was performed. Data regarding patient demographics, co-morbidities, pre-operative investigations, bypass characteristics, and discharge outcomes were collected. Surveillance ultrasound scans were reviewed to gain information on graft patency and compliance up to 2 years post-operatively. The primary outcome was graft failure. Secondary outcomes were mobility status and amputation-free survival at 1 year. A total of 239 IIBs were performed on 207 patients during the 10-year period. Significant predictors for primary graft occlusion included regional referral (P < 0.01), low pre-operative haemoglobin level (P < 0.01), post-operative transfusion requirement (P = 0.02), use of prosthetic conduit (P < 0.01) and non-compliance to ultrasound surveillance (P < 0.01). Patients with a thrombosed graft were 2.4 times more likely to experience deterioration in mobility status (P < 0.01) and 8.6 times more likely to have major limb amputation or death at 1 year. The amputation-free survival was 88.3% at 1 year. Optimization of pre-operative haemoglobin level for IIB should be advocated in clinical practice in order to reduce the risk of graft failure, deterioration in ambulatory function, major limb amputation and mortality.

Endovascular Treatment for Subclavian Artery Stenosis and Occlusion: A Single-Center Retrospective Study.

Subclavian artery stenosis and occlusion are common arterial diseases in the upper extremities, with atherosclerosis being the main cause. Endovascular treatment has emerged as a promising alternative to open surgical repair, but data are limited. This study aimed to evaluate the safety and effectiveness of endovascular procedures in the treatment of subclavian artery lesions at a tertiary vascular center in Vietnam. A retrospective analysis was conducted on patients who underwent endovascular treatment for symptomatic subclavian artery stenosis or occlusion between October 2013 and April 2022. Clinical characteristics, procedural details, short- and long-term outcomes, and patency rates were assessed. Twenty-five patients were included in the study, with a mean age of 56.8 years. The majority of patients had risk factors for atherosclerosis, and all presented with symptoms related to subclavian artery disease. The endovascular procedures were successful in 96% of cases, with a low complication rate of 8%. During a median follow-up of 43 months, the overall patency rate was 92% at three years. Endovascular treatment of subclavian artery stenosis and occlusion is a safe and effective option, with excellent long-term patency rates. These findings support the use of percutaneous revascularization as the first-line therapy, particularly in experienced centers. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these results.

1045 A 6-Year Cohort Study Assessing Outcomes Following Calf Fasciotomies at a Single Tertiary Vascular Trauma Centre

Abstract Background Acute compartment syndrome (ACS) is a surgical emergency.Delayed diagnosis and fasciotomy can result in irreversible muscle necrosis causing permanent disability and major amputation.This study compared outcomes following prophylactic (Group1) versus therapeutic calf fasciotomies (Group2), as well as early (within 6 hours) versus delayed fasciotomies (&amp;gt;6 hours) at a single tertiary vascular trauma centre. Method All patients undergoing calf fasciotomies between 1st January 2017 and 31st November 2022 were identified from a prospectively collected vascular departmental database.The primary outcomes included foot drop, amputation and mortality while infection, wound debridement,neuropathic pain and negative-pressure dressing were secondary outcomes.Statistical analysis with SPSS was performed using Fisher’s exact test. Results 88 patients (65 men, 23 women) of median age (IQR) 67 (56-74) underwent calf fasciotomies.Of these, 43 (48.9%) were therapeutic (Median age = 62) and 45 (51.1%) were prophylactic (Median age = 67).Ischaemia was more prevalent among Group1 while trauma among Group2.There were no significant differences among outcomes between both groups apart from higher 30-day mortality rate (26.7% vs. 7.0%, p = 0.014)and incidence of neuropathic pain (22.2% vs. 4.7%, p = 0.027)in Group1 versus Group2.Most patients (79.5%) underwent early calf fasciotomy with no significant differences in primary and secondary outcomes between early and delayed fasciotomy groups.The delay was attributed to theatre unavailability (n = 6) and on-going resuscitation (n = 5) . Conclusions Higher rates of neuropathic pain and 30-day mortality in group1 may be attributed to co-existing lower limb ischaemia.Further work is required to establish the impact of neuropathic pain.Pathways should be developed to ensure rapid access to theatres for patients with suspected ACS.