Vascular Surgery Unit Research Articles

Use of ultra-low contrast dose CT aortography for the management of aortic aneurysmal disease

PurposeComputed tomography aortography (CTA) is used in the assessment of aortic pathologies and planning of surgical intervention. However, its dependence on iodinated contrast can result in development of contrast-induced acute kidney injury (CI-AKI). The potential concern of CI-AKI has spurred research into the potential of administration of low contrast volumes in CTA investigations while maintaining overall diagnostic appeal. Several studies have shown that CTA using contrast volumes as low as 30 mL (equivalent to 10.5 g of iodine) can still yield scans of diagnostic quality. We present a retrospective pilot study to evaluate the feasibility of utilising an ultra-low volume of iodinated intravenous contrast in a population of patients with severe renal insufficiency with referral from our vascular surgery unit for CTA evaluation of the thoracic and abdominal aorta.MethodsThis retrospective pilot study examined 12 CTA scans performed with 20 mLs of iodinated contrast and assessed image quality with both quantitative and qualitative markers. All scans were performed on a Siemens SOMATOM Force dual-source CT scanner. Quantitative assessment values were measured via attenuation values at eight aortoiliac locations and used to calculate a signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) at each location. Qualitative analysis of image quality and viability for surgical intervention was obtained from subjective clinical assessment by an interventional radiologist and vascular surgeon.ResultsObtained quantitative assessment values included mean attenuation 189.9 HU, mean SNR 9.6 and mean CNR 8.0. All 12 scans demonstrated individual mean SNR values above predetermined quality thresholds while only five scans produced individual mean CNR values above threshold. Eleven of 12 scans were determined to be of sufficient quality for diagnosis and planning of surgical intervention.ConclusionsOur results suggest that CTA utilising an ultra-low contrast dose of 20 mLs (6 g iodine) yields scans of diagnostic quality for therapeutic decision-making in vascular surgical intervention.

In-Stent Restenosis after Carotid Artery Stent Placement Comparing Maximum Plaque Predilation and Postdilation

PurposeTo compare the incidence of in-stent restenosis (ISR) and ipsilateral neurologic symptoms in patients treated with maximum plaque dilation before stent deployment (max-pre-D) and stent placement followed by angioplasty (post-D) technical variants of carotid artery stent placement at midterm follow-up. Materials and MethodsThis was a single-center, real-world, retrospective comparative study of 307 patients treated in a single vascular surgery unit between 2014 and 2018. The follow-up protocol consisted of duplex ultrasound (US) performed at 1, 6, and 12 months and annually thereafter. The primary outcome was to compare the incidence of ISR ≥70% in patients treated with post-D and max-pre-D. Secondary outcomes included between-group comparison of the following: (a) symptomatic ISR, (b) reinterventions, and (c) ipsilateral neurologic events. ResultsA total of 270 patients (121 in the max-pre-D group and 149 in the post-D group) fulfilling the inclusion criteria were included in the statistical analysis. Mean follow-up was 30.5 months (SD ± 25.6). The ISR rate was 4.1% (n = 5) in the max-pre-D group and 2.7% (n = 4) in the post-D group, with no significant difference in the survival analysis (log-rank P = .664). Symptomatic ISR and retreatment occurred in 3 patients (33.3% of the total ISR for each outcome). Twenty-one ipsilateral neurologic events occurred, 7 in the max-pre-D group (5.8%) and 14 in the post-D group (9.9%), with no statistically significant difference in survival analysis (log-rank P = .315). ConclusionsISR and major neurologic events did not differ significantly between the max-pre-D and post-D groups. Max-pre-D seems to be as effective as post-D technique in midterm follow-up.

Vein bypass first vs. best endovascular treatment first revascularisation strategy for chronic limb-threatening ischaemia due to infra-popliteal disease: the BASIL-2 RCT.

Chronic limb-threatening ischaemia with ischaemic pain and/or tissue loss. To examine the clinical and cost-effectiveness of a vein bypass-first compared to a best endovascular treatment-first revascularisation strategy in preventing major amputation or death. Superiority, open, pragmatic, multicentre, phase III randomised trial. Thirty-nine vascular surgery units in the United Kingdom, and one each in Sweden and Denmark. Patients with chronic limb-threatening ischaemia due to atherosclerotic peripheral arterial disease who required an infra-popliteal revascularisation, with or without an additional more proximal infra-inguinal revascularisation procedure, to restore limb perfusion. A vein bypass-first or a best endovascular treatment-first infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation strategy. The primary outcome was amputation-free survival. Secondary outcomes included overall survival, major amputation, further revascularisation interventions, major adverse limb event, health-related quality of life and serious adverse events. Participants were randomised to a vein bypass-first or a best endovascular treatment-first revascularisation strategy. The original sample size of 600 participants (247 events) was based on a hazard ratio of 0.66 with amputation-free survival rates of 0.72, 0.62, 0.53, 0.47 and 0.35 in years 1-5 in the best endovascular treatment-first group with 90% power and alpha at p = 0.05. The sample size was revised to an event-based approach as a result of increased follow-up time due to slower than anticipated recruitment rates. Participants were followed up for a minimum of 2 years. A cost-effectiveness analysis was employed to estimate differences in total hospital costs and amputation-free survival between the groups. Additionally, a cost-utility analysis was carried out and the total cost and quality-adjusted life-years, 2 and 3 years after randomisation were used. Between 22 July 2014 and 30 November 2020, 345 participants were randomised, 172 to vein bypass-first and 173 to best endovascular treatment-first. Non-amputation-free survival occurred in 108 (63%) of 172 patients in the vein bypass-first group and 92 (53%) of 173 patients in the best endovascular treatment-first group [adjusted hazard ratio 1.35 (95% confidence interval 1.02 to 1.80); p = 0.037]. Ninety-one (53%) of 172 patients in the vein bypass-first group and 77 (45%) of 173 patients in the best endovascular treatment-first group died [adjusted hazard ratio 1.37 (95% confidence interval 1.00 to 1.87)]. Over follow-up, the economic evaluation discounted results showed that best endovascular treatment-first was associated with £1690 less hospital costs compared to vein bypass-first. The cost utility analysis showed that compared to vein bypass-first, best endovascular treatment-first was associated with £224 and £2233 less discounted hospital costs and 0.016 and 0.085 discounted quality-adjusted life-year gain after 2 and 3 years from randomisation. Recruiting patients to the Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 trial was difficult and the target number of events was not achieved. A best endovascular treatment-first revascularisation strategy was associated with better amputation-free survival, which was largely driven by fewer deaths. Overall, the economic evaluation results suggest that best endovascular treatment-first dominates vein bypass-first in the cost-effectiveness analysis and cost-utility analysis as it was less costly and more effective than a vein bypass-first strategy. The Bypass versus Angioplasty in Severe Ischaemia of the Leg Trial-2 investigators have a data sharing agreement with the BEst Surgical Therapy in patients with Chronic Limb threatening Ischaemia investigators. One output of this collaboration will be an individual patient data meta-analysis. Current Controlled Trials ISRCTN27728689. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/35/45) and is published in full in Health Technology Assessment; Vol. 28, No. 65. See the NIHR Funding and Awards website for further award information.

Directional atherectomy with anti-restenotic therapy versus open repair in patients with restenotic disease after surgical revascularization of the common femoral artery.

This study evaluated the performance of directional atherectomy with anti-restenotic therapy (DAART) compared to surgery in patients with restenosis of the groin arteries after endarterectomy or femoral bypass anastomosis. Consecutive patients with restenotic lesions from two vascular surgery units were retrospectively evaluated. Detailed medical history, type of previous reconstruction, anatomical and perioperative data, 30-day mortality and morbidity as well as data during follow-up were documented. The primary outcome measure was primary patency, whereas technical success, secondary patency, target lesion revascularization (TLR), freedom from major amputation, overall morbidity and mortality were additionally evaluated. The endovascular (25 patients) and surgical (17 patients) groups were comparable regarding the initial surgical reconstruction, demographics, comorbidities and medication. In the DAART group technical success was 100% without any residual stenosis >30%, distal embolization, perforation or bailout stenting. Hospital stay was shorter after DAART (medial 2 vs. 7 days, P<0.001), while more wound complications were documented in the surgical group within the first 30-days (29.4% vs. 0%, P=0.004). Primary patency, secondary patency and TLR were comparable between the groups (66.7% vs. 64.7%, HR 0.95, 95% CI 0.3-2.9, P=0.93, 86.4% vs. 93.8%, HR 0.65, 95% CI 0.65-6.6, P=0.71, 68% vs. 70.6%, HR 0.95, 95% CI 0.3-2.9, P=0.93, respectively). During follow-up no major amputation was observed, the improvement of the Rutherford class was comparable between the two groups and there were two deaths in the surgical group. In this study, DAART for restenotic atherosclerotic disease of the common femoral artery and its branches is a safe alternative to redo surgery and is associated with shorter hospital stay, fewer wound complications, comparable patency and freedom from TLR rates.

Carotid artery stenting with flow inversion cerebral protection and MicroNet-covered stent.

The study aims to evaluate the association of proximal flow-inversion cerebral protection and MicroNet-covered CGuard stents in reducing early and late embolic events in carotid artery stenting procedures. From 2018 to 2023, we performed 204 procedures in 180 patients with flow inversion cerebral protection and CGuard stents at the Vascular Surgery Unit of Sant'Eugenio Hospital in Rome. Cerebral protection was achieved with a Flow-Gate2 catheter connected to a peripheral vein. The tip balloon is inflated in the CCA to obtain an effective endoclamping, the pressure difference between the carotid bifurcation and the venous compartment ensures a constant back flow with wash-out in the venous compartment. Inclusion criteria were: life expectancy of >12 months, target lesions indicating treatment according to ESVS Guidelines, increased surgical risk due to comorbidities or anatomic issues. ECD follow-up was performed immediately postoperatively, at 30 days, 6 and 12 months, and subsequently annually. The treatment protocol was successfully implemented in 99% of cases. No major strokes occurred, while one minor stroke (0.5%) occurred within 8 hours of the procedure, regressing in the following months. One perioperative death (0.5%) due to cerebral hemorrhage occurred three hours after the procedure. All patients remained asymptomatic, with no short or medium-term neurological score deterioration. One hemodynamically significant restenosis (0.5%) was detected at the 6-month follow-up. All patients completed the 6 months follow-up, though 6 (3%) were lost at the 12-month appointment. Our prospective monocentric study has demonstrated the effectiveness and safety of the FlowGate2 flow inversion cerebral protection system in association with MicroNet covered CGuard stent.

To Treat or not to Treat? The Fate of Patients with Intermittent Claudication Following Different Therapeutic Options.

Peripheral artery disease (PAD) is recognized as a significant contributor to the public health burden in the cardiovascular field and has a significant rate of morbidity and mortality. In the intermediate stages, exercise therapy is recommended by the guidelines, although supervised programs are scarcely available. This single-center observational study aimed to evaluate the long-term outcomes of patients with PAD and claudication receiving optimal medical care and follow-up or revascularization procedures or structured home-based exercise. The records of 1590 PAD patients with claudication were assessed at the Vascular Surgery Unit between 2008 and 2017. Based on the findings of the recruitment visit, patients were assigned to one of the three following groups according to the available guidelines: Revascularization (Rev), structured exercise therapy (Ex), or control (Co). The exercise program was prescribed at the hospital and executed at home with two daily 10-minute interval walking sessions at a pain-free speed. The number and date of deaths, all-cause hospitalizations, and peripheral revascularizations for 5 years were collected from the Emilia-Romagna regional database. At entry, 137 patients underwent revascularization; 1087 patients were included in the Ex group, and 366 were included in the Co group. At baseline, patients in the Rev group were significantly younger and had fewer comorbidities (p 0.001). A propensity score matching analysis was performed, and three balanced subgroups of 119 patients were each created. The mortality rate was significantly (p 0.001) greater in the Co (45%) group than in the Rev (11%) and Ex (11%) groups, as was the incidence of all-cause hospitalizations (Co: 95%; Rev 56%; Ex 60%; p 0.001). There were no differences in peripheral revascularizations (Co: 19%; Rev: 17%; Ex 11%). In PAD patients with claudication, both revascularization procedures and structured home-based exercise sessions are associated with better long-term clinical outcomes than walking advice and follow-up only.

Vertical Mesh-Mediated Fascial Traction and Negative Pressure Wound Therapy: A Case Series of Nine Patients in General and Vascular Surgery.

Two patients in a vascular surgery unit and seven patients in an abdominal surgery unit with an OA were treated with VMMFT in combination with NPWT between September 2019 and June 2023. A DFC was achieved in seven of nine cases. The mean duration of OA was 9.6 ± 3.8 days, and fascial dehiscence at the beginning of OA was 14.2 ± 4.0 cm on average. Time to DFC after VMMFT was established was 6.2 ± 3.5 days (mean). No method-related complications occurred. The standardized combination of VMMFT and NPWT gave positive results in achieving DFC in our heterogenic patient group. Following a strict treatment pathway as shown here seems to improve OA outcome. It represents a promising further development of mesh-mediated fascial traction for OA treatment.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use

Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, and operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 out of 75 (97%) units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiogram being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n=1) and graft-related mortality of 0%. During follow-up (median 13months, range 6-34months), reinfection was 5.2% and primary graft patency 94.7%. The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Extra-anatomic bypass procedures for severe aortoiliac occlusive disease-A cohort study.

Extra-anatomic bypass (ExAB) grafting has been questioned due its inferior durability compared to anatomic bypass for aortoiliac occlusive disease (AIOD). This study aims to present early and late outcomes of patients treated with ExAB as well as to evaluate potential prognostic factors. This is a retrospective cohort study presenting a series of patients treated with ExAB for AIOD. All patients were treated between 2005 and 2022 within the Vascular Surgery Unit of a University Surgery Clinic. Both early (30-day) and late outcomes were evaluated. Univariate and multivariate analyses were conducted for potential predictors. Kaplan-Meier curve was produced for long-term patency. A total of 41 patients were treated (85.3% males; mean age: 76.3 ± 4.2years). Indication for treatment included severe claudication or critical limb ischemia (Rutherford stages III-VI). The following procedures were recorded: Femorofemoral bypass (FFB; n = 21) and axillofemoral bypass (AxFB; n = 20). All procedures were conducted using synthetic grafts with external rings. Early outcomes included no death, no myocardial infarction, no major bleeding, no graft infection, and no major amputation. Regarding late outcomes, 14.6% patients were lost after the first month. For the rest of patients (n = 35), five-year primary patency was 88.6%, primary-assisted patency was 94.3%, and secondary patency was also 94.3%. Limb salvage was 100% within follow-up. Endarterectomy at the distal anastomosis was the only independent predictor associated with worse patency in the long-term (OR = 5.356; 95% CI (1.012-185.562); p = .041). FFB and AxFB is a safe and durable strategy for treating patients with severe AIOD where no other option is feasible. Regarding predictors, only endarterectomy at the distal anastomosis site was associated with an increased risk for graft failure.

Use of infrared thermography in patients undergoing primary amputation due to peripheral arterial obstructive disease.

Peripheral Arterial Disease (PAD) is highly prevalent and the final stage of the disease is the Critical Ischemia (CI) of the Lower Limbs (LL), culminating, in most cases, with amputation of the limbs as part of the proposed treatment. Infrared Thermography (IT) is an inexpensive method, painless, without emission of radiation and easy to manage, which aims to determine the temperature of the skin of the limb to be amputated, and could help the surgeon to evaluate the level of the lower limb amputation. To Evaluate Whether IT is a useful method to determine the level of lower limb amputation in patients with PAD and CI. Method: Prospective cohort study performed from April 2023 to November 2023, at the Unit of vascular surgery - Hospital de Base do Distrito Federal (Brasília-DF). It evaluated patients with PAD and CI that were in the preoperative period for lower limb amputation. All Patients Underwent IT evaluation standards protocols. The results showed a wider longitudinal thermal gradient in PAD smoking (S) patients compared to non-smokers. It was also observed that (S) patients with wide thermal gradients were more likely to undergo an above the knee amputation. Infrared thermography was a useful method in discriminating thermal differences in patients with PAD and CI could be employed in preoperative evaluation to choose the level of lower limb amputation. Smoking patients with greater longitudinal thermal gradients are more likely to undergo an above the knee amputations.

Standards of radiation protection amongst UK vascular surgeons: a clinician’s perspective

Objective: To evaluate training in radiation protection, knowledge of local policies and current practices regarding safe working with ionising radiation in vascular surgery units across the UK. Methods: A validated 37 question online survey was distributed to vascular surgery trainees (VTs) and consultants (VCs) by the Vascular Society of Great Britain and Ireland (VSGBI), British Society of Endovascular Therapy (BSET) and Rouleaux Club through their national mailing lists between March and May 2024. Responses were collated using the survey server SurveyMonkey. Results were summarised using descriptive statistics and appropriate tests. Results: Ninety-one VCs and 87 VTs, representing approximately 15% and 44% of the UK VC and VT workforce, respectively, responded. In total, 94% of VCs and 97% of VTs expressed concerns over the effects of ionising radiation on their health; 91% of VCs and only 74% of VTs had undergone formal radiation safety training. Of these, only 18% of VCs and 43% of VTs had undergone training within the last two years. Overall, 34% of VCs and most VTs (75%) did not know who their local radiation safety officer was; 4% of VCs and 32% of VTs (p&lt;0.001) were completely unaware of local radiation safety policies. A total of 13% of both were not aware of ‘As Low As Reasonably Achievable’ (ALARA) principles, with 20% of VCs and 35% of VTs failing to consistently employ them. Custom-made or retrofitted lead gowns were accessible to 55% of VCs but only 2.4% of VTs (p&lt;0.001). Radiation protection glasses were worn by 52% of VCs compared with 16% of VTs (p&lt;0.001). 84% of VCs were allocated a dosimeter versus only 44% of VTs (p&lt;0.001). Most VCs (76%) and VTs (86%) believed that their employer should prospectively record their annual radiation exposure into a National Registry. A total of 86% of VCs and 96% of VTs agreed that employers should record their cumulative radiation exposure during their entire working life. One in four VCs and VTs experienced a health condition potentially related to their work with ionising radiation. Musculoskeletal pain was the most common, prevalent in 17% and 18% of VCs and VTs, respectively. Overall, 2% of VCs had a malignancy and 5% cataracts. Almost all VCs (94%) and VTs (96%) agreed that these illnesses should be recorded in a national registry. Conclusion: This survey highlights significant and concerning deficiencies in knowledge, access to personal radiation protection and failures in monitoring individual exposure to ionising radiation amongst the UK vascular surgical workforce.

Anatomical suitability for branched endovascular aortic arch repair and balloon-expandable bridging stent grafts in a cohort of patients previously treated with a hybrid approach

ObjectiveWe assessed the suitability of two triple branch arch devices (aBranch) (Terumo aortic and Cook Medical) and a balloon-expandable covered stent (VBX, W. L. Gore & Associates, Johnson & Johnson) to incorporate the brachiocephalic trunk (BCT) in a cohort previously treated with hybrid thoracic endovascular repair (TEVAR). MethodsThis is a single-center, retrospective, all-comers, preclinical suitability study. We conducted an analysis of preoperative computed tomography scans in surgical patients between 1999 and 2022 in a single vascular surgery unit. The primary outcome was the aortic suitability of aBranch devices and VBX as mating stent for BCT in previous hybrid TEVAR. Hybrid repair of the aortic arch included TEVAR, fenestrated or branched TEVAR associated with any surgical debranching of the supra-aortic trunks and chimney TEVAR with proximal landing in zones 0 to 2. Secondary outcomes included (i) suitability assessment when excluding minor instruction for use (IFU) criteria, (ii) a comparison of suitable and nonsuitable patients, (iii) risk factors analysis for nonsuitability, and (iv) a description of the exclusion causes. ResultsDuring the study period, 120 patients were treated. Among elective patients (n = 73), the suitability of any aBranch was 82.2% (60/73) and VBX was suitable in 64.4% of BCTs (47/73). The aBranch suitable patients had a significantly longer sinotubular-BCT length (P = .017) and smaller distal ascending aorta (P = .043) as compared with nonsuitable ones. The suitability of Terumo Aortic and Cook Medical devices was 52.1% (38/73) and 46.6% (34/73), respectively. When minor IFU criteria were ignored, suitability increased to 82.2% (60/73) and 63.0% (46/73), respectively. Left common carotid artery diameter and sinotubular-BCT length were significant nonsuitability risk factors for Terumo Aortic aBranch in multivariable analysis. No associations were found for Cook Medical device. The outcomes were tested in the entire cohort demonstrating a global suitability of 82.9%, increasing to 86.3% when ignoring minor IFUs. VBX was anatomically suitable to use in BCT in 73.2% of patient BCTs. ConclusionsaBranch devices are anatomically suitable in a vast majority of patients (86%) undergoing hybrid TEVAR. The innominate artery seems eligible for incorporation with VBX in almost two-thirds of patients. This mating stent may help to overcome some minor IFU restrictions.

Internal Iliac Artery Patency as a Predictor of Above-Knee Amputation Stump Healing

PurposeThe primary aim of this study is to assess role of internal iliac patency in predicting outcome of AKA stump healing. The secondary objectives were assess accuracy of Wound, Ischemia, and foot Infection (WIfI) classification system in predicting AKA stump healing and association of delayed mortality. Materials and MethodThis is a retrospective study performed in Vascular Surgery Unit, in a tertiary hospital, on patients who underwent above-knee amputations over one year, from July 2021 until June 2022. Patient demographic data, WIfI scoring, outcome of above-knee amputations and patency of profunda femoris and internal iliac artery were collected. To minimize confounding, a single vascular surgeon performed all CT imaging reviews and arterial measurements. Approval for this study was obtained from the National Research Registry NMRR ID-23-01865-KQ4 (IIR). ResultNinety patients underwent AKA over one year, from July 2021 until June 2022. Occluded internal iliac artery in the presence of patent profunda femoris did not affect the wound healing of AKA stump. There was significant association between WIfI scoring with mortality. Patients with WIfI scoring 3 to 4 was observed to have higher mortality rate compared to patients with normal healing 47 (72.0%) vs 4 (80.0%); p= 0.021. ConclusionIn this study, the internal iliac artery patency shows no statistically significant effect on AKA stump healing; however, the small number of patients is a study drawback. This study also demonstrates that the WIfI score can be a prognostic factor for mortality in patients undergoing above-knee amputation.

The Role of Ankle Brachial Index in Patient with Peripheral Arterial Disease; Diagnostic and Prognostic Tool

Objectives: Peripheral arterial disease is an independent risk factor for developing major cardiovascular events, and even death; this makes its diagnosis important in early detection and prevention of these events. Ankle brachial index is a non-invasive, simple, bedside screening, diagnostic and even prognostic tool, patients with ABI less than 0.9 were found to have PAD, and at risk of cardiovascular events. Methods: A descriptive cross-sectional study of 338 patients was conducted during the period October 2021 to December 2022. They were referred to vascular and endovascular surgery unit at Ghazi Al-Hariri multispecialty teaching hospital/ Medical city teaching, they were presented with intermittent claudication and other PAD symptoms. Peripheral endovascular angioplasty was done; all were subjected to Ankle brachial index measurement. Results: The study involves 338 patients, among them males were 242 (72%), females were 96 (28%). Age ranged from 25-92 years old, with an age average of 61 years. A total of 203 (60%) were presented with classical lower limb claudication, 100 (30%) patients with atypical symptoms and only 35 (10%) patients with critical limb ischemia. A total of 216 (64%) patients with ABI between 0.4-0.9; 100 (29%) patients with ABI greater than 0.9; 19 (6%) patients with ABI less than 0.4, and only 3(1%) patients with ABI more than 1.4. Conclusion: Ankle brachial index is a useful, cost effective, simple non-invasive diagnostic tool in patients with peripheral arterial disease.

Assessing the Patient Outcomes and Performance of a Cardiothoracic and Vascular Surgery (CTVS) Unit During Its First Two Years in a Tier-2 City in India: A Comprehensive Audit and Analysis.

This detailed article presents a comprehensive overview of the initial two-year experience in establishing a new cardiothoracic vascular surgery (CTVS) facility in a tier-2 city in India. The article discusses various aspects of setting up and operating a specialized healthcare facility. The first two years of developing the CTVS facility were included in the study period.The manpower included one cardiothoracic vascular surgeon, onecardiac anesthesiologist,two perfusionists, and two physician assistants, along with four other ancillary staff to assist in the smooth functioning of the operation theater. The CTVS recovery staff included 15 nursing officers. There was only one modular operation theater reserved for cardiothoracic vascular surgeries, along with a five-bed recovery room (CTVS intensive care unit). One-hundred-seventy-two procedures were done, including 122 open heart surgeries, 36 vascular procedures, and 14 thoracic procedures. The majority of patients were discharged by the seventh day postoperatively. Overall complication and mortality rates were 8% and 4.6%, respectively. This article also discusses relevant hospital policy, challenges faced, and future recommendations for similar endeavors. The findings highlight the successful implementation of the facility and its impact on providing specialized cardiac care to the local population.

Pre-operative exercise therapy to increase blood vessel diameter in patients undergoing radiocephalic arteriovenous fistula creation

Background Post-operative upper extremity exercise is recommended to patients with arteriovenous fistulas. It is postulated that increased blood flow to vessels improves maturation and patency rates. Recent studies favour pre-operative exercise therapy to improve the outcomes of arteriovenous fistula creation. Objectives To investigate if pre-operative exercise therapy increases vessel diameter and maturation in patients undergoing distal arteriovenous fistula creation. Methods 34 patients planned for radiocephalic arteriovenous fistula creation were recruited at a tertiary university hospital Vascular Surgery Unit. Patients underwent a 6-week period of self-directed daily upper extremity exercises before surgery. Patients were reviewed up to 6 months post-surgery. The primary outcome investigated was change in venous and arterial diameters following exercise intervention. The secondary outcome investigated was the primary failure rate of the newly created arteriovenous fistulas. Results After exercise therapy, mean hand grip strength increased from 20.3 ± 6.62 kg to 21.9 ± 7.16 kg ( p=.01). There was a statistically significant increase in basilic vein diameter amongst those who demonstrated strict compliance to at least 42 days of pre-operative exercise therapy by 0.51 mm from 3.23 ± 1.09 mm to 3.74 ± 1.31 mm ( p=.03). Primary failure rate of newly created radiocephalic arteriovenous fistulas was 25% (7 of 28), comparable to our previous series of 436 distal arteriovenous fistulas created which had a failure rate of 26%. Conclusions There was a trend of increase in vein diameters after pre-operative exercise therapy. Although not statistically significant, patients with successful arteriovenous fistula creation had longer mean completion of exercise days.

Use of steerable sheaths for complex aortic procedures.

To demonstrate the ease with which steerable sheaths, designed for cardiac electrophysiological applications, can be used to aid endovascular treatment of a wide range of non-cardiac vascular disease and to assist with target vessel cannulation in branched and fenestrated aortic grafts. A retrospective medical chart review was carried out to identify cases from a single vascular surgery unit (2019-2022) where the HeartSpan Steerable Sheath (HSS) (Merit Medical, South Jordan, UT, USA) was utilised to enable endovascular management of complex vascular pathology. A case presentation of branch graft insertion performed entirely via distal access is described and used to help identify pertinent sheath characteristics and technical considerations, and to illustrate the advantages and disadvantages of the design for modified use in target vessel cannulation. The HSS was used in the endovascular treatment of different vascular pathologies in 15 patients (23 target vessels) where access to the vessels using standard catheters and approaches was not possible. Cannulation and subsequent stenting were successful for 21 of the 23 target vessels in total. Of these cases, the HSS was used as an adjunct for deployment of fenestrated endovascular graft systems when conventional techniques for canulation of target vessels had failed on five occasions. On another four occasions, the HSS enabled full deployment of the entire Zenith® t-Branch™ Thoracoabdominal Endovascular Graft system from an exclusively femoral approach. An additional three cases involved use of the HSS for superior mesenteric artery cannulation in patients with mesenteric ischaemia. The device was also used once in each of the following cases: contralateral common iliac cannulation, cannulation of contralateral internal iliac artery for coil embolisation, and access of a contralateral iliac branched device. There were no stent dislocations and all aortic branches that were patent at the completion of each case remained so 1-year post procedure. Steerable sheaths designed for cardiac electrophysical applications, like the HSS Introducer, can be successfully utilised for cannulation of challenging target vessels in a wide range of aortic endovascular procedures. This modified approach may salvage cases that would otherwise be considered inoperable in regions of the world where steerable sheaths designed for aortic use are not readily available.

Results of the tibioperoneal trunk repair in patients with advanced atherosclerosis

Objective: To study immediate and long-term results of the tibioperoneal trunk repair (plastic reconstruction or prosthetic repair) during femoropopliteal bypass.Materials and methods: In our retrospective cohort study we analyzed surgical treatment results of 109 patients with lower extremities atherosclerosis who were treated in the Vascular Surgery Unit of Interregional Clinical Diagnostic Center (Kazan, Russian Federation) from 2018 to 2020. 26 (23.8%) patients were hospitalized for stage IB-IIA acute arterial insufficiency with atherothrombosis, and 83 (76.1%) patients were admitted with critical limb ischemia (CLI) as a result of advanced atherosclerosis. Among the CLI patients, 43 (39.4%) of them had stage III chronic arterial insufficiency, and 40 (36.7%) patients had stage IV chronic arterial insufficiency. The study selection criteria included extensive femoral and popliteal arteries disease and significant stenosis or occlusion of the tibioperoneal trunk. TASC II type C lesions were detected in 2 (1.8%) patients, while 107 (98.2%) patients were diagnosed with TASC II type D lesions. Based on the GLASS classification, all 109 (100%) patients had FP grade 3-4 femoropopliteal lesions with concomitant IP grade 1-4 tibial lesion. The main group included 24 (22%) patients who underwent femoropopliteal bypass with plastic or prosthetic repair of the tibioperoneal trunk using an original technique. The control group included 85 (78%) patients who underwent bypass surgery without the tibioperoneal trunk repair. Isolated femorotibial bypass was performed in 7 (8.2%) patients, and 78 (91.7%) patients underwent femoropopliteal bypass with a reversed autogenous vein.Results: We followed up patients for 2 years after surgery. Immediate technical success was 97.24% (106/109). Graft thrombosis was reported in 3 cases. No difference between the groups was observed. Long-term graft patency was significantly higher in the main group (P = .044) and significantly associated with age (RR = 0.96; 95% CI of 0.92 to 1.00, P = .03), type 2 diabetes mellitus (RR = 2.10; 95% CI of 1.10 to 4.10, P = .03), and history of the tibioperoneal trunk repair (RR = 0.43; 95% CI of 0.18 to 1.00, P = .06). Variables associated with patency in the univariate regression at a significance level P ≤ .1 were included in a multivariate model that demonstrated the combined effect of predictors on the outcome.Conclusions: Femoropopliteal bypass with the tibioperoneal trunk repair improves treatment results in patients with extensive peripheral artery disease and immediately threatened limbs or a threat to a limb within 2 years.

P18 Components of the ideal spoke vascular surgery unit

Abstract Introduction The ‘Hub and Spoke’ system consists of a leading unit that offers all services (Hub), supported by peripheral units providing less extensive services (Spokes). Cases requiring more complex interventions are often transferred from Spoke Units to the Hub. We wish to shed light on the factors that comprise an ideal Spoke Unit. Methods We did a retrospective review of the Peripheral arterial and Venous cases at our Spoke unit, and analysed patient records, took note of the contributions of various specialities and teams within the unit, allowing us to provide optimal care. Results We found that over an 8-month period (5th April 2022- 1st December 2022), the spoke unit undertook 105 lower limb venous procedures, and 55 arterial revascularisations, as day cases. This was possible due to the support we have from the podiatrists, vascular scientists, interventional radiologists, anaesthesiologists, physiotherapists, clinical specialist nurses and allied nursing teams as well as vascular unit managers. In cases where the hub may be overburdened, the Spoke unit can provide support by managing patients within their domain. Our main Hub Unit has an estimated capacity of 70-80 patients per week at any given time. When referrals to the Hub exceed the capacity, the spoke unit supports them to ensure optimal patient care and avoid physician burnout. Conclusion Having a strong multidisciplinary team contributes to an ideal spoke unit. Creating the ideal spoke unit is essential to optimise patient healthcare within a Hub and Spoke system, but also in preventing physician burnout.