Department Of Vascular Surgery Research Articles

Evaluation of the lower extremity blood supply in no-option critical limb ischemia patients with stem cell transplantation by time maximum intensity projection CT perfusion: A single-centre prospective study.

Cell therapy has had satisfactory safety and efficacy outcomes for no-option critical limb ischaemia (NO-CLI) patients. In the current study, we aimed to compare the image quality of ischaemic lower limb blood vessels shown on volumetric CT-based time maximum intensity projection CT perfusion (t-MIP CTP) versus single-phase CTA (sCTA). We also tried to quantify the blood flow of the ischaemic lower extremity based on the t-MIP technique, not only to precisely show the dynamic change in blood flow from before to after cell therapy but also to detect any relationship between this change and patient prognosis. A total of 31 patients with thromboangiitis obliterans (TAO)-induced NO-CLI who had been referred from the department of vascular surgery to undergo autologous stem cell transplantation into a single limb from January 2020 to March 2021 were prospectively enrolled in this study. Preoperative sCTA or t-MIP CTP and postoperative 1-month t-MIP CTP were performed in all patients. Clinical outcomes, including the 1-month ankle-brachial index (ABI) and 3-month CLI status, were also analysed. Image quality, including objective scores (attenuation, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]), subjective scores and collateral scores, was compared between preoperative sCTA and t-MIP CTP. Vascular volume was calculated as the total volume (mL) of lower limb arteries within the scanning range. All images and calculations were performed by 2 separate radiologists. Receiver operating characteristic curves were drawn to reveal the sensitivity and specificity of vascular volume and ABI in predicting prognosis. Both sCTA and t-MIP CTP images exhibited good quality for diagnosis. t-MIP CTP images showed significantly higher attenuation, SNR and CNR in all arterial segments (popliteal artery, anterior tibial artery, posterior tibial artery and peroneal artery). In subjective and collateral score evaluations, t-MIP CTP images were also significantly better than sCTA images (both p < .05). At 1 month after transplantation, both vascular volume and ABI showed significant improvement (both p < .01). At 3months after transplantation, 38.71% of patients (12/31) achieved CLI relief (Rutherford class < 4). Through the receiver operating characteristic (ROC) curve, the 1-month vascular volume increase ratio showed better ability to predict the 3-month prognosis (radiologist 1: AUC, 0.757; sensitivity, 0.750; specificity, 0.840; radiologist 2: AUC, 0.803; sensitivity, 0.500; specificity, 1.000) than the 1-month ABI increase ratio (AUC, 0.607; sensitivity, 0.230; specificity, 0.820) or 1-month ABI (AUC, 0.410; sensitivity, 0.080; specificity, 0.580). t-MIP CTP showed significantly higher-quality images of ischaemic limb vascularity than sCTA. t-MIP CTP can reveal the anatomical information of collaterals more accurately, which is of great importance for NO-CLI patients undergoing cell transplantation. The 1-month vascular volume increase ratio can predict the 3-month prognosis more precisely on this basis.

Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma

In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology. Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

QUALITY OF LIFE OF A PATIENT AFTER ENDARTERECTOMY OF THE INTERNAL CAROTID ARTERY (ICA) FOLLOWINGAN ACUTE ISCHEMIC STROKE (AIS) DURING COVID-19

The aim of the study was to evaluate the quality of life of a patient af- terendarterectomy (CEA) of the Internal Carotid Artery (ICA) following an Acute ischemic stroke (AIS) during COVID-19.A right-handed, 51-year-old patient, a visual artist, single, in good health and no chronic illnesses to date, became infected with SARS-CoV-2 and contracted COVID-19. The presence of SARS-CoV-2 virus was confirmed by a RT PCR antigen test. The patient was hospitalized, and required mechanical ventilation at an Intensive Care Unit (ICU) before an acute ischemic stroke (AIS) onset. Except for untreated hypertension, her medical history was unremarkable. Her blood pressure was 180/100 mm Hg; her pulse was 76 beats per minute and was regular. AIS from the left middle cerebral artery (MCA) has resulted primarily in damage to the left hemisphere, and secondary effects on the right side resulting in body weakness and mild anomic aphasia. Magnetic resonance imaging (MRI) confirmed stroke and detected brain tissue damaged by an AIS. It revealed hyperintense foci in the T2 and FLAIR sequences, 21 mm in size in the left hemisphere of the brain. In search of the cause of AIS, CT angiography was performed. It revealed a large (90%) ICA occlusion. The patient was admitted to the emergency room at the Vascular Surgery Clinic with an Endovascular Subunit. The revascularization procedure (CEA) was performed under general endotracheal anesthesia with the use of the protocol and techniques (elaborated at the Department of Vascular Surgery and Endovascular Procedures, The John Paul II Hospital in Krakow). The CEA procedure improved her general health: she regained the ability to name objects and her HRQOL also improved in her perception. The improvement achieved was statistically significant. She returned to painting and functions well in society.The patient’s perception of HRQoL measured by the SF-36 domains was better after the CEA: a significant improvement in self-reported overall health has occured. The HRQoL outcome measures may be valuable in future clinical trials of comparing different methods of treatment offered after AIS.

Eleven-Year Outcomes of a Screening Project for Abdominal Aortic Aneurysm (AAA) in 65-Year-Old Men.

Since 2011, the Department of Vascular Surgery at Oslo University Hospital has offered screening for abdominal aortic aneurysm (AAA) to 65-year-old men living in Oslo, Norway. The aim of this study was to evaluate the effect of the screening project on AAA-related mortality and rupture and repair rates in the screened population. This cohort study included men that participated in AAA screening at the Department of Vascular Surgery at Oslo University Hospital in the period May 2011 to September 2019. All men with screen-detected AAA (aortic diameter ≥30 mm) and subaneurysmal aortic dilatation (aortic diameter 25-29 mm) were included. A stratified (1:1 with the subaneurysm group), randomized selection of men with normal aortic diameter (<25 mm) upon screening was also included. The follow-up data on events (ruptures, repairs, and deaths) after screening were collected retrospectively from patient electronic medical records at Oslo University Hospital, the National Population Register and the Norwegian Cause of Death Registry (CoDR). In total, 2048 men were included, with a median follow-up time of 7.1 years (IQR 3.8). Among men with screen-detected AAA, 0.6% died of AAA-related causes (0.9 AAA-related deaths per 1000 person-years). The rupture rate was 0.3% among men with screen-detected AAA or subaneurysmal aortic dilatation, giving an incidence of 0.5 ruptures per 1000 person-years. The overall repair rate in the AAA group was 20.6% (36.1 repairs per 1000 person-years) and 0.6% (0.9 repairs per 1000 person-years) in the subaneurysm group. In a population screened for AAA, the incidence of rupture and the AAA-related mortality was very low. Almost one-fifth of the participants with screen-detected AAA underwent elective repair, representing a group that might have presented with rupture if untreated. These results indicate that screening is valuable in preventing AAA rupture and AAA-related mortality.

Lack of experienced surgeons in vascular surgery-Ajoint task

An increasing shortage of specialists and training assistants is also being lamented in vascular surgery. Despite acontinuous increase in the number of physicians and medical students in Germany in recent years, the need for specialists and training assistants in vascular surgery is enormous in asustained manner. Professional policy analysis from amedical vascular surgery perspective including currently available statistics, especially from the Federal Statistical Office, the Federal Medical Association, the Saxony-Anhalt (SA) State Medical Association and selective references from current medical scientific literature on epidemiological topics. In 2022, according to the basic data of the Federal Statistical Office 200 vascular surgery departments provided atotal of 5706 beds for care. In2021, 1574physicians with the regional and specialist title in vascular surgery were registered by the medical associations. In the following years, there was an increase of 404 vascular surgeons. The recognition of the specialist title for vascular surgery fell from 166 in 2018 to 143 in 2021. There are 23vascular surgery care units in Saxony-Anhalt (SA). At the SA Medical Association, there were 52registered doctors with the specialist title in vascular surgery in the inpatient sector in 2021. In comparison, at the North Rhine Medical Association in 2021 there were 362 registered doctors with regional and specialist titles in vascular surgery overall and 292 in the inpatient sector. The age-standardized hospital incidence of peripheral arterial occlusive disease (PAOD) rose from approximately 190 to over 250 per 100,000 inhabitants in Germany between 2005 and 2016 and plateaued at this level. This corresponded to arelative increase of 33%. During the same observational period, the number of procedures performed doubled, mainly due to astrong increase in the number of endovascular interventions (approximately 140% increase) and interventions for arterial embolism/thrombosis (approximately + 80%). Aresearch report commissioned by the German Hospital Society (DKG) in 2010 predicted areplacement requirement for physicians of approximately 108,000 by 2019 and an additional requirement of almost 31,000 physicians. While 14.6-27.2% of those employed in 2008 will have retired by 2020, between 45.6% and 68.5% will retire by 2030. Despite the statistically verifiable improvement in the staffing situation of specialists in vascular surgery in the inpatient and outpatient sectors in Germany, it can be assumed that there is aproblem in recruiting young specialists. In order to target the recruitment of junior staff, it is first necessary to comprehensively record basic data on the staff situation and staff development in the area of residents in vascular surgery. In addition, further work should be done on implementing the recommendations for action already put forward years ago by scientific reports at state and federal levels.

A commentary on "Clinical outcomes of different endovenous procedures among patients with varicose veins and iliac vein compression: a retrospective cohort study".

Department of Vascular Surgery, Shenzhen Second Hospital (First Affiliated Hospital of Shenzhen University), Shenzhen 518035, Guangdong, China Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. Published online ■ ■ *Corresponding author. Address: CHINA. E-mail address: [email protected] (H. Yang). This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Results Following Stent-Graft Coverage of the Hypogastric Artery in the Management of Aortoiliac Aneurysms in Endovascular Aneurysm Repair

AIM:The aim of our study was to assess the outcomes of stent-graft coverage of the hypogastric artery in the management of aortoiliac aneurysms in endovascular aneurysm repair.MATERIAL AND METHODS:From January 2013 to March 2017, a total of 93 patients with aortoiliac aneurysms were treated with EVAR, which required occlusion of one or both of the hypogastric arteries in the Department of General, Endocrine and Vascular Surgery. The patients were included in the study continuously and all procedures carried out were elective. RESULTS:A total of 93 patients with aortoiliac aneurysms required a unilateral or bilateral procedure. Six patients were excluded from our study as they did not show up to their follow-up appointments. The current study included 87 patients (80 men; mean age 71.9 (7.9) years, range 54-88), 30 patients had a unilateral procedure and 57 had a bilateral procedure. In 8 procedures (5.55%, N=7) there was a type II endoleak that resolved during follow-up and required no surgical intervention. In 10 procedures (6.94%, N=10) there was a type IB endoleak with 8 procedures requiring surgical re-intervention in the form of an extension. In 12 procedures (8.33%, N=9) the hypogastric artery thrombosed. CONCLUSION:Coverage of the hypogastric artery by the stent-graft has been proven to be a safe procedure but there is still a risk of type II endoleak. Although 5.55% (N=7) of the procedures had a type II endoleak in our study, none required surgical intervention.

Comprehensive frailty assessment with multidimensional frailty domains as a predictor ofmortality among vascular and cardiac surgicalpatients.

The frailty concept has become a fundamental part of daily clinical practice. In this study our purpose was to create a risk estimation method with a comprehensive aspect of patients' preoperative frailty. In our prospective, observational study, patients were enrolled between September 2014 and August 2017 in the Department of Cardiac Surgery and Department of Vascular Surgery at Semmelweis University, Budapest, Hungary. A comprehensive frailty score was built from four main domains: biological, functional-nutritional, cognitive-psychological and sociological. Each domain contained numerous indicators. In addition, the EUROSCORE for cardiac patients and the Vascular POSSUM for vascular patients were calculated and adjusted for mortality. Data from 228 participants were included for statistical analysis. A total of 161 patients underwent vascular surgery, and 67 underwent cardiac surgery. The preoperatively estimated mortality was not significantly different (median: 2.700, IQR (interquartile range): 2.000-4.900 vs. 3.000, IQR: 1.140-6.000, P = 0.266). The comprehensive frailty index was significantly different (0.400 (0.358-0.467) vs. 0.348 (0.303-0.460), P = 0.001). Indeceased patients had elevated comprehensive frailty index (0.371 (0.316-0.445) vs. 0.423 (0.365-0.500), P < 0.001). In the multivariate Cox model an increased risk for mortality in quartiles 2, 3 and 4 compared with quartile 1 as a reference was found (AHR (95% CI): 1.974 (0.982-3.969), 2.306 (1.155-4.603), and 3.058 (1.556-6.010), respectively). The comprehensive frailty index developed in this study could be an important predictor of long-term mortality after vascular or cardiac surgery. Accurate frailty estimation could make the traditional risk scoring systems more accurate and reliable.

Professor Anatoly Yakovlevich Ivanov – surgeon, scientist, teacher (on the 120th anniversary of his birth)

In 2023, the 120th anniversary of the birth of the famous surgeon, prominent scientist, talented teacher, Professor A.Ya. Ivanov will be celebrated. Graduated from the Odessa Medical Institute in 1926, he worked as a surgeon in hospitals of the Ukrainian SSR, and then in Leningrad. During the Great Patriotic War – senior surgeon of the hospital in besieged Leningrad, and since 1943 – the chief surgeon of the army of the 3rd Ukrainian Front. After the war, Anatoly Yakovlevich’s entire career was connected with the Department of General Surgery of the Leningrad Sanitary and Hygienic Medical Institute, where he made the way from assistant (1947), associate professor (1951), professor (1957) to head of the department (1960). From 1956 to 1973, A.Ya. Ivanov simultaneously held the position of director (rector) of the Leningrad Sanitary and Hygienic Medical Institute. He proved himself as a high-class surgeon, organizer of the scientific and pedagogical process. Under his leadership, new areas of work of the clinic were created, in particular, one of the first vascular surgery departments in the country was opened. It should be noted the breadth of A. Ya. Ivanov’s horizons and the variety of the studied scientific issues. Under his leadership, 3 doctoral and 20 candidate dissertations were defended, he was the author of more than 100 scientific papers. He was awarded orders and medals of the USSR. He died on August 26, 1988, and was buried at the Bolsheokhtinskoye Cemetery in St. Petersburg.

The Effect of Age on Peri-Operative Outcomes after FEVAR.

Fenestrated endovascular aortic repair (FEVAR) has become a popular custom-made treatment option for juxtarenal and pararenal aneurysms. It has been previously investigated whether octogenarians as a distinct subgroup are at increased risk for adverse outcomes after FEVAR. With diverging results and an inconclusive understanding of age as a risk factor in general, an analysis of the historical data of a single center was conducted to add to the available body of evidence and further investigate the effect of age as a continuous risk factor. A retrospective data analysis of a prospectively maintained single-center database of all patients who underwent FEVAR at a single department of vascular surgery was performed. The main endpoint was post-operative survival. In addition to association analyses, potential confounders such as co-morbidities, complication rates, or aneurysm diameter were examined. In terms of sensitivity analyses, logistic regression models were created for the dependent variables of interest. During the observation period from April 2013 to November 2020, 40 patients over the age of 80 and 191 patients under the age of 80 were treated by FEVAR. The 30-day survival showed no significant difference between the groups (95.1% in octogenarians and 94.3% in patients under 80 years of age). The sensitivity analyses conducted also showed no difference between the two groups, and complication and technical success rates were comparable. The aneurysm diameter was 67 ± 13 mm in the study group and 61 ± 15 mm in those under 80 years of age. Additionally, the sensitivity analyses showed that age as a continuous variable exhibits no effect on the outcomes of interest. In the present study, age was not associated with adverse peri-operative outcomes after FEVAR, including mortality, lower technical success rates, complications, or length of hospital stay. Essentially, the most highly associated factor with hospital and ICU length of stay was time spent in surgery. However, octogenarians had a significantly larger aortic diameter at the time of treatment, which might indicate the potential introduction of bias by pre-interventional patient selection. Nevertheless, the usefulness of research on octogenarians as a distinct subgroup might be questionable regarding the scalability of results, and future studies might focus on age as a continuous risk factor instead.

Clinical Comparison of the Efficacy of Systemic Thrombolysis,Catheter-Directed Thrombolysis,and AngioJet Percutaneous Mechanical Thrombectomy in Acute Lower Extremity Deep Venous Thrombosis

Objective To compare the clinical effects of three treatment methods including systemic thrombolysis(ST),catheter-directed thrombolysis(CDT),and AngioJet percutaneous mechanical thrombectomy(PMT)in acute lower extremity deep venous thrombosis(LEDVT). Methods The data of 82 patients diagnosed with LEDVT in the Department of Vascular and Gland Surgery of the First Affiliated Hospital of Hebei North University from January 2017 to December 2020 were collected.The patients were assigned into a ST group(n=50),a CDT group(n=16),and a PMT group(n=16)according to different treatment methods.The efficacy and safety were compared among the three groups. Results Compared with that before treatment,the circumferential diameter difference of both lower limbs on days 1,2,and 3 of treatment in the ST,CDT,and PMT groups reduced(all P<0.001).The PMT group showed smaller circumferential diameter difference of lower limbs on days 1,2,and 3 of treatment than the ST group(all P<0.001)and smaller circumferential diameter difference of the lower patellar margin on day 1 of treatment than the CDT group(P<0.001).The PMT group showed higher diminution rate for swelling of the affected limb at the upper and lower edges of the patella than the ST group(P<0.001)and higher diminution rate for swelling at the upper edge of the patella than the CDT group(P=0.026).The incidence of complications after treatment showed no significant differences among the three groups(all P>0.05).The median of hospital stay in the PMT group was shorter than that in the ST and CDT groups(P=0.002,P=0.001).The PMT group had higher thrombus clearance rate than the ST group(P=0.002)and no significant difference in the thrombus clearance rate from the CDT group(P=0.361).The vascular recanalization rates in the PMT(all P<0.001)and CDT(P<0.001,P=0.002,P=0.009)groups 3,6,and 12 months after treatment were higher than those in ST group,and there were no significant differences between PMT and CDT groups(P=0.341,P=0.210,P=0.341). Conclusions ST,CDT,and PMT demonstrated significant efficacy in the treatment of LEDVT,and PMT was superior to ST and CDT in terms of circumferential diameter difference of the lower limbs,diminution rate for swelling of the affected limb,thrombus clearance rate,length of hospital stay,and long-term vascular recanalization.There was no obvious difference in safety among the three therapies.

Upper extremity arterial thrombosis, experience at the General Hospital of Mexico Dr. Eduardo Liceaga: case-series

The upper extremity arterial thrombosis has a low frequency of presentation, which is why they have been little studied and their therapeutic alternatives can be controversial with a high risk of limb loss, which represents a crucial factor in the quality of life of patients. In this investigation, cases of upper extremity arterial thrombosis are reported, evaluated and treated by the Department of angiology, vascular and endovascular surgery of the General Hospital of Mexico Dr. Eduardo Liceaga in Mexico City during the period of March 2022 to March 2023.

Is carotid web an arterial wall dysplasia? A histological series

IntroductionDescribed for 60 years under various names, the carotid web is a suspected cause of cryptogenic stroke, especially in young patients. The web creates an intraluminal protrusion that may contribute to turbulent flow and thrombus embolization into cerebral arteries. Although the carotid web has frequently been related to arterial fibrodysplasia, its natural history and pathological description remain unclear. PatientsAmong all consecutive patients admitted to the stroke unit of Sainte-Anne Hospital and referred to the vascular surgery department from January 2015 to December 2022, we retrospectively identified 9 patients with a carotid web. The surgical specimens of the 9 patients were submitted to systematic pathological analysis. ResultsThe patients with a histologically confirmed carotid web were young (median age was 42 years), prominently women (7/9), and presenting with low cardiovascular risk. Eight patients had a stroke proven by a magnetic resonance imaging, and 1 had transient monocular amaurosis. The typical pathological lesion supporting the imaging pattern of the carotid web was a focal eccentric intimal hyperplasia forming a protruding lesion characterized by a population of vascular smooth muscle cells intermingled in an abundant, most often loose extracellular matrix. Pathologically proven thrombus was observed in 4 cases. Importantly atherosclerosis was absent. ConclusionHistological features in our 9 cases strengthen carotid web characterization as a homogeneous pattern of localized intimal hyperplasia. It is a unique entity consistent with intimal fibroplasia, distinct from medial fibromuscular dysplasia and early atherosclerosis.

Embolectomy at the Time of Ligation of Femoral Vessels in Psuedoaneurysm in Intravenous Drug Addicts can save Limb

Aim: To determine the impact of embolectomy at the time of ligation of femoral artery in management of pseudoaneurysmin intravenous drug addicts Study design: Descriptive cross-sectional study Methods: This study was carried out at Vascular surgery department, CMH Lahore and included 28 patientsof intravenous drug addiction of both genders presenting in emergency of CMH Lahore with viable limb from 1st August 2021 to31st January 2023. Unsalvageable limbs at the time of presentation were excluded from the study. SPSS Version 20.0 was used for data analysis of age, sex, co-morbidities (infection), mode of presentation and outcome variables. Results: This study comprised of28 patientsadmitted through Emergency Department of CMH, Lahore. The mean age was found to be 32.16 years ±7.63 years. All patients 28(100%) were males with majority belonging to third decade of life 20(71.4%).Chronic viral infection was present in all cases. Almost half of them had hepatitis B virus infection (48%) while cases positive with hepatitis C virus and HIV infections were 37% and 15% respectively.Majority of the patients came to the hospital with bleeding from ruptured pseudoaneurysm (60.7%) and infected pulsatile swelling (32.1%), while pulsatile swelling without bleedingand wrong diagnosis were least common.Alllimbs were salvaged in first and second follow-up visits, 20 patients were lost on follow up on 12th week. Conclusion/Practical implication: Embolectomy is a very useful adjunct in the management of pseudoaneurysm of intravenous drug addicts. It should be routinely practiced in treatment of these patients to save limbs. Keywords: Embolectomy, ligation, femoral vessels, intravenous drug addicts

EXPERIENCE OF HYBRID SURGICAL TREATMENT FOR MULTILEVEL OCCLUSIVE-STENOTIC ARTERIAL LESIONS IN LOWER EXTREMITIES

Peripheral artery disease affects approximately 20% of individuals over the age of 70 and is particularly prevalent among smokers and diabetics. The increasing global prevalence of metabolic syndrome, diabetes, and smoking suggests a further rise in its occurrence. The treatment of this disease incurs significant economic costs, which are projected to continue growing. This disease is associated with high rates of disability, morbidity, and mortality. Without revascularization, 20 to 40% of patients face limb loss, and over 20% die within six months. Conservative therapies are often ineffective, leading to the surgical methods. In cases of critical limb ischemia, revascularization is performed to improve blood flow distal to stenotic or occlusive lesions. Open surgery remains the standard of care, demonstrating good limb preservation and long-term outcomes. The success of bypass procedures depends on multiple factors. The use of endovascular techniques is rapidly increasing, supported by substantial long-term data. While endovascular surgery reduces perioperative complications, choosing the appropriate instrumentation and assessing associated costs remain contentious. Method selection depends on several factors. For certain patients where open surgery is technically challenging or impractical, endovascular surgery provides a viable solution for revascularization. In such cases, revascularization of all arterial lesion levels using a combination of methods is indicated to restore limb blood supply. Isolated revascularization of a single anatomical level is often insufficient and rarely leads to the healing of trophic changes. Hybrid surgery, involving a combination of techniques during a single intervention, is a common approach. This type of surgical procedure includes endovascular correction of the iliac segment with femoral endarterectomy and/or infrainguinal bypass. Another common option is an "above knee bypass" with tibial balloon angioplasty. Surgical treatment using hybrid procedures demonstrates high technical success, good primary and secondary patency rates, limb preservation, and economic efficiency. In this article, we present two clinical cases of hybrid surgical lower extremity revascularization performed at the Department of Vascular Surgery of the M.V. Sklifosovsky Poltava Regional Clinical Hospital. These cases involve patients with stage IV peripheral artery disease (Fontaine classification) caused by an atherosclerotic process. Computed tomography with angiography and digital subtraction angiography were employed as two distinct methods for studying the vascular bed in routine patient management. The method selection was based on angiosomal targets and the suspected vascular lesions initially diagnosed. The objective of this study is to analyze the effectiveness of various hybrid surgical treatment methods for patients with critical limb ischemia resulting from multilevel occlusive-stenotic arterial lesions.

Effect of Hyaluronic Acid Iontophoresis on Healing of Chronic Venous Ulcer

Purpose: The purpose of the study is to evaluate the effect of hyaluronic acid iontophoresis on healing of chronic venous ulcer. Methods: Forty patients of both genders suffering from chronic venous ulcer in area below the knee and above the ankle with area (5-20 cm2) with less than 50% necrotic tissue participated in this study. Their ages ranged from (45 to 60) years. They were selected from Vascular Surgery Department, Al Ahrar Teaching Hospital between June 2022 and January 2023. Patients were divided randomly into 2 equal groups; each one had 20 patients. Group (A) received Hyaluronic acid iontophoresis 1 session per day, 3 sessions per week, for 4 weeks, and follow up 4 weeks after the end of the treatment. In addition to conventional, medical treatment and traditional care. Group (B) received conventional medical treatment and traditional care (ulcer cleansing, debridement, dressing, compression, medication, exercise). Measurements were done by photographic digital camera for wound Surface area (WSA) and wound volume using saline injection into a wound cavity before treatment and after 4 weeks of treatment. Results: The findings of this study indicated significant decrease in WSA and wound volume after treatment in all groups A, B (p&lt;0.001) at day 60 post treatment. There was significant decrease in ulcer surface area and ulcer volume at day 60 post treatment of study group (group A) compared with that of control group (group B) (p = 0.001).Conclusion: Hyaluronic acid iontophoresis for 6 weeks is an effective and safe adjuvant therapy in treatment of unhealed venous ulcers through accelerating wound healing, reducing Wound Surface Area (WSA) and wound volume. Keywords: Hyaluronic Acid, iontophoresis, Chronic Venous leg ulcers, Wound Healing

Radiation Exposure in Endovascular Surgery According to Complexity: Protocol for a Prospective Observational Study.

In the past decades, we have witnessed tremendous developments in endovascular surgery. Nowadays, highly complex procedures are performed by minimally invasive means. A key point is equipment improvement. Modern C-arms provide advanced imaging capabilities, facilitating endovascular navigation with an adequate open surgical environment. Nevertheless, radiation exposure remains an issue of concern. This study aims to analyze radiation used during endovascular procedures according to complexity, comparing a mobile X-ray system with a hybrid room (fixed X-ray system). This is an observational and prospective study based on a cohort of non-randomized patients treated by endovascular procedures in a Vascular Surgery department using two imaging systems. The study is planned for a 3-year duration with a recruitment period of 30 months (beginning 20 July 2021) and a 1-month follow-up period for each patient. This is the first prospective study designed to describe the radiation dose according to the complexity of the procedure. Another strength of this study is that radiologic variables are obtained directly from the C-arm and no additional measurements are required for feasibility benefit. The results from this study will help us determine the level of radiation in different endovascular procedures, in view of their complexity.

Fenestrated Endovascular Aortic Repair After Failed Endovascular Aortic Repair.

Fenestrated endovascular aortic repair (FEVAR) is technically more challenging when performed after a failing EVAR procedure (FEVAR after EVAR). This study aims to assess the technical outcome of FEVAR after EVAR and to identify factors that may influence complication rates. A retrospective observational study was conducted at a single department of vascular and endovascular surgery. The rate of FEVAR after EVAR compared to primary FEVAR is reported. Complication and primary unconnected fenestration (PUF) rates as well as survival were assessed for the FEVAR after EVAR cohort. PUF rates and operating time were also compared to all primary FEVAR patients. Patient characteristics and technical factors such as number of fenestrations or use of a steerable sheath were assessed as possible influencers on technical success when performing FEVAR after EVAR. Two hundred and nine fenestrated devices were implanted during the study period (2013 to April 2020). Thirty-five patients (16.7% of all FEVAR patients) had undergone FEVAR after EVAR and were included in the study. Overall survival at last follow-up (20.2±19.1 months) was 82.9% in FEVAR after EVAR patients. Rates of technical failure dropped significantly after 14 procedures (42.9% vs. 9.5%; p=0.03). Primary unconnected fenestrations were seen in 3 cases of FEVAR after EVAR (8.6%) and 14 of 174 primary FEVAR cases (8.0%; p>0.99). Operating time for FEVAR after EVAR was significantly higher than for primary FEVAR (301.1±110.5 minutes vs. 253.9±103.4 minutes; p=0.02). The availability of a steerable sheath was a significant predictor of reduced risk of PUFs, whereas age and gender, number of fenestrations or suprarenal fixation of the failed EVAR did not significantly influence PUF rates. Fewer technical complications were seen over the study period in FEVAR after EVAR patients. While rates of PUFs were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR can be a valuable and safe tool to treat patients with progression of aortic disease or type Ia endoleak after EVAR but may be more complex to achieve than primary FEVAR. This retrospective study assesses the technical outcome of fenestrated endovascular aortic repair (fenestrated EVAR; FEVAR) after prior EVAR. While rates of primary unconnected fenestrations were not different from primary FEVAR, operating time was significantly longer in patients undergoing FEVAR for failed EVAR. Fenestrated EVAR after prior EVAR may be technically more challenging than primary FEVAR procedures, but could be performed with equally good results in this patient cohort. FEVAR offers a feasible treatment option for patients with progression of aortic disease or type Ia endoleak after EVAR.

Blood flow restricted walking in patients suffering from intermittent claudication: a case series feasibility and safety study.

Sixteen patients with IC were recruited from two departments of vascular surgery. The BFR-W programme implied the application of a pneumatic cuff around the proximal part of the affected limb at 60% limb occlusion pressure in five intervals of 2min, four times per week for 12 weeks. Feasibility was evaluated by adherence and completion rates of the BFR-W programme. Safety was evaluated by adverse events, ankle-brachial index (ABI) at baseline and follow-up, and pain on a numerical rating scale (NRS pain) before and 2min after training sessions. Furthermore, changes in performance between baseline and follow-up were evaluated with the 30 seconds sit-to-stand test (30STS), the 6-minute walk test (6MWT) and the IC questionnaire (ICQ). Fifteen out of 16 patients completed the 12-week BFR-W programme and adherence was 92.8% (95% CI: 83.4; 100%). One adverse event unrelated to the intervention was reported causing one patient to terminate the programme 2 weeks prematurely. Mean NRS pain 2min following BFR-W was 1.8 (95% CI [1.7-2]). ABI, 30STS, 6MWT and ICQ score were improved at follow-up. BFR-W is feasible and appears to be safe in terms of completion rate, adherence to the training protocol, and adverse events in patients with IC. Further investigation of the effectiveness and safety of BFR-W compared to regular walking exercise is needed.

A Treatment Approach for Carotid Blowout Syndrome and Soft Tissue Reconstruction after Radiotherapy in Patients with Oral Cancer: A Report of 2 Cases.

This retrospective case series study aims to demonstrate a salvage technique for the treatment of carotid blow-out syndrome (CBS) in irradiated head and neck cancer patients with a vessel-depleted neck. Between October 2017 and October 2021, two patients (N = 2) with CBS were treated at our institution in a multidisciplinary approach together with the Department of Vascular Surgery. Patients were characterized based on diagnoses, treatment procedures, and the subsequent postoperative course. Surgical emergency intervention was performed in both cases. The transition zone from the common carotid artery (CCA) to the internal carotid artery (ICA) was resected and reconstructed with a xenogic (case 1) or autogenic (case 2) interposition (end-to-end anastomosis). To allow reconstruction of the vascular defect, an additional autologous vein graft was anastomosed to the interposition graft in an end-to-side technique, allowing arterial anastomosis for a free microvascular flap without re-clamping of the ICA. Because of the intraoperative ICA reconstruction, none of the patients suffered a neurological deficit. The techniques presented in the form of two case reports allow for acute bleeding control, cerebral perfusion, and the creation of a vascular anastomosis option in the vessel-depleted neck.