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Latest Published Articles

30.01.15

 

 

 

The frozen elephant trunk technique for the treatment of complicated type B aortic dissection with involvement of the aortic arch: multicentre early experience.

 

Providing effective treatment for complicated type B aortic dissection (AD) with concomitant pathologies of the aortic arch or ascending aorta is challenging, especially if the aortic anatomy is contraindicated for thoracic endovascular aortic repair (TEVAR). This study presents the early results of a multicentre study using the frozen elephant trunk (FET) technique for type B AD.

The in-hospital mortality rate was 14% (8/57). Stroke and spinal cord injury occurred in 6 (10%) and 2 patients (4%), respectively. The 1- and 3-year survival was 81 and 75%, respectively.

The FET technique is a feasible therapeutic option for complicated type B AD with involvement of the aortic arch if TEVAR is contraindicated. In contrast to conventional aortic surgery via a lateral thoracotomy, the FET procedure can provide simultaneous treatment of the ascending aorta and aortic arch.

Eur J Cardiothorac Surg. 2014 Mar 5, doi: 10.1093/ejcts/ezu067

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Aneurysm Disease

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

The Impact of Early Pelvic and Lower Limb Reperfusion and Attentive Peri-operative Management on the Incidence of Spinal Cord Ischemia During Thoracoabdominal Aortic Aneurysm Endovascular Repair

 

 

This study suggests that the early restoration of arterial flow to the pelvis and lower limbs, and aggressive peri–operative management significantly reduces Spinal Cord Ischemia (SCI) following type I–III thoracoabdominal aortic aneurysm (TAAA) endovascular repair. With the use of these modified protocols, extensive TAAA endovascular repairs are associated with low rates of SCI.

EJVES, 01/19/2015

doi: http://dx.doi.org/10.1016/j.ejvs.2014.11.017

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Aneurysm Disease

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

23.01.15

 

 

Emergency open surgery for aorto-oesophageal and aorto-bronchial fistulae after thoracic endovascular aortic repair: a single-centre experience

 

Severe complications after thoracic endovascular aortic repair (TEVAR), such as secondary aorto-oesophageal (AOF) or aorto-bronchial fistulae (ABF), are most likely under-reported; however, once detected, emergent surgery becomes necessary.

AOF and ABF represent uncommon but fatal complications-if treated conservatively after TEVAR that may occur during short- and mid-term follow-up. Surgery for AOF/ABF requires early diagnosis and should be performed promptly and in a radical fashion to totally excise all infected tissues in these high-risk patients.

Eur J Cardiothorac Surg. 2015 Feb; 47 (2):374-83.

doi: 10.1093/ejcts/ezu147

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Aneurysm Disease

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Comparison of outcomes in patients with venous leg ulcers treated with compression therapy alone versus combination of surgery and compression therapy: a systematic review.

 

 

Compression therapy is generally considered the primary intervention for both ulcer management and prevention of recurrence. However, recent studies suggest that surgical correction of venous insufficiency may enhance healing of venous ulcers or help prevent recurrence. The objective of this systematic review was to compare wound healing and recurrence rates in patients managed with compression therapy alone versus compression therapy plus surgery.

Existing evidence supports compression therapy as the most critical element in the management of venous leg ulcers. However, evidence also suggests that surgical obliteration of incompetent perforator veins may promote longer ulcer free periods and lower rates of recurrence.

J Wound Ostomy Continence Nurs. 2015 Jan-Feb; 42(1): 42-6

doi: 10.1097/WON.0000000000000079

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Venous disease

            Venous leg ulcers

            Varicose veins

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

Second Toe Systolic Pressure Measurements are Valid Substitutes for First Toe Systolic Pressure Measurements in Diabetic Patients: A Prospective Study

 

Toe systolic pressure is a component of the standard vascular and diabetic foot assessment. Until now, clinicians have measured only first toe pressure given a lack of evidence for measurements of the other toes. In diabetic patients, first toe measurements are often not possible because of ulceration or amputation. It was hypothesized that the adjacent second toe systolic pressure measurements would be interchangeable with those of the first toe. Eighty-two percent of the variations in the second toe measurements were accounted for by knowing the first toe measurements and vice versa. Ordinary Least Products regression showed no fixed or proportional bias between the two methods of measurement: second toe systolic pressure=(−0.579) + (1.038) first toe systolic pressure. Repeatability analysis showed a 0.5% variation between duplicate measurements.

This is the first study, which demonstrates that second toe systolic pressures are interchangeable with those of the first toe. Second toe pressures can be used in diabetic patients whose first toe pressures cannot be assessed.

 

EJVES, Jan 2015, Volume 49, Issue 1, Pages 77–82

Doi: http://dx.doi.org/10.1016/j.ejvs.2014.09.011

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Peripheral vascular Disease

            Diabetic foot disease

            Open and endovascular treatment options

            Selection of Patients

16.01.15

 

 

Vascular Presentations from SARS annual meeting 2015:

 

METABOLIC PROFILING OF PATIENTS WITH DIFFERING SEVERITY OF VENOUS

DISEASE

Presented by Spagou et al, Imperial College, London

 

This study aimed at investigating whether there is a difference between the metabolic profile of patients presenting with varying clinical severity of venous disease. For 44 patients with variable degrees of venous disease; urine, serum and vein tissue were analysed using mass spectrometry and proton nuclear magnetic resonance. Sphingomyeline, phosphatidylcholine and phosophorylethanolamine were found to be elevated in vein tissue and for the first time identified in serum in both groups whilst taurine was present in urine. Multivariate models demonstrated no significant difference between the metabolic profile of the two groups in vein tissue, urine or serum.
 

Take home message:
1. There may be a systemic component to venous disease.
2. Skin manifestations of venous disease may be determined by localised tissue interactions.

 

 

 

 

AN INTERNATIONAL, MULTICENTER, RANDOMIZED, SINGLE-BLIND, CONTROLLED

TRIAL OF A DRY POWDER, FIBRIN SEALANT TO STOP SURGICAL BLEEDING IN PATIENTS

UNDERGOING VASCULAR SURGICAL PROCEDURES

Presented by Chetter et al, University of Hull, on behalf of multiple centres/investigators

 

In this randomised controlled trial, the effect of topical sealants: fibrin + gelatin sponge vs. gelatin sponge alone were compared in patients undergoing vascular surgery with suture hole bleeding. 175 were randomised (2 to 1: to fibrin sealant or gelatin sponge) and showed that Fibrin sealant significantly reduced time to hemostasis compared to gelatin sponge used alone. It also reduced it in patients who were on both anticoagulant and antiplatelet agents.

Take-home message:

A ready to use, dry powder fibrin sealant was well tolerated and reduced time to hemostasis in

patients undergoing vascular procedures, including those receiving anticoagulant and antiplatelet

agents, demonstrating its safety and usefulness as an adjunct to hemostasis.

 

 

 

 

OPPORTUNITY FOR CARDIOVASCULAR RISK FACTOR REDUCTION IN AAA

SURVEILLANCE PROGRAMS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF

CARDIOVASCULAR MORTALITY IN PATIENTS WITH SMALL AAA

Presented by Bath et al, University of Leicester

 

This is an increasingly important topic, highlighted in most of the recent international vascular conferences. The authors presented results from a systematic review and meta-analysis that included cardiovascular outcome data from > 2000 patients included in 10 studies. A total of 335

cardiovascular deaths occurred, 37 of which were due to AAA-rupture, showing a cardiovascular

mortality risk of 3.00% per year in small AAA patients (R^2=0.902, p<0.001). The prevalence of

ischaemic heart disease (44.9%), myocardial infarction (26.8%), heart failure (4.4%) and cerebrovascular disease (14.0%) was significantly higher in patients with small AAA than in the general population.

 

Take-home message:

Small AAA patients have a high risk of cardiovascular mortality, and screening/surveillance is the ideal opportunity to manage these.

 

 

 

 

19.12.14

 

 

 

 

Drug-Coated Balloon versus Standard Percutaneous Transluminal Angioplasty for the Treatment of Superficial Femoral and/or Popliteal Peripheral Artery Disease: 12-month Results from the IN.PACT SFA Randomised Trial

 

This is a multicentre, single-blinded, randomised trial from the USA. 331 patients with intermittent claudication or ischaemic rest pain due to SFA and/or popliteal artery disease were randomly assigned to either treatment with a drug-coated balloon (DCB – with paclitaxel) or standard PTA. The primary outcome measure was primary patency at 12 months. Both patient and lesion characteristics were similar between groups. DCB resulted in higher primary patency than PTA (82.2% vs. 52.4%; P<0.001) and less clinically-driven target lesion revascularisation (2.4% vs. 20.6%; P<0.001).

Circulation. Published online before print December 3, 2014.
DOI: 10.1161/CIRCULATIONAHA.114.011004

 

Selected by: Alastair McKay; Core Trainee, West of Scotland

 

UK Vascular Curriculum Topics – Vascular Anatomy; Vascular pathology; Chronic lower limb ischaemia; Endovascular procedures.

 

 

 

 

A ‘Christmas Tree’ Band for the Treatment of Arteriovenous Dialysis Access-Related Steal Syndrome

 

Dialysis access steal syndrome (DASS) is an uncommon but often serious complication in the formation of dialysis access. This short case series of 6 patients describes the use of a PTFE carotid patch shaped with a slit at one end and saw tooth edges which provide a ratchet mechanism to progressively constrict the draining vein of the AVF. This is performed with finger perfusion pressure measurements to allow optimal compromise between distal extremity and AVF. All 6 patients over a mean follow up of 14 months had relief of DASS symptoms with ongoing patency of the AVF.

Ann Vasc Surg. 2013; 27(2): 239

 

UK Vascular Curriculum Topics – Vascular anatomy; Vascular physiology; Vascular Access

 

Selected by Alastair McKay

Core Trainee, West of Scotland

 

The ‘Christmas Tree’ Band – A New Approach to Access Related Steal Syndrome

 

12.12.14

 

 

 

Prize winning papers from the Vascular Society of Great Britain and Ireland annual meeting – Glasgow, 2014

 

 

Sol Cohen (Clinical) Prize:
Randomised controlled trial of preoperative supervised exercise in patients undergoing

elective abdominal aortic aneurysm repair

 

Barakat et al, Hull York Medical School

The aim was to assess whether a period of preoperative medically supervised exercise

improves clinical outcomes following elective abdominal aortic aneurysm (AAA) repair.

Patients scheduled for open or endovascular (EVAR) repair were randomised to either six weeks of supervised exercise or standard treatment.

The primary outcome measure was the occurrence of postoperative complications (A composite end point of cardiac, pulmonary and renal complications). Secondary outcome measures were: Thirty-day mortality, lengths of hospital and critical care stay, APACHE II scores recorded at critical care admission, re-operation and postoperative bleeding.

Patients were followed up for three months.

A total of 124 patients (62 in each group) were included (111 men, mean (s.d.) age 73 (7) years) of which 46 patients underwent EVAR (23 in each group). 14 patients (22.6 per cent) sustained postoperative complications in the exercise group, compared to 26 (41.9 per cent) in the non-exercise group (P=0.021). Four patients (3.2 per cent, 2 in each group) died within 30 days postoperatively.

Patients in the exercise group stayed less in hospital [median (IQR) 7 (5-9) days vs 8 (6.0 -

12.3) days] (P=0.025). There were no significant differences in the length of critical care stay (P=0.845), APACHE II scores (P=0.256), incidence of re-operations (P=1.000) and postoperative bleeding (P=0.343).

A period of preoperative supervised exercise training reduces postoperative cardiac,

respiratory and renal complications and length of hospital stay in patients undergoing elective

AAA repair.

 

BJS (Scientific) Prize:

Diabetes protects against abdominal aortic aneurysms via modulation of glucose

transporters

 

Dattani et al, University of Leicester

Diabetes mellitus (DM) is a strong negative risk factor for abdominal aortic aneurysm (AAA)

development and growth. The mechanisms underlying this protective effect are poorly understood. This study investigated whether glucose transporters (GLUTs), a group of transmembrane proteins implicated in the development of diabetic complications such as retinopathy and nephropathy, are important in mediating this effect.

Whole aortic tissue samples (WATS) collected from AAA patients and cadaveric controls were used to study differential GLUT gene expression (qRT-PCR) and perform aortic smooth muscle cell (AoSMC) explant culture. AoSMCs were then used to study GLUT gene expression (qRT-PCR) and GLUT activity (2-deoxy-D-[3H]-glucose transport assay) at baseline and in response to hyperglycaemia (12.5mM, 25mM, 50mM).

A comparison of 20 AAA and 15 control patients revealed significantly elevated GLUT3

(Fold Change 18.37; p=0.035) and GLUT6 (FC 2.49; p=0.039) mRNA levels in AAA WATS. AoSMCs from AAA patients also demonstrated significantly elevated GLUT activity levels compared with controls (n=10 versus 10; 48% higher; p=0.023). Exposing AoSMCs to incremental hyperglycaemia was associated with no change in GLUT gene expression but produced a significant stepwise decline in GLUT activity selectively in cells from AAA patients (30% decrease; p=0.013).

AAA is associated with up-regulation in both GLUT gene expression and activity. Using an

In vitro model of AAA, the diabetic phenotype can down-regulate GLUT activity to levels seen in non-aneurysmal cells. This effect represents a putative mechanism by which DM slows aneurysm growth in patients with AAA. Future studies should investigate GLUT inhibition as a novel therapeutic target.

 

 

Richard Wood Prize

A material conferring haemocompatibility in the absence of an endothelium, and its

application in cardiovascular implants

 

Everett et al, UCL, London
L-Arginine is required for endogenous up-regulation of nitric oxide (NO), for the protection of cardiovascular implants. This study aimed to investigate L-arginine methyl ester (L-AME),

an L-arginine analogue, as a novel anti-thrombogenic agent in the absence of a functional endothelium. L-AME was therefore incorporated into polyhedral oligomeric silsesquioxanepoly(carbonate-urea)urethane (POSS-PCU), a material widely applied for the fabrication of surgical implants, with a focus upon the effect of L-AME on the material's physicochemical

properties, and its haemocompatibility, with the aim of wider application of L-AME in cardiovascular implants.

L-AME incorporated into POSS-PCU was subject to tensile strength testing, and L-AME elution rate testing; surface characterisation through contact angle measurements, Fouriertransform infrared spectroscopy, the Kaiser test, Time-of-Flight secondary ion mass spectrometry, confocal and scanning electron microscopy; and haemocompatibility was determined through thromboelastography and platelet morphology examination.

Successful, uniform incorporation of increasing concentration of L-AME was confirmed through surface analysis. The tensile strength of the highest concentration of L-AME-POSSPCU (1.05 M) was 42.7 MPa (POSS-PCU control was 66.6 MPa). L-AME incorporation produced a hydrophilic (the contact angle for the 1.05 M incorporated L-AME was 70.07°, p < 0.001), porous structure (with pore diameter of 1.90 m at 6.915 x104 mm-2 for 1.05 M LAME).

Isolated L-AME exhibited anti-thrombogenic characteristics (p < 0.045), which was replicated when L-AME was incorporated into POSS-PCU (p < 0.012). L-AME demonstrated anti-thrombogenic properties and was successfully incorporated into POSS-PCU. L-AME can potentially be applied to a range of materials to confer haemocompatibility, and L-AME-POSS-PCU in the development of a range of

cardiovascular implants.

 

 

 

The 2014 Kinmonth Lecture from Prof AR Naylor, titled: Carotid trials and tribulations
 

 

 

 

05.12.14

 

 

 

 

International trends in patient selection for elective endovascular aneurysm repair: sicker patients with safer anatomy leading to improved one year survival

 

This retrospective review of patient data from 3 countries (Australia, Canada and England) over a 13 year period (1999-2012) sought to identify trends in patient selection and also early patient survival following elective EVAR. Including audit data from over 4000 patients, the study identified that overall 1-year survival is improving despite the selection of increasingly “sick” patients for surgery (as measured by ASA grade).  Although the results are obviously unique to the participating centres, by collating data from such a large number of patients (and including multiple centres from England) the authors are able to identify trends which may be generalisable to many other developed nations. Country-specific trends – such as the tendency to operate on older patients in England, and smaller aneurysms in Australia – will need further investigation to elucidate the underlying causes and potential consequences, but overall this study highlights the improvement in early survival in elective EVAR patients and attributes this to both increased surgical knowledge and improved medical management. 

Annals of Vascular Surgery: Published online Nov 15, 2014

DOI: http://dx.doi.org/10.1016/j.avsg.2014.09.015

 

 

Selected by Miss Kathryn Griffin (BHF Research Fellow)

 

Vascular Curriculum Topics:                 

Vascular Epidemiology

Principles of Audit & Quality Control

Evidence based Vascular Practice

 

 

 

 

Factors Associated With Small Abdominal Aortic Aneurysm Expansion Rate

 

It has been difficult to conclusively identify factors associated with abdominal aortic aneurysm  growth. This has largely been due to the large sample sizes required to attempt suitable statistical growth modelling. This study used the ultrasound derived aneurysm growth data from 534 patients from the original ADAM (Aneurysm Detection and Management) study. A multivariable mixed effects model was used to estimate growth and co-variables added into the model to determine if they had a significant affect. Current cigarette smoking and diastolic blood pressure increased AAA growth rate, whereas diabetic patients had a reduced AAA growth rate. These findings largely support those of the RESCAN collaborators. The authors recommend direct action with regards smoking cessation and blood pressure control for patients with known AAA to slow progression.

JAMA Surgery

doi: 10.1001/jamasurg.2014.2025. [Epub ahead of print]

 

Selected by Mr Marc Bailey (BHF Research Fellow)

 

Vascular Curriculum Topics:     

Evidence based vascular practice

Abdominal aortic aneurysm (elective)

 

 

 

 

A systematic review and meta-analysis of the association between markers of hemostasis and abdominal aortic aneurysm presence and size

 

A systematic review and meta-analysis was performed in order to summarise the current evidence surrounding the links between haemostasis and the presence and size of AAA.  A total of 22 non-randomised studies were included, with a total of 9862 patients. Levels of fibrinogen, D-dimer (the plasmin mediated breakdown product of fibrin), and Thrombin-Anti-thrombin complex (a marker of thrombin neutralisation) were significantly increased in patients with AAA compared with control subjects. Meta-regression between plasma D-dimer concentration and AAA diameter suggested a strong and significant association. This study suggested that AAA is associated with increased fibrin turn over, fibrinolysis and thrombin generation.

Journal of Vascular Surgery 2014;59:528-35

DOI 10.1016/j.jvs.2013.10.088

 

Selected by Miss Katy Bridge (BHF Research Fellow)

 

Vascular Curriculum Topics:     

Haematology – coagulation and fibrinolysis pathways

Assessment and management of elective aneurysms

Risk factors for aneurysm rupture

Evidence based Vascular Practice

 

 

 

 

 

 

 

 

 

21.11.14

 

 

 

 

Comparison of Vascular Closure Devices vs Manual Compression After Femoral Artery Puncture

The ISAR-CLOSURE Randomized Clinical Trial

 

Postprocedure complications and hemostasis following transfemoral coronary interventions present a real challenge for the vascular surgeon. This multicentre, large RCT compared the outcomes achieved with Vascular Closure Devices (VCDs) (intravascular and extravascular) vs standard manual compression.

3015 patients were randomised to: a VCD group (1509 intravascular VCD & 1506 extravascular VCD) and a manual compression group (1509 patients).

Access site–related vascular complications at 30 days were observed in 208 patients (6.9%) assigned to a VCD and 119 patients (7.9%) assigned to manual compression. Time to hemostasis was significantly shorter in patients with VCD and significantly shorter among patients with intravascular VCD. Closure device failure was significantly lower among those with intravascular (vs. extravascular VCD).

JAMA. 2014 Nov.

doi:10.1001/jama.2014.15305.

 

Selected by Mr Hashem Barakat, Vascular SpR, North Bristol NHS

 

UK Vascular Curriculum Topics:

Outcomes: Endovascular procedures

Aneurysms: Peripheral Arterial/ Pseudoaneurysms/ Iatrogenic

 

 

 

 

Complex Relationship of Body Mass Index with Mortality in Patients with Critical Limb Ischemia Undergoing Endovascular Treatment

 

This multicentre study aimed at investigating the relationship between BMI and long-term outcomes of patients with CLI after endovascular treatment.

1088 consecutive patients who underwent interventions for infrapopliteal lesions (1306 limbs) were included. Average age was 72 years.

Interestingly; 3-year overall survival was significantly lower in underweight patients and significantly higher in overweight/obese patients compared to patients with normal weight (p < .0001). Freedom from major adverse limb events did not differ significantly among the three groups.

A BMI of < 18 was one of the independent predictors of inferior long-term survival.

European Journal of Vascular and Endovascular Surgery. 2014 In Press.

http://dx.doi.org/10.1016/j.ejvs.2014.10.014

 

 

 

Selected by Mr Hashem Barakat, Vascular SpR, North Bristol NHS

 

UK curriculum topics:

Critical limb ischaemia

Outcomes

Endovascular Interventions

 

 

 

 

 

Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey

 

This international survey evaluated how patient characteristics and duplex ultrasound findings influence management decisions of physicians with specific expertise in the field of chronic venous disease. The survey was delivered online, and assessed for differences in management strategies in patients with great saphenous vein (GSV) reflux and refluxing tributaries by enquiries on the treatment preferences for several clinical vignettes.

211 physicians (68% surgeons, 12% dermatologists, 12% angiologists and 8% phlebologists) from 36 different countries completed the survey showing a wide variation in management options, frequently tailored to specific patient and ultrasound characteristics.

European Journal of Vascular and Endovascular Surgery, In Press

http://dx.doi.org/10.1016/j.ejvs.2014.11.006

 

Selected by Mr Hashem Barakat, Vascular SpR, North Bristol NHS

 

UK curriculum topics:

Varicose veins management options

 

 

 

 

 

 

14.11.14

 

 

 

 

An Early Validation of the Society for Vascular Surgery Lower Extremity Threatened Limb Classification

 

The Society for Vascular Surgery recently established a staging system named WIFI (Wound characteristic, Ischaemia, Foot Infection) to stratify patients according to their 1-year limb amputation risk. This prospective validation study looked at 139 patients with foot wounds who presented for lower extremity revascularisation. A number of wound characteristics were recorded and adapted to the WIFI classification. The WIFI clinical stage was predictive of 1-year limb amputation (stage 1 = 3%, stage 2 = 10%, stage 3 = 23%, stage 4 = 40%) and wound non-healing (stage 1 = 8%, stage 2 = 10%, stage 3 = 23%, stage 4 = 40%). Clearly, this early validation is promising but requires further corroboration with other multicentre data.

J Vasc Surg. 2014 Oct 1. doi: 10.1016/j.jvs.2014.08.107. [Epub ahead of print]

 

 

UK Vascular Curriculum Topics – Vascular Anatomy; Vascular pathology; Chronic lower limb ischaemia; Vascular complications of diabete

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

 

A Randomised Trial Comparing Treatments for Varicose Veins

 

This multicentre randomised trial from the UK compared outcomes of ultrasound-guided foam sclerotherapy, endovenous laser ablation, and traditional open surgery for primary varicose veins in 798 patients. The mean disease-specific quality of life was worse after foam than after surgery (p=0.006) but there was no significant difference between surgery and laser groups. Complications were similar between surgery (7%) and foam (6%) but significantly lower in the laser group (1%). The foam group showed a significantly less successful ablation rate of the main trunks of the saphenous vein compared to surgery (p=<0.001).

N Engl J Med. 2014; 371:1218-1227 DOI: 10.1056/NEJMoa1400781

 

UK Vascular Curriculum Topics – Vascular Anatomy; Vascular pathology; Superficial venous disease

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

 

 

 

 

Technique and Results of Femoral Bifurcation Endarterectomy by Eversion

 

This prospective study looked at 121 patients who underwent 147 consecutive femoral endarterectomies using an eversion technique. 60% of procedures were for claudication the rest for critical ischaemia. Technical success rate was 93.2%, 30-day mortality was 0%, and the complication rate was 8.2%. A reintervention was necessary in 18.3% of limbs at 2 years. 100% of lims were preserved in the claudicant population. Limb salvage was 88.6% in the critical ischaemia population. The paper concludes by highlighting some of the notable advantages of the eversion technique, namely, the lack of need for arterial patching and the associated benefits of this.

J Vasc Surg. Published online on October 28, 2014. DOI: http://dx.doi.org/10.1016/j.jvs.2014.09.025

 

UK Vascular Curriculum Topics – Vascular Anatomy; Vascular pathology; Open vascular surgery; Chronic lower limb ischaemia

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

 

 

 

24.10.14

 

 

 

 

The Beneficial effects of preoperative exercise therapy in patients with an abdominal aortic aneurysm: A systematic review

 

A number of study centres have assessed the role of pre-operative exercise training in patients with AAA. This systematic review groups 5 studies to attempt to suggest the overall benefits to patients’ post-operative recovery, aerobic capacity and recovery.

Although the review analyses 5 studies, only one focused on the outcomes following surgery. Three studies did however focus on patient fitness and aerobic capacity.

Broadly the review highlights the benefits of patient fitness and aerobic capacity but struggles to conclude on the overall impact of PET on patient recovery and complications.

Ahead of print; EJVES DOI: http://dx.doi.org/10.1016/j.ejvs.2014.10.008

 

Selected by: Sandip Nandhra, Vascular Registrar, Northern Deanery

 

Topics: Abdominal Aortic Aneurysms

            Outcomes

            Exercise training and pre-operative fitness

            Principles of clinical research

            Evidence based vascular practice

 

 

 

 

 

Multi-centre Double-Blinded Randomized Controlled Trial of Standard Abdominal Wound Edge Protection With Surgical Dressings Versus Coverage With a Sterile Circular Polyethylene Drape for Prevention of Surgical Site Infections: A CHIR-Net Trial (BaFO; NCT01181206)

 

 

Although not an isolated vascular study per se this multicentre double blind randomised controlled trial compares standard intra-operative surgical dressings to a circular polyethylene circular drape in the prevention of SSI’s following elective laparotomy. 

Across 16 centres 608 patients were randomised to either the control or the new device. The study found a significant reduction in the rate of SSI in the circular device group (9.9%) compared to the standard intraoperative wound protection group (19.1%).

This promising new intra-operative device could be applied to open vascular surgery with a potential reduction in SSI rates.

Annals of Surgery: Papers of the 21st Annual ESA Meeting

November 2014 - Volume 260 - Issue 5 - p 730–739

doi: 10.1097/SLA.0000000000000954

 

Selected by: Sandip Nandhra, Vascular Registrar, Northern Deanery

 

Topics: Surgical Site Infection

            Principles of clinical research

            Evidence based vascular practice

 

 

 

 

 

 

Durability of open popliteal artery aneurysm repair

 

This paper presents a retrospective analysis of 206 popliteal aneurysms repaired by open technique. The end-points of the study were perioperative mortality, morbidity, patency and limb salvage. Despite location or size the overall surgical mortality was 2% (2% for elective and 3% for emergency). Patency rates high at 5 and 10 years with no significant difference between emergency and elective procedures. Limb slavage rates were significantly lower in the emergency group than the elective group at both 5 and 10 years. Re-intervention rates increased over time. This paper highlights the success of this unit’s open surgical popliteal aneurysm repair with low morbidity, mortality and good long term results.

J Vasc Surg. 2014 Oct;60(4):951-7. doi: 10.1016/j.jvs.2014.04.035. Epub 2014 Jul 1.

 

 

Selected by: Sandip Nandhra, Vascular Registrar, Northern Deanery

 

Topics: Popliteal aneurysm

            Post-operative outcomes

            Principles of clinical research

            Evidence based vascular practice

 

 

17.10.14

 

 

 

 

AKIN better predict AKI related mortality after AAA repair than RIFLE

 

It is established that acute kidney injury (AKI) is a complication of either open or endovascular AAA repair. There are two widely used clinical scoring systems to identify and diagnose AKI: AKIN and RIFLE. AKI is associated with increased mortality after surgery. Here the authors compared the two scores in their ability to predict mortality after AAA repair. 444 patients were included and data analysed with a multivariate Cox proportional hazards model. AKI as per AKIN criteria was more frequent than by RIFLE. Overall, AKI was associated with both 30 day and long term mortality. However, AKIN criteria better predicted mortality in AAA patients compared to RIFLE.

Br J Anaesth. 2014 Sep 25. pii: aeu320. [Epub ahead of print]

 

UK Vascular curriculum topics:
Abdominal Aortic Aneurysms

Outcomes

Principles of clinical research

Evidence based vascular practice

 

Selected by Mr Marc Bailey, University of Leeds

 

 

 

 

 

 

 

No difference in healthcare costs between EVAR devices or with Open Repair

 

Medical device costs make up a significant amount of the EVAR expenditure. Here, the authors of the OVER trial use their data to evaluate 2 year total health costs. In total, 423 open repair patients and 431 EVAR patients were included. The devices compared were: Zenith (Cook), Excluder (Gore) and AneuRx (Medtronic). In this study implantation costs were 38% of the initial hospital treatment cost for the EVAR group. At the two year time point, there was no significant difference in overall costs between any of the devices or between EVAR and open repair overall. There was, however, a large amount of variation.

J Vasc Surg. 2014 Sep 16. pii: S0741-5214(14)01506-7.
doi: 10.1016/j.jvs.2014.08.003. [Epub ahead of print]

 

 

UK Vascular curriculum topics:
Abdominal Aortic Aneurysms

Outcomes

Principles of clinical research

Evidence based vascular practice

 

Selected by Mr Marc Bailey, University of Leeds

 

 

 

 

 

 

Aspirin for the Prevention of Recurrent Venous Thromboembolism

The INSPIRE Collaboration

 

Recurrent events in patient with idiopathic DVT once initial anticoagulation is stopped are common, with recurrance rates been quoted as between 30-50% at 10 year. Practically, aspirin may represent a convenient intermediate therapy between no treatment and indefinite anticoagulation, balancing the risk of bleeding with the benefit of preventing recurrent thrombosis in a moderate risk population. This study, the Aspirin for the prevention of recurrent venous thromboembolism study (INSPIRE) was set up to assess the effects of aspirin therapy on DVT recurrence after anticoagulation therapy is discontinued. In this study, those taking aspirin had a lower recurrence rate (13.1% vs 18.4% on placebo) over 2-4years, without an increase in significant bleeding events. It also identified the group of patients who are most likely to benefit from this ongoing anti-platelet treatment following initial anticoagulation (men, and those aged>65years). 

The authors summarise that aspirin after anticoagulant treatment reduces the overall risk of recurrence by more than a third in a broad cross-section of patients with a first unprovoked VTE, without significantly increasing the risk of bleeding.

Circulation. 2014; 130: 1062-1071 Published online before print August 25, 2014,
doi: 10.1161/CIRCULATIONAHA.114.008828

Comment in: Circulation. 2014; 130: 1031-1033 Published online before print August 25, 2014, doi: 10.1161/CIRCULATIONAHA.114.012235.

 

UK Vascular Curriculum topics:

Deep Venous Thrombosis

Management of uncomplicated DVT

Long term complications of DVT

Evidence based vascular practice

 

Selected by - Katy Bridge, University of Leeds

 

 

 

10.07.14

 

 

 

 

Cost-effectiveness of ultrasound-guided foam sclerotherapy, endovenous laser ablation or surgery as treatment for primary varicose veins from the randomized CLASS trial

 

In this study, the CLASS trial’s cost and utility data was used to ascertain the cost effectiveness of the three main interventions for primary varicose veins. They used a regression model that was developed to incorporate available evidence on clinical recurrence rates and was developed to extrapolate the trial data over a 5-year time frame.

The investigators found that Sclerotherapy reduced the mean costs to NHS by £655 compared to surgery at 6 months, EVLA reduced mean costs by £160 respectively. These savings were £902 for sclerotherapy and £392  for EVLA when additional overhead costs associated with theatre use were included. UGFS produced fewer QALYS while EVLA produced more. Extrapolating to 5 years, EVLA was associated with increased costs and QALYs compared with UGFS  and generated a cost saving and QALY gain compared with surgery. EVLA had the highest probability (78.7%) of being cost-effective.

Br J Surg.  Nov 2014.

doi: 10.1002/bjs.9565.

 

Selected by Hashem Barakat, Clinical Fellow, Vascular Surgery

 

UK curriculum topics:

Vascular pathology; varicose veins, cost effectiveness

Elective procedures; Endovenous procedures

 

 

 

 

 

 

 

Failure-to-rescue and interprovider comparisons after elective abdominal aortic aneurysm repair

 

This was a large retrospective analysis where Hospital Episode Statistics (HES) databases, a multicentre audit of data quality and case-note verification were done aiming at quantifying and validating failure-to-rescue (FTR) rates for elective AAA repair in England. Postoperative complications were extracted, FTR rates quantified, and differences in FTR and in-hospital death rates established. A total of 19 638 AAA repairs were included in analysis: overall mortality rate 4.6% as patients were more likely to die if they sustained a complication or stayed longer in hospital. A strong correlation was seen between FTR and death rates. 41.5% had complications recorded upon case-note review. There was evidence of systematic under-reporting of complications in HES.

Br J Surg.  Nov 2014.  

doi: 10.1002/bjs.9633

 

Selected by Hashem Barakat, Clinical Fellow, Vascular Surgery

 

UK curriculum topics:

Operative outcomes, reporting, Audit & Research

Abdominal aortic aneurysms

 

 

 

 

 

 

Intra-procedural pain score in a randomised controlled trial comparing mechanochemical ablation to radiofrequency ablation: The Multicentre Venefit™ versus ClariVein® for varicose veins trial

 

These are the early results of a randomised controlled trial that aimed at comparing the degree of pain with mechanochemical ablation or radiofrequency ablation for truncal varicose veins. 119 patients were randomised to mechanochemical ablation (ClariVein®) (n=60) or radiofrequency ablation (Covidien® Venefit™). Maximal and average pain scores were lower in the mechanochemical ablation group. At one month, the clinical and quality of life scores for both groups had similar improvements.

Phlebology [Online]

doi: 10.1177/0268355514551085

 

Selected by Hashem Barakat, Clinical Fellow, Vascular Surgery

 

UK curriculum topics:

Varicose veins; Endovenous treatment

 

 

 

 

06.10.14

 

 

 

Paclitaxel-coated balloon angioplasty versus drug-eluting stenting for the treatment of infrapopliteal long-segment arterial occlusive disease the IDEAS randomized controlled trial

 

This study showed that compared with Paclitaxel-coated balloon (PCB) in long infrapopliteal lesions, drug-eluting stent (DES) are related with significantly lower residual immediate post-procedure stenosis and have shown significantly reduced vessel restenosis at 6 months. PCB may produce positive vessel remodeling.

J Am Coll Cardiol Intv. 2014;7(9):1048-1056.

doi:10.1016/j.jcin.2014.04.015

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Peripheral vascular Disease

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Predictors of paraplegia with current thoracoabdominal aortic aneurysm repair

 

The purpose of this study was to find predictors of paraplegia following thoracoabdominal aortic aneurysm repair in the authors' institute, using the current spinal cord protection strategies. This study suggests that the predictors of postoperative paraplegia in the institution were perioperative hypotension and an open distal anastomosis technique. Avoidance of these risk factors might diminish the incidence of postoperative paraplegia.

 

Asian Cardiovasc Thorac Ann 2014 Sep 7

pii: 0218492314549563

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Abdominal aortic aneurysm

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Abdominal Aortic Aneurysms with High Thrombus Signal Intensity on Magnetic Resonance Imaging are Associated with High Growth Rate

 

The purpose of this study was to investigate whether AAAs with high thrombus signal intensity (SI) at T1–weighted (T1w) magnetic resonance imaging (MRI) exhibit a faster aneurysm growth rate. This study suggests that abdominal aortic aneurysms with high thrombus SI on T1w MR images are associated with higher aneurysm growth rates.

 

Eur J Vasc Endovasc Surg 2014 Jun 13

doi: 10.1016/j.ejvs.2014.04.025

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Abdominal aortic aneurysm

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Evolution in management of adolescent blunt aortic injuries—a single institution 22-y experience

 

The aim of this study was to evaluate a single ACS Level 1 Pediatric Trauma Center’s 22–year experience with traumatic aortic injuries in children. Traumatic aortic injuries are an uncommon injury in children and can result from motor vehicle collisions or other sudden deceleration mechanisms. Surgical intervention is required in the majority of cases and can be performed safely and effectively with low morbidity using an endovascular approach, which is the evolving approach of choice for thoracic aortic injuries. Lengthy follow–up care is recommended in children treated with an endovascular device to monitor for endoleaks and device complications.

 

Journal of Surgical Research, Sep 2014

DOI: 10.1016/j.jss.2014.08.058

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Trauma

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

26.09.14

 

 

 

 

Comparison of the Impact of Open and Endovascular Abdominal Aortic Aneurysm Repair on Renal Function

 

This case-control study looked at short and long-term renal function outcomes following different types of aneurysm repair, namely: open repair (OR), suprarenal EVAR fixation, and infrarenal EVAR fixation. Both OR and suprarenal EVAR fixation patients had a mean reduction in eGFR of  > 5 units at 1 and 2 years which was significant. Infrarenal EVAR fixation patients had a mean reduction in eGFR of 0.53 and 2.23 units at one and two years, respectively. The paper concludes that both OR and suprarenal EVAR fixation result in significant reduction in eGFR at 2 years, however, the different patterns seen suggest that the mechanism may be different for each.

J Vasc Surg. 2014; 60(3): 597-603

 

Curriculum Topics – Vascular physiology; Vascular pathology; Open vascular surgery; Aneurysm – elective

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

Open Repair Versus Fenestrated Endovascular Aneurysm Repair of Juxtarenal Aneurysms

 

This meta-analysis identified 35 case series looking at a total of 2326 patients who underwent elective repair of juxtarenal AAA through either open repair or fenestrated endovascular repair (FEVAR). Perioperative mortality was 4.1% (OR 1.059 [0.642-1.747], p = 0.822) and post-operative renal impairment was not significantly different (OR 1.136 [0754-1.713], p = 0.542). However, FEVAR patients had higher rates of secondary intervention, renal impairment during follow up, and a poorer long-term survival compared to open repair. This, the paper concludes, reflects the selection bias of FEVAR as the first choice procedure in juxatrenal AAA for high-risk patients.

J Vasc Surg. Article in press

 

Curriculum Topics – Aneurysm – elective; Open vascular surgery; Endovascular procedures

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

 

Vitamin D Promotes Vascular Regeneration

 

This scientific paper from a group based in Frankfurt hypothesised that 1,25-VitD3, due to its anti-inflammatory properties, may promote vascular regeneration after vascular injury. They showed that in both healthy human subjects and mouse models, vitamin D3 supplementation resulted in an increase of several factors, including angiogenic myeloid cells, which promote vascular regeneration. The group showed that the mechanism of this action is through vit-D3 up-regulation of hypoxia-inducible factor 1-alpha, which in turn induces stromal cell-derived factor 1 (SDF1).

Circulation. 2014; 130: 976-986

 

Curriculum Topics – Vascular physiology; Vascular pathology; Nutrition; Clinical audit, research and health economics

 

Selected by: Alastair McKay, Core Trainee, West of Scotland

 

 

 

 

29.08.14

 

 

 

 

Cardiovascular risk in patients with small and medium abdominal aortic aneurysms, and no history of cardiovascular disease
 

The patient with an abdominal aortic aneurysm (AAA) is a common encounter within the discipline of vascular surgery. The evidence base around AAA is extensive and serves as an integral part of the vascular surgeons’ everyday practice. Studies have demonstrated the disease progression, the role of intervention and optimising patient clinical and patient reported outcomes. Often this condition is viewed in isolation in those individuals who are seemingly fit and well. This is perhaps not a neglect of the bigger picture but more of a combination of sub-specialization and patient volume. This study emphasises the importance and value of stringent secondary prevention. The study authors highlight the links between AAA’s and cardiovascular disease (CVD) in the seemingly ‘well’ and CVD free patient. The study suggests that individuals with an AAA and without overt CVD diagnos are at higher risk of mortality than those without an AAA; a poignant reminder of the systemic health risk CVD presents.

 

Br J Surg, 101: 1238–1243. doi: 10.1002/bjs.9567

 

 

Selected by: S Nandhra, Clinical Research Fellow in Vascular Surgery, HYMS

 

UK Vascular Curriculum Topics:

AAA

Cardiovascular risk modification

Evidence based vascular practice

 

 

 

 

A Systematic Review and meta-analysis of the role of varicosity treatment in the context of truncal vein ablation
 

This meta-analysis attempts to define the ideal time point for addressing lower limb varicosities in patients undergoing truncal vein ablation. The paper describes a meta-analysis of four randomised controlled trials with two main questions; firstly the need for further intervention if the varicosities were not addressed at the initial treatment visit and secondly the impact on disease specific quality of life when simultaneous varicosities were treated. The paper results demonstrated that there is no difference in the need for intervention over time and that there is a demonstrable improvement in QoL for those patients undergoing simultaneous tributary treatment in the short term, however this difference is not maintained into the medium term. The authors conclude that simultaneous treatment of varicosities leads to early gains in quality of life, with a non-significant trend for fewer further procedures but more venous thrombotic events. In the NHS where productivity versus cost at the forefront perhaps this paper could influence procedure planning.

 

Phlebology. 2014 Aug 18. pii: 0268355514548473.

 

Selected by: S Nandhra, Clinical Research Fellow in Vascular Surgery, HYMS

 

Vascular Curriculum Topics

            Superficial venous insufficiency

            Patient reported outcomes

            Evidence based vascular practice

 

 

 

 

 

The Influence of the CIVIQ Dimensions on Quality of Life of Patients with Primary Superficial Venous Incompetence

 

The disease specific quality of life impact of superficial venous insufficiency has been extensively reported. To better understand the impact of the patient reported disease burden and the subsequent improvements that treatment can bring a French group has developed what they describe as a more sensitive tool for measuring disease burden. This paper explores the sensitivity and specificity of the Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ). The study sampled 468 patients with primary superficial venous insufficiency from a bredth of CEAP classifications. The paper describes that pain and physical restricition were the domains with the greatest influence on QoL. The worse CIVIQ scores were in those patients aged betwee 45-64, with CEAP 2-3 disease. BMI and anatomic distribution had no influence on the QoL. This paper is a useful tool to assess the impact of venous disease and the decision to treat. The next prudent step would be to appreciate sensitivity of this method compared to the AVVQ commonly utilised in the literature. 

 

Eur J Vasc Endovasc Surg. 2014 Aug 20. pii: S1078-5884(14)00405-5.
doi: 10.1016/j.ejvs.2014.07.006. [Epub ahead of print]

 

Selected by: S Nandhra, Clinical Research Fellow in Vascular Surgery, HYMS

 

Vascular Curriculum Topics

            Superficial venous insufficiency

            Patient reported outcomes

            Disease specific QoL

            Evidence based vascular practice

 

23.08.14

 

 

 

 

Preoperative Methylprednisolone Enhances Recovery After Endovascular Aortic Repair: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

 

This trial evaluated the use of perioperative high dose steroids to ameliorate the ‘post implantation syndrome’ following EVAR and the overall effect on systematic inflammatory response, inflammatory markers, morbidity and time to discharge.
153 patients were randomised to receive methylprednisolone (30ml/kg) or placebo preoperatively. MP reduced systemic inflammatory response syndrome from 92% to 27%, plasma IL6, IL8, CRP and soluble TNF and was associated with an earlier fulfilment of discharge criteria. There were no differences in terms of morbidity criteria between the two groups.

 

Annals of Surgery, Sep 2014

doi: 10.1097/SLA.0000000000000895

 

Selected by Hashem Barakat, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Abdominal aortic aneurysms
Endovascular/minimally invasive

Medical management

Perioperative outcomes

 

 

 

 

 

A comparison of open surgery versus endovascular repair of unstable ruptured abdominal aortic aneurysms
 

This is a large retrospective study, which aimed at comparing the outcomes of open repair versus EVAR for patients with unstable rAAA. It used the American college of surgeons NSQIP database to identify more than 1400 patients with rAAA admissions and considered those with features of haemodynamic unstability and an ASA of 4 or 5 as unstable at presentation. 65.5% underwent open repair and 34.5% EVAR. 45% of presentations were unstable; of those 28.7% had an EVAR. Generally the 30-day mortality was much higher in unstable patients (47.9% vs 22.4% in stable patients) and significantly lower with EVAR than open repair for both unstable (35.6% vs 52.8% with OR) and stable (16.4% vs 26.3% with OR) rAAA. OR was a predictor of 30-day mortality in multivariate analysis for both stable and unstable patients.

Journal of Vascular Surg. In Press.

doi: http://dx.doi.org/10.1016/j.jvs.2014.06.122

 

Selected by Hashem Barakat, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Vascular emergency
Abdominal aortic aneurysm

Endovascular treatment options

 

 

 

 

 

 

 

Stenting Versus Endarterectomy for Restenosis Following Prior Ipsilateral Carotid Endarterectomy: An Individual Patient Data Meta-analysis.

 

This is a meta-analysis that aimed at comparing the outcomes following carotid artery stenting (CAS) or carotid endarterectomy (CEA) for restenosis following a previous CEA.
It included 13 studies, with data on 1132 patients. The primary outcomes were perioperative stroke or death and these did not differ significantly with either form of intervention. The secondary outcome was the incidence restenosis >50%; also similar with both interventions. A 5.5% incidence of cranial nerve injuries followed CEA and a 5% risk of other complications followed CAS.

Annals of Surgery, Ahead of Print

 doi: 10.1097/SLA.0000000000000799

 

Selected by Hashem Barakat, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Carotid artery disease
Open surgery
Endovascular treatment options

 

 

 

 

 

 

 

 

 

13.08.14

 

 

 

 

The Abdominal Aortic Aneurysm Statistically Corrected Operative Risk Evaluation (AAA SCORE) for predicting mortality after open and endovascular interventions

 

There is a need to be able to predict risk in patients undergoing open or endovascular AAA repair. However, current clinical risk models do not perform well. Here, the authors used the UK National Vascular Database records to generate novel models (pre-operative and peri-operative models) to predict 30 day mortality in these patients. The group used data from over 8,000 patients; missing data was handled by multiple imputation techniques. ROC curves demonstrated that the new AAA SCORE risk model outperformed all previously published models in terms of predicting mortality at 30 days.

 

The pre-op score predicts risk based on age, creatinine, systolic BP, white cell count, if the operation is a redo procedure, if there is a clinical history of cardiovascular disease, the type of aortic repair, the mode of admission and the ASA grade. The perioperative score requires additional inclusion of pre-op albumin, lowest inra-operative BP and highest pulse and intra-operative blood loss. A freeware version of the tool can be accessed at the following address (published with the permission of the first author on the paper, Mr Grame Ambler): http://ambler.me.uk/Vascular/AAARisk/index.shtml

 

J Vasc Surg. 2014 Jun 28 [Epub ahead of print].

 

Selected by: Mr Marc Bailey, BHF Fellow in Vascular Surgery, Leeds Vascular Institute


UK Vascular Curriculum Topics:            

   Abdominal Aortic Aneurysms,

   Open and endovascular treatment options

   Outcomes

   Principles of Clinical research

   Evidence based vascular practice

 

 

 

 

 

Vitamin D Promotes Vascular Regeneration

 

The role of Vitamin D (in its active form, 1,25-dihydroxy-viatmin D3) in the cardiovascular system is controversial; high levels induce vascular calcification, whilst deficiency has been linked to cardiovascular disease due to its anti-inflammatory properties. The authors of this paper hypothesised that 1,25-VitD3 would promote regeneration after vascular injury. They were able to show that, in humans, supplementing vitD3 increased the number of angiogenic myeloid cells. In a murine model, this was also shown, and in addition, they demonstrated that this promoted re-endothelisation in the carotid artery injury model. Even in a diabetic mouse model, vitD3 promoted re-endothelisation and restored impaired angiogenesis in the femoral artery ligation model. Downstream, they were able to show that these effects were as a result of vitD3 on levels of stromal cell-derived factor 1 (SDF1). To conclude, they showed that by inducing SDF1, VitD3 provides a new target to promote vascular repair.

Circulation. 2014 Jul 11. pii: CIRCULATIONAHA.114.010650. [Epub ahead of print]

 

Selected by: Miss Katherine Bridge, BHF Fellow in Vascular Surgery, Leeds, UK

 

UK Vascular Curriculum Topics:            
   Principles of Clinical research

   Risk factor modification – dietary factors

   Keeping up to date and understanding how to analyse information

 

 

 

 

 

 

Alcohol Consumption, Specific Alcoholic Beverages, and Abdominal Aortic Aneurysm

 

Studies investigating the role of alcohol consumption in development of abdominal aortic aneurysm (AAA) are scarce. This study took >44000 men and >35000 women from Swedish cohort studies (the Cohort of Swedish Men and the Swedish Mammography cohort), who were aged 46-84years, and followed them from recruitment in 1998 to the end of 2011. During this follow up, AAA occurred in 1020 men and 194 women. Compared with a consumption of 1 glass of alcohol/week (12 grams of ethanol), the HR of AAA among men who consumed 10 glasses/week was 0.80 (95% CI, 0.68-0.94). Corresponding HR among women who consumed 5 glasses/week was 0.57 (95% CI, 0.40-0.82). Among participants free from cardiovascular disease, total alcohol consumption did not seem to be associated with AAA. Moderate alcohol consumption, specifically wine and beer (there was no association with liquor), was associated with a lower hazard of abdominal aortic aneurysm. The associations between higher doses of alcohol and risk of AAA remain unknown.

Circulation. 2014 Jun 25. pii: CIRCULATIONAHA.113.008279. [Epub ahead of print]

 

Selected by: Miss Katherine Bridge, BHF Fellow in Vascular Surgery, Leeds, UK

 

UK Vascular Curriculum Topics:            
Principles of Clinical research

Risk factor modification – dietary factors

Abdominal Aortic Aneurysm

 

 

 

 

 

Multimedia


1. You tube video from “geeky medics” outlining the principles of diabetic foot examination: 


UK Vascular Curriculum Topics:            

The vascular complications of diabetes

Assessment and management of patients with complications of diabetes affecting the leg/foot

Clinical Skills - Examination of diabetic foot/ulceration

 

2. Link to instant anatomy webpage for “layer-by-layer” anatomy of the foot (podcasts / lectures are available by subscription)

 

UK Vascular Curriculum Topics:            

The vascular complications of diabetes

Anatomy of the foot

 

3. Recent review article (from Diabetic Foot and Ankle, 2013) giving an update on the imaging of Charcot foot

 

UK Vascular Curriculum Topics:            

The vascular complications of diabetes

Complications of diabetes affecting the foot including neuropathy, ulceration, osteomyelitis and Charcot

Investigations (XRay, ultrasound & MR of foot, arteriography)

 

Selected by: Miss Kathryn Griffin, BHF Fellow in Vascular Surgery, Leeds, UK

 

 

 

18.07.14

 

 

 

 

A Comparison of the Effectiveness of Treating Those With and Without the Complications of Superficial Venous Insufficiency

 

This study compared quality of life measures amongst patients undergoing surgical and endovenous interventions for Superficial Venous Insufficiency (SVI) with and without soft-tissue changes, using data from a randomised clinical trial. Most measures improved with intervention apart from the SF36 bodily pain domain; where patients with less severe disease (C2) showed more improvements. Patients with C3&4 also had more recurrence and required more secondary interventions.

Annals of Surgery – Aug 14

doi: 10.1097/SLA.0000000000000541

 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, HYMS

 

UK Vascular Curriculum Topics:

            Venous disease

            Open and endovenous treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

 

Early and delayed rupture after endovascular abdominal aortic aneurysm repair in a 10-year multicenter registry

 

This multi-centre study represents a 10 year experience of more than 1700 EVARs. The authors retrospectively investigate factors associated with early or delayed aneurysm rupture after EVAR. 25% were early ruptures (within 2 days of EVAR) and were predominantly associated with intraoperative adverse events (Type I and III endoleaks) and needed re-intrevention resulting in perioperative death in 2 out 5 patients. In those sustaining delayed ruptures, the median time to rupture was 31.1 months. In 15 patients, 9 had new endoleaks, and most were preceded by AAA sac increase. Symptomatic or ruptured AAA at initial intervention and age (80-89 years) were independently associated with delayed ruptures. The overall mortality with rupture after EVAR was very high.

 

Journal of Vascular Surgery, In Press

DOI: http://dx.doi.org/10.1016/j.jvs.2014.05.046

 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, HYMS

 

 

UK Vascular Curriculum Topics:

            Abdominal Aortic Aneurysms

            Open and endovascular treatment options

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

 

Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force

 

This study aimed at evaluating the evidence on screening and treating asymptomatic carotid artery disease. The review selected good-fair quality trials of screening, carotid endarterectomy (CEA), or stenting compared with medical therapy or of intensification of medical therapy, in addition to others.

The authors list the many limitation the literature has in order to answer their query, and so conclude that there is not enough evidence to support CEA, stenting or intensification of medical therapy for asymptomatic disease. The review article is available free online.

 

Annals of Internal Medicine, July 2014

doi:10.7326/M14-0530
 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, HYMS

 

UK Vascular Curriculum Topics:

            Carotid Disease

Screening, epidemiology

            Open and endovascular treatment options

            Selection of Patients

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

15.07.14

 

 

Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study

 

Researchers sought to measure the incidence of venous reflux and associated risk factors, and the association between venous reflux and the incidence of chronic venous disease (CVD). They found that for every year of follow–up, around 1% of their adult study population developed venous reflux; and that in two thirds of cases, the superficial system was affected. Venous reflux increased the risk of developing varicose veins, especially when combined deep and superficial reflux was present.

EJVES, June 2014

doi: 10.1016/j.ejvs.2014.05.017

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Venous Disease

Varicose veins

Venous ulcers

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: A systematic review and meta-analysis of phase III trials

 

Researchers undertook this review of the efficacy and safety of new oral anticoagulants (NOAs) in the management of venous thromboembolism (VTE), and concluded that compared with vitamin K antagonists (VKAs), NOAs are not only effective in treating VTE but also safer in terms of bleeding, thereby conferring clinical benefit. Secondary prevention trials confirmed their safety and efficacy.

EJVES, June 2014

doi: 10.1016/j.ejvs.2014.05.001

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Venous Disease

Venous Thrombo-embolism

            Best medical treatment

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

The effect of deep venous stenting on healing of lower limb venous ulcers

 

The study aims to report the outcomes of endovascular interventions on deep veins in patients with venous ulcers (C6). Endovascular interventions to the deep veins appear to be an effective adjunct in achieving the healing of recalcitrant ulcers.

EJVES, June 2014

doi: 10.1016/j.ejvs.2014.04.031

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Venous Disease

Venous ulcers

            Best medical treatment

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

11.07.14

 

 

Outcomes of carotid endarterectomy versus stenting in comparable medical risk patients

 

The purpose of this study was to compare risk–stratified outcomes of carotid artery stenting (CAS) and CEA. In the Vascular Study Group of New England, asymptomatic normal– and high–risk patients do equally well after CEA or CAS. However, normal– and high–risk symptomatic patients have substantially worse outcomes with CAS compared with CEA. High medical risk alone might be an insufficient indication for CAS in symptomatic patients.

 

J Vasc Surg, Jun 2014

doi: 10.1016/j.jvs.2014.05.044

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Carotid Artery Disease

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

 

Mid-term outcomes and aortic remodelling after thoracic endovascular repair for acute, subacute, and chronic aortic dissection: The Virtue Registry

 

The VIRTUE Registry describes the mid–term clinical and morphological results of thoracic endovascular repair (TEVR) in patients with type B aortic dissection. The principle clinical findings suggest that TEVR is able to provide good protection from aortic–related death in the mid–term, but with a high rate of aortic reintervention. Analysis of aortic morphology suggested that aortic remodelling in subacute patients is similar to the acute group and retention of aortic plasticity in the subacute group lengthens the therapeutic window for the treatment of uncomplicated type B dissection.

 

EJVES, June 2014

doi: 10.1016/j.ejvs.2014.05.007.

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Aortic Disease

Aortic dissection

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

Pathology specific early outcome after thoracic endovascular aortic repair

 

 

The aim of this study was to compare the incidence of all–cause and aortic–related in–hospital mortality, stroke, spinal cord ischaemia, and major adverse event rate for patients undergoing thoracic aortic endovascular intervention to see if there is a pathology–specific effect. The results suggest that, there was no difference in the incidence of in–hospital mortality, stroke, and spinal cord ischaemia between aneurysm and dissection. The higher rate of aortic related death in the dissection group may indicate the need to refine the clinical management of these patients, including procedural planning, endograft design, and operative technique.

 

EJVES, June 2014

DOI: 10.1016/j.ejvs.2014.04.004

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Aortic Disease

Aortic dissection

            Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

04.07.14

 

 

 

 

Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins

 

This randomised clinical trial explores the debate surrounding the optimal management of symptomatic varicose tributaries following ablation of the main saphenous trunk by EVLA. The study follows up 50 patients over five years. Patients undergoing EVLA of the GSV axis from a single centre were randomised equally to either concomitant phlebectomy or delayed sequential phlebectomy after at least a 6 week delay. Outcomes included disease-specific quality of life (QoL) (Aberdeen Varicose Vein Questionnaire; AVVQ), requirement for secondary procedures, clinical severity (Venous Clinical Severity Score; VCSS), residual and recurrent varicose tributaries, and generic QoL. The EVLTAP group had lower VCSS scores at 12 weeks (median 0 (i.q.r. 0-1) versus 2 (0-2); P < 0·001), and lower AVVQ scores at 6 weeks (median 7·9 (i.q.r. 4·1-10·7) versus 13·5 (10·9-18·1); P < 0·001) and 12 weeks (2·0 (0·4-7·7) versus 9·6 (2·2-13·8); P = 0·015). VCSS and AVVQ scores were equivalent by 1 year, but only 16 of 24 patients in the EVLA group, compared with one of 25 in the EVLTAP group (P < 0·001), had received a secondary intervention. From 1 to 5 years both groups had equivalent outcomes. The authors concluded that EVLA with either concomitant or sequential management of tributaries is acceptable treatment for symptomatic varicose veins, with both treatments achieving excellent results at 5 years. Concomitant treatment of varicosities is associated with optimal improvement in both clinical disease severity and QoL.

 

Br J Surg. 2014 Jun 11.

doi: 10.1002/bjs.9565. [Epub ahead of print]

 

Selected by Sandip Nandhra, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Vascular pathology; varicose veins

Elective procedures; Endothermal ablation

 

 

 

 

 

A Prospective Randomized Study Assessing Optimal Method for Teaching Vascular Anastomoses

 

This randomised study tackles an area of medical education. The author group from UCLA medical centre aimed to improve the evidence base for the teaching and training of vascular residents. Laboratory skills training is now required for general surgery residents in the USA. The optimal method of teaching vascular anastomosis (VA) is not well defined; as such the authors proposed ot explore the optimal method of training skills (VA) with the hypothesis that teaching VA skills one-on-one with a faculty instructor will result in a more rapid accumulation of skills than teaching in a large group setting. Residents were shown an instructional video on how to perform a VA using a standardized model (cadaver saphenous vein and porcine aorta). Each resident then performed a baseline VA. Sixteen first- and second-year surgical residents were then randomized to 2 VA teaching sessions that consisted of either 1) group teaching (GT, 8 residents in a room with 1 faculty instructor circulating) or 2) one-on-one teaching (1-on-1, faculty member focused on individual resident). After each of these sessions, residents performed a standardized VA. The anastomoses were video recorded. Performance was evaluated using a standardized scoring system by a separate expert who viewed the video recordings in a blinded fashion. Outcome measures included total errors, total time, global rating scale, and an anastomosis-specific end-product evaluation (leak and passage of coronary dilator). Overall, significant decreases in total errors (21 to 15, P = 0.001) and time to complete anastomoses (42 to 38 min, P = 0.02) and an increase in global rating scales (7 to 11, P = 0.003) were noted in both groups from baseline after 2 VA teaching session. The 1-on-1 group demonstrated significantly greater improvement in terms of reduced anastomotic time (30 vs. 42 min, P = 0.007) and in reduction of errors (13 vs. 19 errors, P = 0.09) than the GT group. The authors conclude that their high-fidelity VA model is a useful tool for junior general surgery residents. Both GT and 1-on-1 groups demonstrated significant improvement in total errors and time after only 2 sessions. Greater improvement was noted using the 1-on-1 model in terms of time to perform procedure. This paper may be of use when planning skills courses or indeed training in the new vascular surgical curriculum in the UK.

 

Ann Vasc Surg. 2014 Jul;28(5):1087-93.

doi: 10.1016/j.avsg.2013.10.018. Epub 2014 Jan 10.

 

Selected by Sandip Nandhra, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Vascular anastomosis

Medical education; skills training

 

 

 

 

 

 

Carotid Artery Atherosclerosis Among 65-year-old Swedish Men – A Population-based Screening Study

 

Once again the Uppsala University Hospital showcases their vascular database. This paper presents contemporary epidemiological data on the prevalence of carotid atherosclerosis in the general population. The aim was to determine the prevalence of and risk factors associated with carotid artery atherosclerosis among 65-year-old men. All 65-year-old men in the County of Uppsala, Sweden, who attended screening for abdominal aortic aneurysm (AAA) 2007–2009, were invited for duplex scanning of the carotid arteries (4657 patients). Carotid plaques (>2 × 6 mm) were observed in 1169 (25%) men, 94 (2.0%) had carotid stenosis (50–99%), and 15 (0.3%) had occluded carotid arteries. In a multivariate logistic regression model, smoking (OR 1.7, 95% CI 1.5–1.9), hypertension (1.5, 95% CI 1.3–1.7), diabetes mellitus (1.2, 95% CI 1.0–1.5), and coronary artery disease (1.5, 95% CI 1.3–1.8) were associated with prevalence of carotid atherosclerosis (plaque and/or stenosis). The use of antiplatelet agents and statins in participants with a carotid plaque was 20% and 29%, respectively. The corresponding figures in participants with a stenosis were 42% and 41%. Most of those at risk had no other clinical manifestation of atherosclerosis, and therefore had no secondary prevention. This contemporary epidemiological data demonstrates the prevalence of carotid disease and in light of the recent statin headlines could add to the support of widespread secondary prevention in men over 65.

 

European Journal of Vascular and Endovascular Surgery

doi:10.1016/j.ejvs.2014.02.004

 

 

Selected by Sandip Nandhra, Clinical Research Fellow, Academic Vascular Surgery, Hull

 

UK curriculum topics:

Vascular pathology; Carotid disease prevalence

 

 

24.06.14

 

 

 

 

Activities of Daily Living is a Critical Factor in Predicting Outcome after Carotid Endarterectomy in Asymptomatic Patients

 

This group from the USA utilised a national data set to identify patients who underwent carotid endarterectomy (CEA) and categorised them according to according to their functional status. They identified nearly 20,000 patients, 97.97% were functionally independent, 1.99% were functionally partially dependent, and 0.12% functionally dependent. In the independent group, 1.01% suffered a stroke with a mortality of 0.43%. The partially dependent group had a stroke prevalence of 3.71% and a mortality of 2.65%. A multivariable risk-adjusted model, with functionally independent as a reference, showed partial dependence was associated with death (OR 3.3; 95%CI 1.6-6.8; p<0.001) and stroke (OR 3.0; 95%CI 1.7-5.4; p<0.001).

Stroke. 2014; 45: 1703-1708
doi: 10.1161/​STROKEAHA.113.003956

 

Selected by Alastair McKay; Core Trainee, West of Scotland

 

UK curriculum topics:
Vascular pathology
Vascular epidemiology
Carotid artery disease

 

 

 

 

 

Results of the Anaconda Endovascular Graft in Abdominal Aortic Aneurysm with a Severe Angulated Infrarenal Neck
 

This study from a Dutch cohort presents the initial results of a feasibility study in the use of the Anaconda endovascular graft for treating severely angulated (>60 degrees) infrarenal AAA.
36 patients (30 men, 6 women) with a mean follow up of 40 months were included. Mean angulation was 82 degrees. Primary technical success was achieved in 30 patients. There was no aneurysm related death. Four-year primary clinical success was 69%. The bulk of clinical failures occurred in the first year and the majority of failures were due to leg occlusion. 4 patients needed conversion to open AAA exclusion. The paper concludes that open AAA repair is still preferable in patients with severely angulated aortic neck.

 

J Vasc Surg. 2014; 59(6): 1495-1501
DOI: http://dx.doi.org/10.1016/j.jvs.2013.12.034

 

Selected by Alastair McKay; Core Trainee, West of Scotland

 

UK curriculum topics:
Vascular pathology; Aneurysm –
Elective; Endovascular procedures

Principles of vascular imaging

 

 

 

 

 

 

 

Perioperative Management with Antiplatelet and Statin Medication is Associated with Reduced Mortality Following Vascular Surgery

 

 

This large retrospective study from the USA looked at outcomes from a range of vascular procedures between 2005 and 2012 and assessed whether patients were being optimally medically managed with antiplatelet (AP) and statin medication preoperatively and at discharge. Optimal medical management (AP and statin pre-op and at discharge) improved over time – from 55% in 2005 to 68% in 2012. Carotid surgery had the highest rates of compliance whilst AAA repair the lowest. Preop AP and statin therapy was associated with reduced 30-day mortality (OR 0.76; 95%CI 0.5-1.05; p=0.09). Optimal discharge therapy had a 5-year survival of 79% compared with 61% on neither medication. The paper highlights that a third of patients are still being sub-optimally medically managed and the potential to improve survival following vascular surgery procedures.

 

J Vasc Surg. 2014; 59(6): 1615-1621

DOI: http://dx.doi.org/10.1016/j.jvs.2013.12.013

 

 

Selected by Alastair McKay; Core Trainee, West of Scotland

 

UK curriculum topics:

Vascular pathology
Vascular epidemiology
Risk-factor Modification

 

 

 

 

 

 

 

05.06.14

 

 

 

Change in Smoking Habits After Having Been Screened for Abdominal Aortic Aneurysm

 

Smoking is well established as a critical modifiable risk factor for AAA development and has been linked with AAA progression in a number of previous studies. Here the authors report changes in smoking habits following identification of screen detected AAA in patients in Uppsala, Sweden. Of 8,150 screened men between 2006 and 2011, 292 were found to have AAA. Of these, 53 patients were followed up in 2012 for this study (28 with AAA and 25 with sub aneurysmal aorta, SAA). These patients were compared with matched controls. As would be expected, the AAA patients reported a longer pack year smoking history than controls. Disappointingly smoking cessation rate at follow up was no different between the three groups. However, the AAA patients had cut down their daily cigarette use more than the other groups (reduced by 8/day compared to 3 per day (SAA) or 4.5 per day(controls)). Although standard counselling had some effect on smoking habits, we need more tailored interventions to help our patients with screen-detected AAA stop smoking.
Eur J Vasc Endovasc Surg. 2014 May 27. doi: 10.1016/j.ejvs.2014.04.010

 

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

Vascular Curriculum Topics:
   Aneurysm – Elective
   Evidence Based Vascular Practice

 

 

 

 

 

 

Cost-effectiveness of the National Health Service abdominal aortic aneurysm screening programme in England

 

The UK national AAA screening programme (NAAASP), first introduced in 2009, invites all men aged over 65 in the UK for aneurysm screening on the basis of an abdominal ultrasound. The cost effectiveness of this programme was largely based on 4-year follow-up data from the Multicentre Aneurysm Screening Study (MASS); a randomised trial that estimated the incremental cost per QALY gained (of screening vs no-screening) to be £2970. Here the authors have updated the original cost effectiveness model to incorporate 10-year follow-up data (from MASS). The model has also been updated to reflect changes in known aneurysm prevalence (from 4.9% to 1.5%) and the authors have used numerous sources to estimate current screening and treatment costs. Of note, the costs of surgical aneurysm treatment are considerably higher than those reported in 2000-,1 which reflects an above-inflation cost increase as well as an increase in the proportion of endovascular stent repairs undertaken. Overall the NAAASP was found to be “highly cost effective” with a cost per QALY of £7370, far below the £20,000-£30,000 (per QALY) cost effectiveness threshold imposed by NICE. This publication therefore supports the NAAASP and adds weight to the considerable international evidence for a “one-off” ultrasound based aortic screen for men aged over 65 years.
BJS Early view - Article first published online: 27 MAY 2014 DOI:
10.1002/bjs.9528


Selected by: Kathryn Griffin, BHF Fellow in Vascular Surgery, University of Leeds

 

Vascular Curriculum topics –

Knowledge of the principles of screening

AAA screening and surveillance programme

Governance and quality control of AAA screening

Relevance of QALYS and calculation of incremental cost effectiveness ratios

 

 

 

 

 

 

Why is everyone so excited about Thromboelastrography (TEG)?

 

Thromboelastrography (TEG) is increasingly being used in certain critically ill patient populations, including abdominal aortic aneurysm and vascular trauma. TEG is one of the most commonly used viscoelastic coagulation tests, and measures the clotting of whole blood over time. Unlike conventional coagulation tests, it is able to capture interactions between cellular and plasma components of the coagulation cascade. It is also able to detect heparin and coagulation factor deficiency with higher sensitivity than the routine laboratory tests. It is important to remember this when interpreting and applying TEG results, in order to ensure that management based on TEG is applied to patient populations that will benefit.  This article provides a useful review of this increasingly popular measure of coagulation, as well as summarising the more traditional coagulation related laboratory tests.

Clin Chim Acta 2014 May 28. pii: S0009-8981(14)00233-2. doi: 10.1016/j.cca.2014.05.013. [Epub ahead of print]

 

Selected by: Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

 

Vascular Curriculum Topics –

            Haematology

                        Knowledge of the coagulation and fibrinolysis pathways

                        Interpreting laboratory results

Technical Skills – intra-operative use of heparin and monitoring techniques (TEG)

 

 

 

 

 

 

31.05.2014

 

 

 

Thoracic type Ia endoleak: direct percutaneous coil embolization of the aortic arch at the blood entry site after TEVAR and double-chimney stent-grafts

 

The objective of this study is to introduce a novel percutaneous technique to stop blood entry at the lesser aortic arch curvature by coil embolisation in type Ia endoleak after TEVAR. The authors demonstrate that direct percutaneous puncture of the aortic arch at the blood entry site of a thoracic type Ia endoleak after TEVAR and double–chimney stent–grafts with coil embolisation of the wedge–shaped space between the lesser aortic curvature and the stent–graft is possible.

Eur Radiol, June 2014

doi: 10.1007/s00330-014-3143-8

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

 Aortic Aneurysm Disease, Open and endovascular treatment options

Selection of Patients, Outcomes, Principles of Clinical research

Evidence based vascular practice

 

 

 

 

 

Retrograde open mesenteric stenting for acute mesenteric ischemia

 

The aim of this study was to evaluate the results of Retrograde open mesenteric stenting (ROMS) in a consecutive series of patients with Acute mesenteric ischemia (AMI). The authors conclude that AMI is still a devastating event. If Percutaneous mesenteric artery stenting (PMAS) is not feasible, ROMS is a reliable alternative and is associated with a relatively low mortality and morbidity rate.

Journal of Vascular Surgery, May 2014

http://dx.doi.org/10.1016/j.jvs.2014.04.001

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

 Open and endovascular treatment options, Selection of Patients

Outcomes, Principles of Clinical research, Evidence based vascular practice

 





The impact of endovascular aneurysm repair on aortoiliac tortuosity and its use as a predictor of iliac limb complications

 

The aim of this study was to investigate the impact of stent grafting on aortoiliac tortuosity and to explore the role of the tortuosity index (TI) as a predictor of iliac limb complications after EVAR. The study suggests that EVAR has a significant effect on aortoiliac tortuosity. Despite the reduction of aortoiliac tortuosity after the insertion of a stent graft, TI may serve as a predictor of iliac limb complications after EVAR.

Journal of Vascular Surgery, May 2014

doi: 10.1016/j.jvs.2014.03.279

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

 Aortic Aneurysm Disease, Open and endovascular treatment options

Selection of Patients, Outcomes, Principles of Clinical research

Evidence based vascular practice

 

 

<< New text box >>

 

 

 

30.05.2014

 

 

Asymptomatic Carotid Stenosis – Identifying Patients at High Enough Risk to Warrant Endarterectomy or Stenting

 

 

This editorial by a group of Canadian physicians cites a recent article, from the same issue of Stroke, which utilises data from the medical therapy arm of the Asymptomatic Carotid Surgery Trial (ACST). The study suggests that substantial progression of asymptomatic carotid stenosis (ACS) predicted ipsilateral stroke or TIA.  The editorial notes that this study may describe one possible method of highlighting those patients with ACS at a higher risk of stroke and, therefore, may benefit from more invasive intervention. However, it also notes that the ACST was conducted before the widespread use of intensive medical therapy, which has been shown in a number of more recent trials (e.g. Carotid Revascularisation Endarterectomy Versus Stenting Trial - CREST) to lower the risk of ipsilateral stroke in ACS below the risks associated with CEA or CAS.  The editorial concludes by highlighting other possible methods that may identify those ACS patients at higher risk, including detection of microemboli, plaque ulceration and intraplaque haemorrhage.

Stroke. 2014; 45: 655-657

 

UK Vascular Curriculum Topics:
Vascular pathology; Vascular epidemiology; Risk-factor modification; Carotid artery disease

 

Selected by: Alastair McKay

Core Trainee, West of Scotland

 

 

 

 

 

Effect of Antifibrinolytic Therapy with Tranexamic Acid on Abdominal Aortic Aneurysm Shrinkage after Endovascular Repair

 

This study from a Japanese group notes both the beneficial effect of aneurysm shrinkage on prognosis following EVAR and  the adverse effect of antiplatelet therapy on aneurysm shrinkage. The group assessed the effect of tranexamic acid on aneurysm shrinkage following EVAR. This was a retrospective analysis of 159 patients who underwent EVAR and were eligible for inclusion – 110 who did not receive TXA and 48 who completed a 6 month course of 1500mg of TXA daily. There were no significant differences between the two groups in baseline characteristics or endoleaks. At 6 months, the TXA group had a significantly greater aneurysm shrinkage (p = 0.035). The group note that more studies are required to identify the optimum dose and timing of TXA.

J Vasc Surg. 2014; 59(5): 1203-8

 

UK Vascular Curriculum Topics:

Vascular pathology, screening and surveillance, haematology, imaging, endovascular procedures, aneurysm – elective

 

Selected by: Alastair McKay

Core Trainee, West of Scotland

 

 

 

 

 

 

Improvement of Venous Pumping Function by Double Progressive Compression Stockings: Higher Pressure Over the Calf is More Important than a Graduated Pressure Profile

 

This small study looked at the effect of higher pressures on the venous calf pump in patients with venous disease using both traditional, graduated pressures and and more recently proven, negative pressure gradients. 20 patients with grade C2 to C5 (CEAP classification) venous disease had their calf pump ejection fraction measured in a standardised fashion under 3 different conditions: 1. Wearing one progressive elastic compression stocking (PECS – creating a negative pressure gradient), 2. Wearing two PECS on top of each other (higher negative pressure gradient), and 3. Wearing one PECS and one conventional gaiter stocking (creating a higher graduated pressure gradient). The greatest improvement was seen with two PECS superimposed – producing ejection fractions in the normal range. Introducing a conventional gaiter compression, thereby creating a graduated pressure profile, did not result any further improvements.

European Journal of Vascular & Endovascular Surgery. 2014; 47(5): 545-49

 

UK Vascular Curriculum Topics:

Vascular physiology, vascular pathology, superficial venous disease, deep venous insufficiency

 

Alastair McKay

Core Trainee, West of Scotland

 

 

 

 

28.04.14

 

 

 

 

Regional co-operation can improve outcomes for patients with ruptured AAA

 

Survival from ruptured AAA is known to be poor despite emergency intervention (often quoted as 20%). Here, the authors report their experience of centralising emergency AAA care in the Amsterdam region of Holland 2004-2011. The Amsterdam region contains 10 hospitals; emergency vascular care was centralised to three hospitals in the region. This prospective observational study reports 30-day outcomes for ruptured AAA in Amsterdam following re-organisation of services. A total of 453 patients were included. The regional survival rate following centralisation was 58.5% compared to 46% for The Netherlands as a whole. Patients treated at the vascular centre had higher survival than those treated in the referring hospitals (OR 3.18). Regional restructuring of services can improve outcome for patients with ruptured AAA.

Br J Surg. 2014 Apr 22. doi: 10.1002/bjs.9518. [Epub ahead of print]

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

UK Vascular Curriculum Topics:
Aneurysm – Emergency
Evidence Based Vascular Practice

Clinical Audit

 

 

 

 


Type A Aortic Dissection in Marfan Syndrome: Extent of Initial Surgery Determines Long Term Outcome

 

Due to a lack of diagnosis, sporadic mutations and a variable phenotypic profile, acute aortic dissection remains a frequent initial presentation of aortic pathology in patients with Marfan syndrome (MFS). This paper aimed to present the largest series to date of Type A aortic dissection in patients with MFS. In doing so, they aimed to present the outcomes following primary surgery in this group of patients, and to investigate the incidence, causes, and results of early and late surgical reinterventions. Data was pooled from two tertiary cardiac centres in the US and Europe over a 25 year period, resulting in a total of 74 patients with confirmed MFS undergoing surgery for acute type A aortic dissection. The rate of aortic reintervention with resternotomy was 24% at a median follow up of 8.4 years. Freedom from need for aortic root reoperation in patients who underwent primarily a composite valved graft or valve-sparing aortic root replacement procedure was 95±3%, 88±5%, and 79±5% and in patients who underwent supracoronary ascending replacement was 83±9%, 60±13%, 20±16% at 5, 10, and 20 years. Failure to extend the primary surgery to the aortic root or arch led to a highly complex clinical course. The authors conclude that emergency surgery for type A dissection in patients with Marfan syndrome is associated with low in-hospital mortality. However, they suggest that aortic root replacement or repair should be highly recommended because supracoronary ascending replacement is associated with a high need (>40%) for root reintervention.

Circulation. 2014 Apr 1;129(13):1381-6. doi: 10.1161/CIRCULATIONAHA.113.005865

 

Selected by Miss Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

UK Vascular Curriculum Topics:

Aortic Dissection

Principles of clinical research

Evidence based vascular practice

 

 

 


 

 

An analysis of the influence of intra-operative blood salvage and autologous transfusion on reducing the need for allogeneic transfusion in elective infrarenal abdominal aortic aneurysm repair

 

 

As blood products become an increasingly limited resource, the Department of Health recommends finding alternatives to allogenic transfusion. The use of Intra-Operative Cell salvage (ICS), is well established in emergency AAA repair. The aim of this study was to analyse the influence of intra-operative cell salvage on reducing the need for allogeneic blood in patients with asymptomatic infrarenal abdominal aortic aneurysm undergoing elective repair. This study collected data retrospectively on 30 patients who underwent AAA repair with the use of a cell saver, and 32 without. They found a significant association between use of the cell saver and a reduced need for allogeneic blood in these patients. Operations performed with the use of a cell saver lasted, on average, less time than those performed without it. The authors therefore conclude that the use of a cell saver in elective abdominal aortic aneurysm repair significantly reduces the need for intra-operative use of allogeneic blood.

Blood Transfus. 2014 Jan;12 Suppl 1:s182-6. doi: 10.2450/2012.0069-12. Epub 2012 Oct 10.

 

Selected by Miss Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

UK Vascular Curriculum Topics: 

Haematology - Methods of blood conservation including pre-donation and intra-operative cell salvage

Haematology - Appropriate use of blood and blood products

 

 

 

 

21.04.14

 

 

 

Endovascular Aneurysm Repair Versus Open Repair for Patients with a Ruptured Abdominal Aortic Aneurysm: A Systematic Review and Meta-analysis of Short-term Survival

The aim of this study was to compare the short-term; 30-day and in-hospital outcomes following open and EV repairs for RAAA. The systematic review-metanalysis was carried out including 32 studies (3 RCTs, 21 Observational and 8 registries) and followed the PRISMA guidelines.  In the RCTs, Risk of bias was lowest, and the pooled OR for death after EVAR versus OR was 0.90 (95% CI 0.65–1.24). The majority of the observational studies had a high risk of bias and the pooled odds ratio for death was 0.44 (95% CI 0.37–0.53). The majority of the administrative registries had a high risk of bias and the pooled odds ratio for death was 0.54 (95% CI 0.47–0.62). Overall it was felt that outcomes are not inferior following EVAR, but no clear preference was presented.

EJVES, Ahead of print, doi:10.1016/j.ejvs.2014.03.003

 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, Hull York Medical School

 

UK Vascular Curriculum Topics:

            Abdominal aortic disease

Open and endovascular treatment options

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

           

 

 

 

 


Long-term cost-effectiveness analysis of endovascular versus open repair for abdominal aortic aneurysm based on four randomized clinical trials.

 

This article published recently in the British Journal of Surgery, is on a study, were a review using Markov models was used to estimate lifetime costs compared between EVAR and OAR from a UK perspective and quality-adjusted life-years (QALYs) based on the results of 4 randomised trials:  EVAR-1, DREAM and ACE trials did not find EVAR to be cost-effective at thresholds used in the UK (up to £30 000 per QALY). EVAR was cost-effective according to the OVER trial. So the authors conclude that they do not feel EVAR would have a cost-effectiveness advantage on the long-term from a UK perspective.

Br J Surg, Online, doi: 10.1002/bjs.9464.

 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, Hull York Medical School

 

UK Vascular Curriculum Topics:

            UK Vascular Curriculum Topics:

            Abdominal aortic disease

Open and endovascular treatment options

            Outcomes

Cost-effective analysis

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 


 

Six-minute walk test closely correlates to “real-life” outdoor walking capacity and quality of life in patients with intermittent claudication


In 49 claudicants, this prospective study evaluated the relationship between outdoor walking capacity test for 40 minutes, the maximum walking distance (MWD), 6-Minute WD test and the Self Reported MWD. Participants also completed the VascuQoL questionnaire.

The authors found a good correlation between distance walked during the 6-minute walk test, the outdoor walking capacity and health-related quality of life.

Journal of Vascular Surgery, In Press, doi:10.1016/j.jvs.2014.03.003

 

Selected by: Hashem Barakat, Research Fellow in Vascular Surgery, Hull York Medical School

 

UK Vascular Curriculum Topics:

            Peripheral Vascular disease

            Selection of Patients

            Principles of clinical research

            Evidence based vascular practice

 

 

 

14.04.14

 

 

 

Compression Therapy Versus Surgery in the Treatment of Patients with Varicose Veins: A RCT

 

This randomized controlled trial assessed effectiveness of compression therapy against surgery for superficial venous reflux. Venous Clinical Severity Score without compression stockings (VCSS-S), Venous Segmental Disease Score (VSDS), Venous Disability Score (VDS), and health-related quality of life (HRQoL) were all significantly improved following surgical treatment compared to compression alone.

EJVES, April 2014, http://dx.doi.org/10.1016/j.ejvs.2014.02.015

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Venous disease, Open and endovascular treatment options, Best medical therapy

Selection of Patients, Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

           

 

 


 

Retrograde pedal access for patients with critical limb ischemia

 

The authors aimed to analyze the outcomes in patients with chronic limb ischemia (Rutherford class IV and V) who were not surgical candidates for a tibial bypass and had undergone an unsuccessful attempt at revascularization through an antegrade access. Retrograde pedal access for limb salvage in high–risk patients is feasible and safe, with acceptable limb salvage rates at intermediate follow–up. Appropriate candidates are those who have failed an antegrade intervention and are poor candidates for a tibial bypass.

J Vasc Surg, April, 2014, doi: 10.1016/j.jvs.2014.02.038.

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Peripheral Vascular disease, Open and endovascular treatment options

            Selection of Patients, Outcomes, Evidence based vascular practice

 

 

 

 

 


 

Endovascular treatment for unilateral chronic total occlusions of the iliac artery categorized as TASC II type D lesions


The study confirms that Endovascular treatment can be indicated for unilateral occlusion of both Common iliac artery (CIA) and External iliac artery (EIA) categorized as type D with a cumulative primary patency rate of 85% and 93% at 5 years.

Surgery Today, April 2014, Doi: 10.1007/s00595-014-0883-7

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Peripheral Vascular disease, Open and endovascular treatment options

            Selection of Patients, Outcomes, Evidence based vascular practice

 

 

 

 

 

 

Risk factors for mortality and failure of conservative treatment after aortic type B dissection

 

 

This study identified the patients at high risk of mortality following uncomplicated type B aortic dissection despite being on best medical therapy. The study revealed both early aortic dilatation and older age as risk factors for increased mortality after conservative treatment of type B dissection. Uncomplicated cases of type B dissection are treated conservatively. The results identified early aortic dilatation and elderly as a risk factor of increased mortality during follow–up and early aortic dilation displayed higher rate of treatment failure of conservative treatment indicating that this sub–group might benefit from more aggressive therapy.

The Journal of Thoracic and Cardiovascular Surgery, April 2014

http://dx.doi.org/10.1016/j.jtcvs.2014.03.053 

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 UK Vascular Curriculum Topics:

            Aortic Aneurysm Disease, Thoraco-abdominal aneurysm

            Aortic dissection, Open and endovascular treatment options

            Selection of Patients

 

 

 

 

 


09.04.14

 

 

 


A Comparison of the Effectiveness of Treating Those With and Without the Complications of Superficial Venous Insufficiency

 

This cohort study aimed to explore the rationale behind treatment rationing applied to those individuals with superficial venous insufficiency. At present treatment is often reserved for patients with severe CEAP graded 3-4 varicose veins primarily for perceived health economic reasons.

By analyzing the treatment data of some 260 patients with disease at two ends of the severity spectrum this study has highlighted that perhaps treating those with severe C3-4 venous disease ahead of those with C2 uncomplicated superficial venous disease is not supported by the evidence presented. In fact those patients with C2 disease had a greater rate of recurrence [odds ratio (OR) = 2.7, 95% CI: 1.2-6.1, P = 0.022] and required more secondary procedures (OR = 4.4, 95% CI: 1.2-16.3, P = 0.028) when compared to C3-4 disease patients.

Ann Surg. 2014 Jan 13. [Epub ahead of print] PMID:2442414

 


Selected by: Mr S Nandhra, Clinical Research Fellow, Vascular Surgery, Hull-York Medical School

UK Curriculum topics:

Superficial venous insufficiency, Health economics, Healthcare rationing, Evidence based vascular surgery

 

 

 


 

 

A Randomised Controlled Trial of Supervised Exercise Regimens and their impact on Walking Performance, Skeletal Muscle Mass and Calpain Activity in Patients with Intermittent Claudication

 

An interesting study by an Australian group that is unique in its findings. 35 patients with IC were randomised to two forms of SEP; standard treadmill SEP vs. SEP with lower-limb resistance training. Outcomes compared included pain-free walking distance, 6-minute walking distance and skeletal muscle mass assessments by a variety of assessments methods including muscle biopsy for Calpain and calpastatin activity.

Analysed on an ITT analysis the study group found that neither SEP was superior in terms of PFWD or 6MWD, but interestingly the study found that those individuals undergoing SEP with resistance training showed a significant deterioration in SMM (p=0.04).  The group postulate that this could in fact be due to repeated ischaemia that leads to reperfusion insults.

The study correctly highlights however that the populations within the study group are small and depend on the degree of symptoms that the participant exhibited. Although a pilot study by nature this paper provides and interesting read as the SEP uptake increases.

Eur J Vasc Endovasc Surg. 2014 Mar;47(3):304-10. doi: 10.1016/j.ejvs.2013.12.021. 

 

Selected by: Mr S Nandhra, Clinical Research Fellow, Vascular Surgery, Hull-York Medical School

UK Curriculum topics:  Intermittent claudication/ peripheral arterial disease, Evidence based vascular surgery

 

                                   

 


 


Time Dependent Changes in Atherosclerotic Plaque Composition in Patients Undergoing Carotid Surgery

 

This article from Utrecht in the Netherlands forms part of the Athero-express longitudinal vascular biobank study. The authors looked at the atheroscelrotic plaques of patients undergoing primary carotid endarterectomy (CEA) from 2002 to 2011. The study analysed the histopathological features of carotid artery plaques in 1583 patients at intervals of 2 years. The authors quantified a number of histopathological features. They noted that a number of key plaque characteristics (currently thought to be critical to plaque instability), including the presence of large atheroma, plaque thrombosis and calcifications, were less frequently observed over the time period. These changes were observed in all patient presenting symptom subgroups (stroke, TIA, amaurosis fugax, asymptomatic). Parallel, to these histopathological changes there was an observed improvement in risk factor management and secondary prevention for patients presenting for CEA.

Circulation 2014; first published on March 17 2014 as doi:10.1161/CIRCULATIONAHA.113.007603

 

Selected by: Alastair McKay

Core Trainee, West of Scotland

UK Curriculum Topics: Vascular pathology; Vascular epidemiology; Risk-factor modification; Clinical audit, research, and health economics; Carotid artery disease

 

 

 

 

Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA

 

There is a noted variance in the outcome of patients presenting with ruptured AAA (rAAA) between different countries. The authors of this study compared the management of rAAA in England and the USA in order to highlight any differences or similarities that may facilitate improvements in care. Data from patients presenting with rAAA between 2005 and 2010 was collated from each country. 11,799 and 23,838 patients with rAAA were included from England and the USA, respectively. In the USA, in-hospital mortality was lower (53.05% vs 65.90%), intervention (open or endovascular) was offered to a larger proportion (80.43% vs 58.45%) and endovascular repair was more common (20.88% vs 8.54%) (p values all < 0.0001). A number of key similarities were also noted: post-intervention mortality was around 41% in both countries and reduced mortality was associated with increased use of endovascular repair, increased case volume, weekday admission, and hospitals with a large bed capacity and teaching status.

The Lancet - 15 March 2014 (Vol. 383, Issue 9921, Pages 963-969 ) DOI: 10.1016/S0140-6736(14)60109-4 

 

Selected by: Alastair McKay

Core Trainee, West of Scotland

UK Curriculum Topics: Vascular epidemiology; Clinical audit, research & health economics; Endovascular procedures; Open vascular surgery; Aneurysm – emergency

 

 

 

17.03.14

 

Ambler GK, Twine CP, Shak J, Rollins KE, Varty K, Coughlin PA, Hayes PD, Boyle JR. Survival Following Ruptured Abdominal Aortic Aneurysm Before and During the IMPROVE Trial: A Single-centre Series. Eur J Vasc Endovasc Surg. 2014 Feb

In this interesting study from the Addenbrooke’s Vascular Unit (UK) compared the relative survival of patients undergoing emergency EVAR for ruptured AAA before the start of the IMPROVE trial and during randomisation to the trial in their unit. The study consisted of 169 patients, 84 before and 85 during the trial period. Before IMPROVE the unit found a significant survival benefit of EVAR over open repair for ruptured AAA (13% vs 30% mortality). This apparent benefit was lost during IMPROVE (35% vs 33%). This supports the important of evaluating the critical importance of using randomised trial data to establish optimal treatments rather than relying on cohort data.

 

Curriculum Topics: Vascular Epidemiology, Clinical Audit & Research, Aneurysm – Emergency

Selected by: Mr Marc Bailey, BHF Fellow, Leeds Vascular Institute

 

 

Stone PA, Aburahma AF, Mousa AY, Phang D, Hass SM, Modak A, Dearing D. Prospective Randomized Trial of ACUSEAL versus Vascu-Guard Patching in Carotid Endarterectomy. Ann Vasc Surg. 2014 Feb 19

It has been proven that patch closure is preferable to primary closure of the arteriotomy following carotid endarterectomy (CEA). The optimal patch choice is not clear. This was a randomised trial of PTFE patch (ACUSEAL) vs. bovine pericardium (Vascu-Guard). The authors randomised 200 patients 1:1 to each patch for their CEA procedure. Patients were followed up for restenosis and stroke free survival. The groups were comparable. There was reduced time to haemostasis in the Vascu-Guard group (p=0.03). Operative duration was similar. There was a trend towards increased need for re-exploration of the neck in Vascu-Guard patients but it did not reach statistical significance. There was no difference in restenosis or stroke free survival between the two groups. The authors failed to show major advantage of either patch for their primary outcome measures.

 

Curriculum Topics: Clinical Audit & Research, Carotid Artery Disease,

Selected by: Mr Marc Bailey, BHF Fellow, Leeds Vascular Institute

 

 

Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC Jr, Goto S, Ohman EM, Elbez Y, Sritara P, Baumgartner I, Banerjee S, Creager MA, Bhatt DL; on Behalf of the REACH Registry Investigators. Statin therapy and long-term adverse limb outcomes in patients with peripheral artery disease: insights from the REACH registry.  Eur Heart J. 2014 Feb 28.

Statin therapy is recommended for all patients with PAD for prevention of cardiac events. Any impact on limb prognosis is less clear. Here the authors report the effect of statin use on limb outcomes in patients in the REACH registry. The study included 5861 patients with PAD, followed up for 4 years. Statin use was recorded at enrolment and during the trial. The main outcome measures were adverse limb outcome (worsening claudication/new episode of critical limb ischaemia, new percutaneous/surgical revascularization, or amputation) or cardiovascular death/myocardial infarction/stroke. Statin use at baseline was 62.2%. Patients taking statins had a lower risk of adverse limb outcomes at 4 years (hazard ratio 0.82, p=0.001). The composite mortality risk was also reduced in statin users (hazard ratio 0.83, p=0.01). The study suggests that statins have a beneficial effect on limb prognosis in patients with PAD in addition to the established benefits for global cardiovascular risk.

 

Curriculum Topics: Risk Factor Modification, Cardio-Respiratory Disease, Clinical Audit & Research, Chronic Lower Limb Ischaemia,   Evidence based vascular practice

 

Selected by: Mr Marc Bailey, BHF Fellow, Leeds Vascular Institute

 

 

 

 

10.03.14

 

 

 

 

 

Preoperative smoking is associated with early graft failure after infrainguinal bypass surgery


In this study, the authors investigated the effect of preoperative tobacco abuse on early outcomes following infrainguinal bypass surgery.
Smokers were defined as patients who smoked for 12 months before surgery. Analysis compared the effect of smoking and a variety of preoperative/intraoperative risk factors on 30-day graft failure; comparing active smokers with nonsmokers.
16,534 infrainguinal bypasses were included, 40% of patients were active smokers (n=6614).

Active smokers were more likely to be younger, male and of non-white race and to have a history of COPD. Nonsmokers were more likely to be functionally dependent and had significantly more comorbidities. Critical limb ischemia was noted in similar proportions in both groups (53.1% of active smokers vs 53.5% of nonsmokers; P = .61). There was a trend toward increased early graft failure in active smokers (5.3% vs 4.7%; P = .08) and with adjustment for other variables active smoking was independently associated with early graft failure (adjusted OR: 1.21; 95% CI, 1.02-1.43; P = .03).

 

Journal of Vascular Surgery, In Press

doi:10.1016/j.jvs.2013.12.011

 

Selected by H Barakat, Research fellow at HYMS

 

UK Vascular curriculum topics
Best medical therapy for vascular disease

Outcomes

Evidence based vascular practice

 

 

 

 


 

Results of F-EVAR in Octogenarians

 

The study aims to evaluate the clinical outcomes after fenestrated endovascular aortic aneurysm repair (F–EVAR) in octogenarians. F–EVAR in octogenarians is associated with a higher 30–day mortality rate but has similar mid–term outcomes compared to younger patients and should be considered as an acceptable therapeutic option in patients with satisfactory life expectancy.

 

Ann Vasc Surg, Feb 2014

doi: 10.1016/j.avsg.2014.02.006

 

Selected by:

Junaid Sultan

SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK Vascular curriculum topics:

Aortic Aneurysm

Open Surgery and Endovascular treatment

Best medical therapy for vascular disease

Outcomes

Evidence based vascular practice

 

 

 

 

 


 

Managing recurrent carotid artery disease with redo carotid endarterectomy:

A 10-year retrospective case series

 

The authors reviewed the results of the operative series on primary and redo carotid endarterectomy (CEA) data to evaluate the short– and long–term outcomes of surgical intervention. They also evaluated the relationship between plaque lesion characteristics with respect to the development of recurrent stenosis. In the retrospective study, the stroke and restenosis rates after RCEAs were similar to those after primary CEA. Therefore, they consider RCEA to be a viable therapeutic option in patients with carotid disease that recurs after a primary CEA.

 

Ann Vasc Surg, Feb 2014

doi: 10.1016/j.avsg.2013.07.020.

 

Selected by:

Junaid Sultan

SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Carotid disease

Open Surgery and Endovascular treatment

Best medical therapy for vascular disease

Outcomes

            Evidence based vascular practice

 

 

 

 

 

 

03.03.14

 

 

 

 

 

Stent-graft therapy for false lumen aneurysmal degeneration in established type B aortic dissection (FADED) results in differential volumetric remodeling of the thoracic versus abdominal aortic segments

 

Despite optimal medical therapy of type B aortic dissections, false lumen aneurysmal degeneration of these established dissections (FADED) occur over the long–term (>6 months). The efficacy of thoracic stent–grafts (TEVAR) in promoting aortic remodeling when placed at late time points remains controversial and was the focus of this investigation. Utilization of TEVAR in patients suffering from FADED can promote true lumen expansion with concurrent false lumen regression, however progressive dilation in the total infra–renal aorta volume may occur and warrants close surveillance.

Ann Surg, Feb 2014

doi: 10.1016/j.avsg.2014.02.009

 

Selected by:

Junaid Sultan , SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Aortic Aneurysm

Aortic Dissection

Best medical therapy for vascular disease

Outcomes

            Evidence based vascular practice

 

 

 

 


 

 

Short-term physical inactivity impairs vascular function

 

Sedentarism, also termed physical inactivity, is an independent risk factor for cardiovascular diseases. Mechanisms thought to be involved include insulin resistance, dyslipidemia, hypertension, and increased inflammation. The authors hypothesized that short–term exposure to inactivity would lead to endothelial dysfunction, arterial stiffening and increased vascular inflammation. The findings show that acute exposure to sedentarism results in decreased endothelial function, arterial stiffening, increased DBP, and an increase in 15–HETE. They speculate that inactivity promotes a vascular “deconditioning” state characterized by impaired endothelial function, leading to arterial stiffness and increased arterial tone.

JSR, Feb 2014

doi:10.1016/j.jss.2014.02.001

 

Selected by:

Junaid Sultan , SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Best medical therapy for vascular disease

Outcomes

            Evidence based vascular practice

 

 

 

 

 


 

Effect of false lumen partial thrombosis on repaired acute type A aortic dissection

 

The authors investigated the effects of a partially thrombosed false lumen on segmental growth rates, distal aortic reoperations, and long–term survival. Partial thrombosis at each segment of a residual false lumen after TAAAD repair was correlated with faster regional aortic growth rate and predicted a higher reoperation rate, but it did not affect long–term overall survival. Studies on the partial thrombosis of false lumens after repairing type A acute aortic dissection report conflicting results, Studies on the partial thrombosis of false lumens after repairing type A acute aortic dissection report conflicting results. They reviewed postoperative CT scans of 67 patients. Partial thrombosis of a postoperative residual false lumen predicted a higher regional aortic growth and reoperation rate, but did not affect long–term overall survival.

The Journal of Thoracic and Cardiovascular Surgery, Feb 2014

doi:10.1016/j.jtcvs.2014.02.003

Selected by:

Junaid Sultan , SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Aortic Aneurysm

Aortic Dissection

Best medical therapy for vascular disease

Outcomes

            Evidence based vascular practice

 

 

 

24.02.14

 

 

Dual antiplatelet therapy (clopidogrel and aspirin) is associated with increased all-cause mortality after carotid revascularization for asymptomatic carotid disease

This study aimed at investigating the effect of dual antiplatelet treatment on the long-term survival of patients following carotid surgery.

Retrospectively, data on 471 patients were analysed. These were divided into 2 groups according to the antiplatelet therapy regimen (Aspirin only vs Aspirin & Clopidogrel – including pts on minimum of postop 30 day antiplatelet treatment). Primary outcome was all-cause mortality, secondary outcomes were bleeding and stroke.

An increased in mortality was seen in in patients with asymptomatic carotid disease receiving dual antiplatelet therapy as compared with aspirin alone and a non-significant decrease in all-cause mortality was seen in symptomatic patients receiving dual antiplatelets. In asymptomatic patients > 75 years of age, a decrease in all-cause mortality was seen with dual antiplatelets in sub-group analysis (82% vs 56%; P = .001). No difference in the incidence of stroke or bleeding was seen.


Journal of Vascular Surgery, In Press
doi:10.1016/j.jvs.2013.10.087

 

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:
            Best medical therapy for vascular disease

Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 


 

Cilostazol is associated with improved outcomes after peripheral endovascular interventions

 

This was a meta-analaysis of 6 studies. The aim was to study the effect of Cilostazol on outcomes after peripheral vascular interventions as compared to the use of antiplatelets alone. 2 RCTs and 4 retrospective cohort studies were included.

The addition of cilostazol was associated with decreased restenosis, improved amputation-free survival, limb-salvage and freedom from target lesions, without a reduction in overall mortality.

 

Journal of Vascular Surgery, In Press
doi:10.1016/j.jvs.2013.11.096

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:
            Best medical therapy for vascular disease

Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 


 

Ultrasound Measurement for Abdominal Aortic Aneurysm Screening: A Direct Comparison of the Three Leading Methods

 

This study evaluates the accuracy, reproducibility and repeatability of 3 different methods of aortic diameter measurement for AAA using ultrasound (USS) and compares these with CT measurements.

6 assessors compared 50 static USS images on 2 occasions, 6-week apart. Inner-to-inner (ITI), leading-to-leading edge (LTL), outer-to-outer (OTO) and CT measurements were recorded.

The three USS methods had high repeatability and reproducibility:  inter-observer reproducibility coefficients between assessors were 0.48 cm, 0.35 cm, and 0.34 cm for ITI, LTL and OTO, respectively, and the intra-observer repeatability coefficients between assessors were 0.30 cm, 0.20 cm, and 0.19 cm for ITI, LTL and OTO, respectively.

USS measures were consistently underestimated AAA diameters when compared to CT, especially with the ITI measurement. This can impact on the sensitivity of USS as a screening test.

 

European Journal of Vascular & Endovascular Surgery, In Press

doi:10.1016/j.ejvs.2013.12.026

 

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:

            Abdominal Aortic Aneurysm disease -screening

Radiology for vascular surgeons

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 

17.02.14

 

 


Results of the Anaconda endovascular graft in abdominal aortic aneurysm with a severe angulated infrarenal neck.

 

Proximal neck angulation limits the utility of EVAR in some patients and is a marker of adverse outcomes in patients who do undergo EVAR for AAA. In this study, the authors report the Dutch experience (across nine hospitals) with the Anaconda device in patients with severe neck angulation, above 60 degrees. Thirty six patients were included followed up to a median of 40 months. The mean neck angulation in the included patients was 82 degrees. Primary technical success was achieved in 83% of cases declining to 69% success at 4 years. Occlusion was the most common problem. The authors conclude that the Anaconda device is feasible in the treatment of AAA with severe neck angulation but there is an increased risk of complications and they recommend open repair for these patients in future.

J Vasc Surg. 2014 Feb 5. pii: S0741-5214(13)02309-4.
doi: 10.1016/j.jvs.2013.12.034. [Epub ahead of print]

 

Vascular Curriculum Topics: Aneurysm – Elective, Evidence Based Vascular Practice, Clinical Audit

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

 


 

 

 

Impact of Long-Term Warfarin Treatment on EVAR Durability: A Meta-Analysis.

 

A number of studies have suggested increased endoleak incidence following EVAR in patients taking long term anticoagulation. Here the authors performed a systematic literature review to determine if this suggestion was indeed true and if there was an increased need for intervention. A total of 81 studies were included in the review including 1499 patients. Of these 14.6% were taking anti-coagulation. Patients taking warfarin had an increased risk of endoleak of any type (OR 1.77) and persistent type II endoleak (OR1.58), however the authors did not detect any change in re-intervention rate.

J Endovasc Ther. 2014 Feb;21(1):148-53. doi: 10.1583/13-4462R.1.

 

Vascular Curriculum Topics: Aneurysm – Elective, Evidence Based Vascular Practice, Clinical Audit

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

 

 


Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism.

 

This paper provides a comprehensive, up-to-date summary of the evidence for duration of anticoagulant treatment in patients with thromboembolic disease. In summary, VTE should generally be treated for either 3 months or indefinitely, and the length of treatment is determined by the long-term risk of recurrence, and secondarily influenced by the risk of bleeding and by patient preference. VTE provoked by a reversible risk factor, or a first unprovoked isolated distal (calf) deep vein thrombosis (DVT), has a low risk of recurrence and is usually treated for 3 months. VTE associated with active cancer, or a second unprovoked VTE, has a high risk of recurrence and is usually treated indefinitely. In the case of PE, the evidence suggests the reverse, with indefinite treatment as the preferred option unless there is a high risk of bleeding. 

Blood. 2014 Feb 4. [Epub ahead of print]  doi: 10.1182/blood-2013-12-512681

 

 

Vascular Curriculum Topics: Deep Venous Thrombosis – Management of Uncomplicated DVT, Evidence Based Vascular Practice

 

Selected by: Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

 


 

Multi-media 


 

Ultrasound Doppler Explained 

 

Curriculum – Vascular Imaging, Understand the principles of Doppler ultrasound

Selected by: Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

MRI Scanning Explained

 

Curriculum – Vascular Imaging, Understand how MR images generated

Selected by: Katy Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

 

13.02.14

 

 

 

 

The Controversy of Peri-operative ß-blockade: What Should I Do?

 

 

Author has reviewed the current literature and feels the question of which patients might benefit from perioperative beta-blockade remains unanswered. However, based on the best available evidence concludes that the initiation of beta blockers in patients who will undergo non-cardiac surgery should not be considered routine, but should be considered carefully by each patient's treating physician on a case-by-case basis.

Journal of Vascular Surgery, Feb 2014

doi:10.1016/j.ejvs.2013.11.005

 

Selected by:

Junaid Sultan

SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Best medical therapy for vascular disease

Outcomes

            Evidence based vascular practice

 

 

 

 

 



Effects of Clustered Comorbid Conditions on Walking Capacity in Patients with Peripheral Artery Disease

 

This cross-sectional study was conducted in patients with peripheral arterial disease and analysed the influence of clustered co-morbidities on their walking capacity. This study concluded that cerebral vascular disease was associated with walking impairment of intermittent claudication patients.

Annuals of Vascular Surgery, Feb 2014

doi:10.1016/j.avsg.2013.01.020

 

 

 

 

 

Cases

 

 


Anterior Thoracolumbar Spine Exposure: Critical Review and Analysis

 

This study reports the results of a single vascular surgeon following anterior thoracolumbar spine exposure. Author reported a very low incidence of non-vessel injury complications. However, multidisc level exposure is associated with an increased incidence of lymphedema, wound infection, and hospital readmission. Redo anterior spine exposure and redo disc exposure cases can be performed safely. Patients with BMI >30 kg/m2 should be approached with caution because there is a significantly increased rate of DVT, wound infection, and hospital readmission.

Annuals of Vascular Surgery, Feb 2014

doi:10.1016/j.avsg.2013.06.026

 

Selected by:

Junaid Sultan

SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Surgical exposure

            Principles of Clinical Research

Evidence based vascular practice

Operative outcome

 

 

 


Endoluminal Stent-Graft Relining of Visceral Artery Bypass Grafts to Treat Perigraft Seroma

 

The author successfully reports the relining of 5- to 8-mm-diameter ePTFE bypass grafts believed to be involved in the seromas with self-expanding Viabahn stent-grafts in percutaneous procedures with complete resorption of seromas at 10 months follow up. This anticipates that this minimally invasive technique could be very valuable in treating aortic, renovisceral, and peripheral perigraft seroma.

Journal of Endovascular Therapy, Feb 2014

doi: http://dx.doi.org/10.1583/13-4391.1

 

Selected by:

Junaid Sultan

SPR Vascular Surgery, Yorkshire and Humber Deanery

 

UK curriculum topics:

            Complications of Vascular Surgery

            Endovascular Surgery

            Principles of Clinical Research

Evidence based vascular practice

 

 

04.02.14

 

 

 

 

Perioperative management with antiplatelet and statin medication is associated with reduced mortality following vascular surgery

 

This study aimed at investigating whether the perioperative use of antiplatelets and statins has any effect on postoperative survival.

Using data on more than 14000 patients who underwent a range of elective vascular surgery at multiple centres, the authors used multivariate analyses models to study the adjusted impact of best medical therapy (Antiplatelets + statins) on 30-day mortality and 5-year survival. Preoperative Antiplatelet and statin use was associated with lower short-term mortality and a significantly superior 5-year survival. The use of medication was variable amongst the study centres.

Journal of Vascular Surgery, In Press
doi:10.1016/j.jvs.2013.12.013

 

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:
            Best medical therapy for vascular disease

Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Retrograde aortic dissection after thoracic endovascular aortic repair
 

This study aimed to provide insight into the occurrence and timing of retrograde type A aortic dissection (RTAD) after TEVAR. The authors used the MOTHER registry database, in addition to a dataset from a recent systematic review. The incidence of RTAD was 1.6-1.7%.

TEVAR for aortic dissection, and oversizing of grafts appeared to be associated with higher incidence of RTAD. RTAD was associated with a high mortality rate of 33.6%. Therefore, although it is a rare complication, it is worth identifying early for prompt management.

Annals of Surgery, In Press
doi: 10.1097/SLA.0000000000000585

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:
            Thoracic aortic disease
            Endovascular management

Operative Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

Early surgical thrombectomy improves salvage of thrombosed vascular accesses

 

The aim in this study was to investigate the potential benefits of early thrombectomy for vascular access thrombosis. The authors analysed 114 thrombectomies performed on 82 patients and classified the interventions according to time from referral or diagnosis, and time to dialysis. They also assessed patency rates during the study follow-up period (mean = 22 months).

Early intervention ( i.e. <6 hrs after diagnosis) was associated with better technical success, secondary patency rates.

Journal of Vascular Surgery, In Press

doi:10.1016/j.jvs.2013.11.092

 

 

Selected by Mr H Barakat, Vascular research fellow at HYMS

 

UK curriculum topics:

            Vascular Access for dialysis

Operative Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

20.01.14

 

 


Obesity as an Independent Predictor of Outcome after Endovascular Abdominal Aortic Aneurysm Repair

 

Obesity is an increasingly common co-morbidity across all surgical specialties. Relatively little has been published on the effect of BMI on outcome following EVAR. In this study the authors compared EVAR outcome in age, sex, smoking status and AAA size matched patients with obesity (BMI 30 kg/m2 n=53) and those where were non-obese (n=106) followed up for 36 months. No difference was found between groups for all-cause mortality or non-aneurysm related morbidity on multivariable analysis, although peri-operative complications occurred more commonly in the obese group. 

Ann Vasc Surg. 2013 Dec 27.

doi: 10.1016/j.avsg.2013.07.008.

Chosen by Mr M A Bailey, BHF Fellow, University of Leeds

 

UK Vascular Curriculum Topics:

Risk factor modification:       Knowledge of vascular risk factors and risk-factor modification

                                                 Dietary factors and weight control

Aneurysm – elective:             Treatment options (medical, open, EVAR, hybrid)

                                                 Endovascular repair infrarenal AAA                                      

 

 

 

 

 

 

 

Influence of gender on outcomes after thoracic endovascular aneurysm repair

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NAQIP) database was undertaken to establish if, like EVAR, female gender was associated with increased morbidity and mortality after thoracic endovascular aortic aneurysm repair (TEVAR). 649 cases over a 6 year period were included. Operative times, transfusion rates, and hospital length of stay were increased in women compared with men. Overall, postoperative complications were similar, and whilst unadjusted mortality was significantly greater in women on multivariable analysis, female gender was no longer a significant predictor of mortality.

The authors conclude that the need for iliac artery exposure, age, and emergency surgery are independently associated with higher mortality rates. Whilst thirty-day unadjusted mortality after TEVAR for non-ruptured thoracic aortic aneurysms is increased in women compared with men, this result does not persist after risk adjustment.

Journal of Vascular Surgery, Jan 2014

http://dx.doi.org/10.1016/j.jvs.2013.06.058

 

Chosen by Miss K I Bridge, BHF Fellow, University of Leeds

  

UK Vascular Curriculum Topics:

Aneurysm – elective:                              Treatment options (medical, open, EVAR, hybrid)                                                                              Thoracic aneurysm/dissection stentgraft

 

 

 

 

 

 

 

 

Five-year results for endovascular repair of acute complicated type B aortic dissection

 

Thoracic endovascular aortic repair (TEVAR) has replaced open surgical management for acute complicated type B aortic dissection due to promising short- and midterm data. Long term results are limited, and this retrospective study presents long term outcomes of TEVAR for acute complicated type B dissection. It includes 50 consecutive patients presenting between July 2005 and September 2012. Between July 2005 and September 2012, 50 consecutive patients underwent TEVAR for management of acute complicated type B dissection at a single referral institution. Patient records were retrospectively reviewed from a prospectively maintained clinical database. Indications for intervention included rupture in 10 (20%), malperfusion in 24 (48%), and/or refractory pain/impending rupture in 17 (34%).There was no in-hospital or 30-day mortalities. Median follow-up was 33.8 months.

The authors conclude that the short-term outcomes of TEVAR for acute complicated type B dissection appear to be durable and sustained over long-term follow-up. These data support the use of TEVAR for acute complicated type B aortic dissection.

Journal of Vascular Surgery, January 2014

http://dx.doi.org/10.1016/j.jvs.2013.07.001

 

 

Chosen by Miss K I Bridge, BHF Fellow, University of Leeds

 

UK Vascular Curriculum Topics:

Aneursym – Emergency:         Endovascular stenting of acute aortic dissection

Screening and Surveillance:   AAA screening EVAR/TEVAR and vein graft surveillance

 

 

14.01.14

 

 

 

 


 

 

The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia

Hybrid procedures; involving combined endovascular and surgical approaches are attracting more attention recently.

In this study, the authors compare their outcomes for surgical arterial thrombo-embolectomies vs hybrid interventions for acute L.L. ischaemia.
A comparison is made between 112 patients undergoing embolectomies and 210 undergoing hybrid procedures. Outcomes include in-hospital complications, 30-day death, primary and secondary patency, re-intervention rate, limb salvage, and overall survival.Interventions included under “Hybrid Procedures” consisted of angioplasty (PTA) ± stenting, catheter-directed intra-arterial thrombolysis + PTA ± stenting, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting, vacuum-based accelerated thromboaspiration by mechanical devices, or primary covered stenting. These followed surgical embolectomies. The authors found that the outcomes; mainly patency rates, limb salvage and freedom from intervention were favorable with hybrid procedures.
Journal of Vascular Surgery, Online-Dec 13
doi:10.1016/j.jvs.2013.09.016

 

Selected by: Mr H Barakat, Vascular Research Fellow, Hull

UK Vascular Curriculum Topics:

            Acute lower limb ischaemia

            Open and endovascular treatment options

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 


 

Metabolic syndrome is associated with type II endoleak after endovascular abdominal aortic aneurysm repair

 

In this study, the authors investigate whether the main components of the Metabolic Syndrome are associated with type II endoleak following EVAR. It was a retrospective series that included 79 male patients undergoing EVAR of whom 52 had metabolic syndrome components. Patients with MetS had a significant increase in acute kidney injury
(n = 7, P = .0128). Endoleaks of all types were detected in 20 patients; patients with MetS had more endoleaks (35% vs 7.4%, P = .0039). Of 19 type II endoleaks, 79% were present at the time of EVAR and 21% developed during surveillance; 95% had MetS (P = .0007).

Journal of Vascular Surgery, Online-Dec 13

doi:10.1016/j.jvs.2013.10.081

 

Selected by: Mr H Barakat, Vascular Research Fellow, Hull

 

UK Vascular Curriculum Topics:

            Abdominal Aortic Aneurysms

            Open and endovascular treatment options

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 


 

 

A Review of Current Reporting of Abdominal Aortic Aneurysm Mortality and Prevalence in the Literature

In view of the recent changes in the epidemiology of abdominal aortic aneurysm disease, the aim of this study was to study the accuracy of AAA prevalence and mortality citations in current literature by a comprehensive literature review.

The reported prevalence of AAA was as low as 1% and as high as 12.7%. Only 47.5% of studies referenced original articles, national reports or NICE. Only 32.4% of cited prevalence matched those from the referenced article.

In total 5 out of 40 studies were completely accurate. 80% of studies cited aneurysm mortality in the USA, with the majority stating 15,000 deaths per year (range 9,000 to 30,000). Current USA crude AAA mortality is 6,289 (2010).

European Journal of Vascular and Endovascular Surgery, In Press
doi:10.1016/j.ejvs.2013.11.007

 

Selected by: Mr H Barakat, Vascular Research Fellow, Hull

 

UK Vascular Curriculum Topics:

            Abdominal Aortic Aneurysms

            Incidence and prevalence

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

07.01.14

 

 

 

 

Preoperative Statins and Limb Salvage After Lower Extremity Revascularization in the Medicare Population

 

Preoperative statins were associated with improved 1-year limb salvage after lower extremity revascularization. The strongest association was found for patients with the diagnosis of claudication. Statins seem to be underused among Medicare patients with peripheral artery disease. Further evaluation of the use of preoperative statins and the potential benefits for peripheral vascular interventions is warranted.

Circulation: Cardiovascular interventions, Dec 2013

doi: 10.1161/ CIRCINTERVENTIONS.113.000274

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Peripherial vascular disease

            Best medical therapy

Open and endovascular treatment options

            Selection of Patients

            Outcomes

 

 

 

 

 


Carotid Endarterectomy National Trends Over A Decade: Does gender matter?

 

In this retrospective national population based study of hospitalized patients undergoing CEA over a decade, authors found that women have lower perioperative cardiac morbidity and mortality rates than men. After adjusting for patient, clinical and hospital factors, there is no discernible difference in timing of CEA based on gender.

Annals of Vascular Surgery, Dec 2013

doi: 10.1016/j.avsg.2013.08.016.

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Carotid disease

Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Evidence based vascular practice

 

 

 

 

 


Modified Elephant Trunk Technique for Chronic Aortic Dissection: The “Double Elephant Trunk”

 

The most widely used technique for chronic dissection of the aortic arch and thoracoabdominal aorta is the “elephant trunk” (ET). A technique, in which an original modification of the ET technique was necessary to avoid visceral malperfusion due to the obliteration of the patent false lumen from where splanchnic arteries arose, is presented.

Journal of Cardiac Surgery, Dec 2013

DOI: 10.1111/jocs.12267

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

            Aortic Aneurysm Disease

            Thoraco-abdominal aneurysm

            Aortic dissection

    Open and endovascular treatment options

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 


 

 

Transaxillary access to aortopulmonary window and paraaortic nodes

 

A minimally invasive video–assisted thoracic surgery procedure to biopsy paraaortic and aortopulmonary window nodes is presented. In contrast to the standard 3–ports procedure, the transaxillary route the authors describe allows very good visualization of these anatomical zones. This procedure is safe and quick, and also cosmetic and painless.

Asian Cardiovascular and Thoracic Annals, Dec 2013

doi: 10.1177/0218492313516326

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:

Minimal Invasive surgery

            Selection of Patients

            Outcomes

            

 

 

 

16.12.13

 

 

 

4-French-Compatible Endovascular Material Is Safe and Effective in the Treatment of Femoropopliteal Occlusive Disease: Results of the 4-EVER Trial

 

4-EVER trial is a prospective multicenter trial, which evaluated the safety and efficacy of treating symptomatic femoropopliteal occlusive disease using 4-F-compatible materials and no closure device. An Astron Pulsar stent was implanted in 70 (58.3%) lesions and a Pulsar-18 stent in 46 (38.3%); 4 (3.3%) patients had both stents implanted for flow-limiting dissection after predilation. 12-month primary patency rate was 81.4%: 85.2% for the Astron Pulsar and 73.4% for the Pulsar-18 (p=0.236). 4-F devices are safe and effective.  This trial confirms that 4F devices have similar patency at 12 months compared to 6F devices but with fewer access site complications, and shorter manual compression times.

J Endovac Therapy, Dec 2013, doi: 10.1583/13-4437MR.1

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

Endovascular treatment options, Peripheral Vascular Disease, Selection of Patients

Outcomes, Principles of Clinical research, Evidence based vascular practice

 

 

 

 

 

Midterm Outcomes of Subintimal Angioplasty Supported by Primary Proximal Stenting for Chronic Total Occlusion of the Superficial Femoral Artery

 

The authors investigated the midterm outcomes of subintimal angioplasty in 150 patients with chronic total occlusion of superficial femoral arteries (SFA) in 172 limbs and evaluated the clinical and procedural factors affecting these results. Technical success was achieved in 161 (94%) limbs; there were no procedure-related deaths or complications requiring surgery, but distal embolization and arterial perforation occurred in 2 and 4 limbs, respectively. The cumulative freedom from binary restenosis rates at 1 and 3 years were 77% and 59%, respectively, in the entire study group. Patency rate was higher at 1 and 3 years in patients without critical limb ischemia (CLI) compared to the patients with CLI. Chronic total SFA occlusions can be safely and effectively treated by subintimal angioplasty with routine stenting.
J Endovasc Therapy, Dec 2013, doi:
http://dx.doi.org/10.1583/13-4398MR.1

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

UK Vascular Curriculum Topics:
Endovascular treatment options, Peripheral Vascular Disease, Outcomes

 

          

Outcomes of infrapopliteal endoluminal intervention for transatlantic intersociety consensus C and D lesions in patients with critical limb ischaemia

 

The authors did a retrospective study of patients who underwent infrapopliteal percutaneous transluminal angioplasty (PTA) with or without stenting.  At 1 and 2 years, freedom from re-intervention, or amputation was 65.1% and 55.6%. Limb salvage was 77.7%. Within 2 years, 2% underwent bypass and 18% repeat infrapopliteal PTA. The 30-day mortality was 5%. Overall survival was 84.5%, 71.8% and 61.6% at 1, 2 and 3 years. Eighty-two per cent were classified as TASC D lesions. Radiological success was achieved in 100% of TASC C lesions in contrast to 86.7% of TASC D lesions. This study encourages attempting at PTA as an alternative to primary amputation even in patients with radiologically demonstrated severe disease.
ANZ J Surgery, Dec 2013, Doi: 10.1111/ans.12460.

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:
Endovascular treatment options, Peripheral Vascular Disease, Outcomes

 

 

 

10.12.13

 

 

 

 

Anemia is an independent predictor of postoperative mortality & cardiac events in the elderly undergoing elective vascular operations


This study assessed the impact of a low hematocrit (<39%) on 30-day outcomes in elderly (>65 years) patients undergoing elective open and endovascular procedures.  The authors used data on more than 30 000 patients, with early death and cardiac morbidity as the main outcomes. In anaemic patients the postoperative mortality and cardiac events were seen in 2.4% and 2.3% of patients, respectively, in comparison to 1.2% and 1.2% in the normal haematocrit population (P<0.0001). 4.2% (95% C.I.: 1.9–6.5) increase in adjusted risk of 30-day death was seen for every percentage point hematocrit drop from normal.

Ann Surg, Dec 13; doi: 10.1097/SLA.0b013e318288e957


Selected by: Mr H Barakat, Vascular Research Fellow, Hull York Medical School

 

 

 

 

 

Treatment of hypertension in peripheral arterial disease

 

This is an updated Cochrane review to determine the effects of anti-hypertensive drugs in patients with both symptomatic PAD & high blood pressure, with focus on the rate of cardiovascular events, death, symptoms of chronic lower limb ischaemia and disease progress measured by ankle brachial index changes + need for revascularisation or amputation.For consideration, RCTs had to include at least 1 anti-hypertensive against placebo or 2 anti- medications against each other, with interventions lasting at least 1 month in patients with symptomatic disease. 8 RCTs satisfied these criteria with a total of 3610 patients. These studies were variable in terms of interventions and outcomes assessed. Studies on ACEis, diuretics, calcium channel and beta blockers were examined. The authors were limited by the lack of evidence on the use of antihypertensives in PAD and did not reach conclusions on their benefits or harms. Appropriate blood pressure control remains a well-documented favourable factor in the best medical treatment of these patients and there is definitely need for further research.

The Cochrane Library; DOI: 10.1002/14651858.CD003075.pub3

 

Selected by: Mr H Barakat, Vascular Research Fellow, Hull York Medical School

 

 

 

 

 

Classification of forefoot plantar pressure distribution in persons with diabetes: a novel perspective for the mechanical management of diabetic foot?


This interesting study aimed at identifying groups of people with similar patterns of forefoot loading and whether specific groups of diabetics can be isolated from non-diabetics.

Barefoot plantar pressure measurement and mapping was done using novel techniques in 97 diabetics and 33 controls. The analysis, which is explained in detail in the accessible article, identified specific physical patterns of plantar pressure in diabetics that can potentially be used to dictate a preventive strategy against diabetic foot disease, reinforcing the developing trends in classifying diabetic feet according to biomechanical bases.

PLoS one;DOI: 10.1371/journal.pone.0079924

 

Selected by: Mr H Barakat, Vascular Research Fellow, Hull York Medical School

 

 

 

 

06.12.13

 

 

Annual General Meeting of the Vascular Society of Great Britain and Ireland, Highlights

 

Summarized by
Mr MA Bailey, BHF Clinical Research Training Fellow, Leeds
Mr H Barakat, Vascular Research Fellow, Hull

 

 

 

 

 

Management of cardiovascular risk in patients with AAA is poor in England.
Sol Cohen, Founder’s Prize Session

 

Karthikesalingam and colleagues from St Georges, London investigated the primary and secondary cardiovascular risk prevention treatments prescribed to patients with AAA in England. Some 20,424 patients over 50 years of age with a diagnosis of AAA were identified from General Practice records (within the Health Improvement Network Database). Of these only 53.4% were receiving anti-platelet and cholesterol lowering therapy. Five year survival was reduced in patients with AAA who were not receiving anti platelet medication, cholesterol lowering therapy or anti-hypertensive therapy. The management of cardiovascular risk in patients with AAA in England is poor and requires urgent attention to improve long term cardiovascular outcomes.

 

 

 

 

 

The new Vascular Society Aneurysm Risk Model for AAA Repair.
Sol Cohen, Founder’s Prize Session

 

Ambler and colleagues from Addenbrooke’s, Cambridge presented a new, streamlined risk prediction model for patients undergoing either open or endovascular AAA repair based on the National Vascular Database records. The model, including pre-operative: age, creatinine, systolic blood pressure, white cell count, history of cardiac disease, type of repair, mode of admission and ASA grade demonstrated higher sensitivity and specificity than any previously reported risk model. The model requires further validation but appears to be a simple and effective tool for AAA risk prediction.

 

 

 

 

Regulation of plasmin activity rather than generation may contribute to AAA
BJS Prize Session

 

Bridge et al investigated four polymorphisms of key regulators of the clotting cascade to further understand their previous work demonstrating denser clots with smaller pores which were more resistant to lysis in patients with AAA. 602 AAA patients and 490 controls were genotyped for 4 SNPs (alpha-2 antiplasmin a2AP Arg6Trp and Arg407Lys, Thrombin activatable fibrinolysis inhibitor TAFI Thr325Ile and tissue plasminogen activator tPA 7351CT). The two a2AP SNPs appeared to be in disequilibrium with the mutant lysine allele negatively associated with AAA. This suggests that the clotting disturbances seen in patients with AAA may be attributable to changes in plasmin activity rather than plasmin generation.

 

 

 

 

 

SOL COHEN Prize winning abstract summary:

 

A significant proportion of peripheral vascular events are AF related and are preventable by safe anticoagulation

Howard et al presented this study at the meeting. In a population-based study that included data on more than 92000 patients, the authors compared a variety of risk factors and outcomes. Age-specific incidence, pre-morbid anticoagulation, thromboembolism risk scores, and outcome of incident AF-related thromboembolic events in all vascular territories were all predetermined.

For 3096 acute cerebral or peripheral arterial events, of which 748 (24.2%) were AF-related, including 42.7% incident peripheral arterial events and 32.7% incident ischaemic strokes. Age- specific incidence rates increased steeply with age, with 338/456 (74.1%) events occurring at >75 years and 171/456 (37.5%) at >85 years. 89% of patients with AF- related peripheral arterial events had known prior AF and 78.5% of these had CHADS2 scores of >2 (98.5% >2 CHA2DS2VASc), yet only 16.9% were anticoagulated prior to event, despite only 23.3% having documented relative/absolute contraindications.

In patients not receiving anticoagulation who had CHA2DS2VASc scores >2, 67.9% (36/53) had HAS-BLED scores of <2 (low bleeding risk). Overall outcomes were worse for AF-related peripheral arterial events compared to non-AF-related events: immediately threatened limb/visceral organ 66.7% vs 38.8% p=0.007; 1-year survival 30.1% vs 50.0%,p=0.02.

Therefore, the authors showed that a large percentage of peripheral vascular events, are preventable, AF-related events in non-anticoagulated patients. The majority of whom had no contraindications to anticoagulation.

 

 

 


BJS Prize winning abstract summary:

 

Regulation of certain miRNAs and their target #genes represents a potential therapeutic pathway to decrease AAA progression 

 

Stather and colleagues from the university of Leicester presented their work at the Vascular Society last week. The aim was to identify circulating microRNAs associated with AAA and explore their functional effects.

754 microRNAs in whole blood samples from 15 AAA and 10 controls were quantified using qRT-PCR. Significant microRNAs were validated in 200 patients (40 each screened controls, peripheral arterial disease (PAD), small AAAs (30-54mm), large AAAs (>55mm), post-operative) peripheral blood and plasma samples using digital PCR. 29 differentially expressed microRNAs were identified. let-7e (P=0.001), miR-15a (P<0.001), and miR-196b (P<0.001) were downregulated in peripheral blood from AAA patients, and miR-411 (P=0.001) was upregulated. Mir-196b was also downregulated in plasma from the same individuals ( P=0.029). Neither exclusion of the aneurysm nor aneurysm size altered miRNA profiles. The same miRNAs were also similarly differentially expressed in patients with PAD. Target prediction analysis using MirWalk revealed that the AAA associated miRNAs were all regulators of AAA related genes; let-7e (COL1A1, COL1A2, COL3A1, MTHFR, MMP1); miR-15a (DAB2IP, MMP3, MTHFR); miR-196b (COL1A1, COL1A2, COL3A1); miR-411 (MMP12, MMP13, MTHFR).

With that, the group conclude: The levels of let-7e, miR-15a, miR-196b and miR-411 are differentially expressed in patients with AAA compared to healthy controls, with miR-196b replicated in plasma. Regulation of these miRNAs and their target genes represents a new therapeutic pathway to decrease AAA progression.

 

 

 

22.11.13

 

 

 

 

 

Percutaneous thrombectomy + thrombolysis is better than thrombolysis alone for fem-pop occlusions

 

Percutaneous mechanical thrombectomy (PMT) is one of the options to treat acute arterial occlusions, in addition to thrombolysis and surgical thrombectomy. This study compared the combined treatment of PMT and local thrombolysis with thrombolysis therapy alone. The total urokinase dosage, the total hours of thrombolysis, time in the intensive care unit, and total hospital stay in the acute PMT plus thrombolysis group were significantly lesser than those in the thrombolysis group. PMT combined with thrombolysis is an efficient therapy for acute and subacute femoropopliteal bypass occlusions.

Eur J Radiol, Dec 2013; doi: 10.1016/j.ejrad.2013.08.016

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

 

UK Vascular Curriculum Topics:

            Open and endovascular treatment options

            Thrombosis

            Selection of Patients

            Outcomes

            Principles of Clinical research

            Evidence based vascular practice

 

 

 

 

 

 


Novel vascular plug prior to EVAR may prevent type II endoleaks

 

The authors evaluated the feasibility of visceral artery and lumbar artery (LA) embolization using AMPLATZER vascular plug (AVP) types 4 and 2 (AVP4, AVP2) prior to endovascular aneurysm repair (EVAR) to prevent the development of a type II endoleak. The success rate was 100%, with total occlusion of all target vessels. No endoleaks were found in follow-up CT angiography. The use of AVP prior to EVAR is an effective embolization technique that prevents the development of type II endoleaks.

Eur J Vasc Endovasc Surg, Nov 2013; doi: 10.1016/j.ejvs.2013.10.003

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

UK Vascular Curriculum Topics:

            Open and endovascular treatment options

            Aneurysm

            Outcomes

 

 

 

 


           

Combined EVLT + pinhole ligation is effective in symptomatic great saphenous varicose veins

 

The aim of this study was to determine the effectiveness and outcomes of endovenous laser therapy (EVLT) combined with pinhole high ligation (PHL) in the treatment of great saphenous varicose veins. Combined EVLT and PHL are less invasive and are effective in the treatment of symptomatic great saphenous varicose veins. PHL prevents DVT, and significantly decreases recanalization of the great saphenous vein after endovenous laser ablation. Short–term outcomes have been satisfactory, but long–term follow–up is needed.

Ann Vasc Surg, Nov 2013;doi: 10.1016/j.avsg.2013.04.015

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 

 

UK Vascular Curriculum Topics:

            Open and endovascular treatment options

            Varicose veins

            Deep vein thrombosis

 

 

 

 

 

14.11.2013

 

 

 


Comparison of open and endovascular treatment of acute mesenteric ischemia

This study used a large database (National InPatient Sample database, US) to compare open and endovascular interventions of acute mesenteric ischaemia, with the primary endpoint being the rate of bowel resections following either intervention.

23 744 patients presented with AMI (2005-2009), 679 underwent a specific vascular intervention (514 Surgical, 165 endovascular). Both treatment groups were similar in terms of co-morbidities, however, the mortality rates were higher in the surgical group (39.3% vs 24.9%; P=0.01). The length of hospital stay was also longer in the surgical group (12.9 vs 17.1 days; P=0.006). The authors note the gradual increase in endovascular interventions offered during the study period. 14.4% of patients undergoing endovascular procedures required bowel resection vs. 33.4% for open revascularization (P < 0.001). Patients undergoing endovascular repair were less likely to require TPN support (13.7% vs 24.4%; P = 0.025).

Journal of Vascular Surgery, In Press
doi:10.1016/j.jvs.2013.06.084

 

 

Selected by Mr H Barakat, Surgical Research Fellow, HYMS

 

UK Vascular Curriculum topics:   Mesenteric Vascular Disease, Acute abdomen, Endovascular procedures, Evidence based practice

 

 

 

 


 

Early Endovascular Treatment of Superior Mesenteric Occlusion Secondary to Thromboemboli

In this study, the authors aim to review their experience of endovascular management of acute thrombo-embolic occlusion of the SMA. This was a retrospective series (May 2005-May2012) including 21 patients.

All patients presented with abdominal pain and 3 had rebound tenderness. 7 patients had complete SMA occlusion, 14 had incomplete occlusion by CTA. The median duration of symptoms was 8.7 hrs. In 6 patients, complete revascularization was successful by endovascular intervention:aspiration alone in 3, and combined aspiration + urokinase in 3.

Partial success was achieved in 15 cases and laparotomy was required in 5 patients; all had SMA trunk complete occlusion and required bowel resection.The reported 30-day mortality was 9.5%. During follow-up (median 26 mo), 15 patients remained asymptomatic, 3 reported occasional abdominal pain, and one had short-bowel syndrome.

 

 

Selected by Mr H Barakat, Surgical Research Fellow, HYMS

 

UK Vascular Curriculum topics:   Mesenteric Vascular Disease, Acute abdomen, Endovascular procedures, Evidence based practice

 

 


 

Intestinal Ischemia: US-CT findings correlations

In this article, the authors provide a very useful and thorough demonstration of key ultrasound and CT features of the variety of syndromes contributing to “Intestinal Ischaemia”. Contrast-enhanced CT remains the most accurate tool for diagnosis, but ultrasound can also be a useful alternative.

Crit Ultrasound J. 2013 Jul 15;5 Suppl 1:S7. doi: 10.1186/2036-7902-5-S1-S

 

 

Selected by Mr H Barakat, Surgical Research Fellow, HYMS

 

UK Vascular Curriculum topics:   Mesenteric Vascular Disease, Vascular Imaging, Acute abdomen, Endovascular procedures, Evidence based practice

 

 

 

 

05.11.13

 

 

 

 

Statin therapy is associated with improved survival after both EVAR and open aneurysm repair

 

It is well established that statins improve outcomes for patients with cardiovascular diseases and that patients on statins exhibit improved peri-operative survival compared to those not prescribed statins. This group used data from the DREAM trial to retrospectively investigate any differences in long term survival after aortic intervention (EVAR and OAR). The study included 351 patients of whom 135 were prescribed statins at recruitment. Patients were followed up for six years and data analysed using a Kaplan-Meier survival curve with multivariate Cox regression analysis. Statin therapy at recruitment was found to be independently associated with improved overall survival and fewer cardiovascular deaths after both EVAR and OAR. Reduced survival was associated with a clinical history of cardiovascular disease and moderate tobacco use. The authors conclude that statin therapy is associated with improved long term survival after aortic intervention.

Journal of Vascular Surgery, 2013:In press

 

 

Selected by Mr MA Bailey, BHF Fellow in Vascular Surgery, University of Leeds              

 

 

Syllabus Topics –  Risk Factor Modification, Pathology of aortic aneurysms, Treatment options   

 

 

 

 

 

 

 

Compression stockings for >2 days after endovenous ablation of the GSV leads to improved physical function

 

A prospective, randomised control trial of 109 patients undergoing EVLT of the GSV for varicose veins between December 2006 and February 2008. Patients were randomised to receive compression stockings for either 2 days (Group A) or 7 days (Group B) post-operatively.  Forty patients were lost to follow up leaving 69 for analysis. Primary outcome measures were quality of life (as measured by the SF36 questionnaire) and pain at each follow up visit (48hours, 1 week, 6 weeks, 3 months). Any associated morbidity was also recorded, and a follow up USS was performed at 3 months to assess GSV occlusion. At 1 week follow up, there was a significant difference in pain, physical dysfunction and vitality, all in favour of group B, which disappeared by week 6. There were no differences in morbidity between groups, and 3 month USS revealed GSV occlusion in all patients.  The authors conclude that prescribing compression stockings for longer than 2 days after endovenous GSV leads to reduced pain and improved physical function during the first week after treatment, but no difference in long term outcome.

Eur J Vasc Endovasc Surg. 2013 Nov;46(5):588-92. doi: 10.1016/j.ejvs.2013.08.001. Epub 2013 Sep 5.

 

 

Selected by Miss K I Bridge, BHF Fellow in Vascular Surgery, University of Leeds

 


Syllabus topics –  Superficial Venous Disease

 

 

 

 

Patients treated surgically for Paget –Schroetter syndrome had better functional outcomes

 

Paget –Schroetter syndrome (or effort related thrombosis of the axillosubclavian vein) is uncommon  (1-2 per 100,000 per year) and  tends to affect young, active individuals. Consensus on management is lacking, with conservative management often leading to residual symptoms. Thrombolysis can restore patency, but without surgical intervention re-thrombosis is likely. Thoracic outlet decompression surgery, aiming to prevent re-thrombosis, can be done early or late post-thrombolysis. The aim of this paper was to analyse late outcomes in a series of patients treated for PSS in order to identify an optimal management strategy. This was a retrospective review of a prospectively maintained database of all patients with PSS between 1995-2011 was undertaken, and included 117 patients. They found that patients treated surgically for PSS had better functional outcomes than those managed conservatively. Prompt thrombolysis and surgery was superior to delayed management with respect to rethrombosis and functional outcome.

Br J Surg. 2013 Oct;100(11):1459-64. doi: 10.1002/bjs.9279

 

 

Selected by Miss K I Bridge, BHF Fellow in Vascular Surgery, University of Leeds


 

Syllabus topics – Vascular disease of the Upper Limb, Thoracic Outlet Syndrome, Ability to recognise and manage Thoracic Outlet Syndrome

 

 

 

 

 

 

 

31.10.2013

 

 

 

Early outcomes from ACST-2 suggest a low risk of major events in asymptomatic/severe carotid stenosis suitable for either CEA or CAS

 


ACST 2 is a trial that is still recruiting. It compares carotid stenting (CAS) with endarterectomy (CEA) for patients with asymptomatic, severe carotid stenosis. Patients are being recruited if the need for revascularization is considered high. This update provides the interim 30 day mortality and morbidity, up to September 2012.

Among 986 patients: 687 males, 70-99% stenosis (median 80%), contralateral stenosis in 50-99% and occlusion in 8%. The overall incidence of postoperative (up to 30 days) serious cardiovascular event rates (incl. fatal MI, stroke and death) was 1% in 691 (30 day follow-up + 6 month Rankin scores).

 

European Journal of Vascular and Endovascular Surgery - Nov. 13
doi:10.1016/j.ejvs.2013.07.020

 

Selected by Mr H. Barakat, Vascular Research fellow, Hull York Medical School

 

UK vascular curriculum topics: Extracranial carotid artery disease, Endovascular treatment options, Outcomes, Principles of Clinical research, Evidence based vascular practice

 

 

 

 

 

 

 

Surgical management is the preferred treatment in endograft infections, but conservative management and IV antibiotics can be of benefit in selected cases

 

 

This retrospective series describes the management of infected endografts at a single centre. In 18 patients (6 thoracic and 12 abdominal), the median time to presentation was 90 days, with blood cultures showing polymicrobes in 7 patients, MRSA & group A streptococcus in 3 each and E.Coli in 1, out of the 18 patients. 10 patients were treated by surgical explantation. Mean follow-up was 24.7 months. Aneurysm-related mortality was 38.9% (2 additional deaths unrelated); higher in patients presenting with aortoenteric or aortobronchial fistulas (60%)(P = .04) and thoracic stent infections (83%)(P = .03). The only survivor of a thoracic infection was managed surgically. Survival for patients with abdominal endografts (n = 12) was similar between the eight patients managed surgically (n = 6/8; 75%) and the four selected for medical management (n = 4/4; 100%)
(P = .39). All survivors remain on long-term suppressive antibiotics. 

 

 

Journal of Vascular Surgery - Nov 13 

doi:10.1016/j.jvs.2013.04.040

  

Selected by Mr H. Barakat, Vascular Research fellow, Hull York Medical School

 

UK vascular curriculum topics: Abdominal aortic disease, Thoracic aortic disease, Endovascular treatment options, Outcomes, Principles of Clinical research, Evidence based vascular practice

 

 


 

 

 

Majority of CNIs following CEA are transient, affect the hypoglossal and facial nerves, and are associated with perioperative stroke and reoperation

 

 

This study used a large registry to assess for independent predictors of postoperative Cranial Nerve Injury (CNI) in patients undergoing CEA.

In 6,878 patients (33.8% symptomatic), CNI rate was 5.6% (n = 382). 60 patients (0.7%) had more than one nerve affected. The nerves affected were:

1. hypoglossal (n = 185, 2.7%), 2. facial (n = 128, 1.9%), 3. vagus (n = 49, 0.7%), 4. glossopharyngeal (n = 33, 0.5%). Only 47 patients (0.7%) had a persistent CNI. Median follow-up was 10 months. Perioperative stroke (0.9%, n = 64) was associated with higher risk of CNI (n = 15, CNI risk 23.4%, p < .01). Predictors for CNI were urgent procedures (OR 1.6, 95% CI 1.2–2.1, p < .01), immediate re-exploration after closure under the same anesthetic (OR 2.0, 95% CI 1.3–3.0, p < .01), and return to the operating room for a neurologic event or bleeding (OR 2.3, 95% CI 1.4–3.8, p < .01), but not redo CEA (OR 1.0, 95% CI 0.5–1.9, p = .90) or prior cervical radiation (OR 0.9, 95% CI 0.3–2.5, p = .80).


 

European Journal of Vascular and Endovascular Surgery - Nov. 13

doi:10.1016/j.ejvs.2013.09.022

 

Selected by Mr H. Barakat, Vascular Research fellow, Hull York Medical School

 

UK vascular curriculum topics: Extracranial carotid artery disease, Endovascular treatment options, Outcomes, Principles of Clinical research, Evidence based vascular practice

 

 

24.10.13

 

 


Surgeons have better outcomes following EVAR for AAA compared to radiologists/cardiologists

This retrospective analysis compared the outcomes following endovascular repairs (EVAR) of aortic aneurysms performed by interventionalists (cardiologists / radiologists) vs. surgeons in 28,094 procedures. Unadjusted mortality rates, length of stay, and total hospital charges were significantly higher for patients treated by interventionalists than those by surgeons (all Ps < 0.001). This difference persisted on multivariate analysis, where interventionalists were associated with increased likelihood of mortality, longer length of stay, and higher total hospital charges.

Ann Surg. 2013 Sep;258(3):476-82. doi: 10.1097/SLA.0b013e3182a196b5.

 

 

 

 


 

Elective outpatient EVAR can be performed safely with minimal morbidity in selected patients

This retrospective study assesses the safety, feasibility, costs, and patient satisfaction of outpatient endovascular aneurysm repair (EVAR) for AAA. From 104 patients selected, 4 (3.8%) preferred primary hospitalization and were excluded from further analysis. Four patients (4%) with access vessel complications required additional procedures and had to be hospitalized overnight. The 30-day readmission rate was 4% (4), all due to access vessel stenosis (2) or false aneurysm (2). There was no 30-day mortality. From the 96 outpatients who completed Outpt EVAR, 93 (97%) would undergo Outpt EVAR again and would recommend it to others. Cost comparison showed in 42 matched contemporary patients treated with just a standard stent graft that costs were significantly lower in 21 Outpt EVAR patients than in 21 inpatient EVAR.

Ann Surg. 2013 Nov;258(5):754-9. doi: 10.1097/SLA.0b013e3182a617f1

 

 

 

 

 


Consumption of fruit, but not vegetables, reduces the risk of AAA and ruptured AAA

The aim of this study was to investigate the associations of fruit and vegetable consumption with the risk to develop AAA in a prospective Cohort of Swedish Men and the Swedish Mammography Cohort, consisting of 44,317 men and 36,109 women. Fruit and vegetable consumption was assessed at baseline with a 96-item food-frequency questionnaire. By linkage to the Swedish Inpatient Register and the Swedish Vascular Registry (Swedvasc), 1086 primary cases of AAA (222 ruptured) were identified. Consumption of 2 fruits per day was associated with 31% lower risk of nonruptured AAA, and 39% lower risk of ruptured AAA, in comparison with no consumption of fruit. No association was observed between vegetable consumption and AAA risk.

Circulation. 2013 Aug 20;128(8):795-802. doi: 10.1161/CIRCULATIONAHA.112.000728.

 

 

 

 


16.10.13

 

 


Use of stent placement should be reserved for cases of angioplasty failure in renal artery stenosis caused by Takayasu arteritis

The authors retrospectively compared the long-term patency and antihypertensive effect of angioplasty versus stent insertion in renal artery stenosis caused by Takayasu arteritis in 16 patients. Restenosis was 8% (1/12 renal arteries) in angioplasty and 66% (6/9 renal arteries) in the stent group. Patency rates of angioplasty were 100%, 91.7%, 91.7% and primary unassisted patency rates of stent placement were 55.6%, 33.3%, 33.3% at 1-, 3- and 5-years, respectively. There was no difference in the clinical benefit between the two groups.
Angioplasty demonstrated better long-term patency with similar clinical benefits on renovascular hypertension in renal artery stenosis of Takayasu arteritis. Authors suggest reserving the use of stent placement in cases of angioplasty failure.
Eur J Radiol. 2013 Nov;doi: 10.1016/j.ejrad.2013.06.019

UK Vascular Curriculum Topics: ​Renovascular disease, ​Endovascular treatment option, ​Selection of Patients, Outcomes, Principles of Clinical research, ​Evidence based vascular practice

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK






No evidence of procedural risk following carotid endarterectomy in the hyperacute period after onset of symptoms

This retrospective study determined the 30-day risk of stroke/death after Carotid endarterectomy (CEA) in symptomatic patients, stratified for delay from the most recent neurological event, mode of presentation, and age. There was no evidence of any systematic differences in procedural risk by operating in the hyperacute period relating to mode of presentation (TIA, stroke, amaurosis) or age (<80 years; >80 years). This audit found no evidence that the procedural risk was increased when CEA was performed in the hyperacute period whether this time period was defined as <48 hours, <7 days, or <14 days.
​EJVES, 2013 Oct;doi.org/10.1016/j.ejvs.2013.08.014

UK Vascular Curriculum Topics: ​Carotid artery disease, ​Open vascular surgery, ​Selection of Patients, ​Outcomes

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK

 




Duplex-guided Percutaneous Transluminal Angioplasty in Iliac Arterial Occlusive Disease
 
In this study authors evaluated the safety and efficacy of Duplex-guided percutaneous transluminal angioplasty (DuPTA) in iliac arteries. Procedural success was achieved in 94% of patients (33/35) with clinical benefits. Post-procedural peak systolic volume (PSV) reduction showed an average improvement of 63%. Mean preoperative ABI was 0.72 and improved to 0.88 postoperatively. Percutaneous Transluminal Angioplasty using Duplex-guidance is a safe technique in patients at risk of developing contrast-induced nephropathy with significant iliac stenosis.
EJVES, Oct 2013;doi: 10.1016/j.ejvs.2013.08.011

UK Vascular Curriculum Topics: Duplex scan, Open vascular and Endovascular surgery, ​Outcomes

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK  


 

 

1 in 5 have arterial complications following in Extracorporeal Membrane Oxygenation via femoral cannulation
Authors evaluated the incidence of peripheral vascular complications in 101 patients undergoing Extracorporeal Membrane Oxygenation (ECMO). 18 (17.8%) patients developed peripheral vascular complications. Two (11%) were managed non-operatively and 16 (89%) needed surgical intervention, 8 (44.44%) of which required femoral endarterectomy with patch angioplasty. One had below-knee amputation but none required distal bypass. Mortality among patients with vascular complications was 28% (P = 0.30). In contrast to the usual speculation of the high incidence of vascular complication related with ECMO, authors found less than 20% of ECMO with vascular complications with majority requiring major femoral reconstruction. However, development of vascular complication does not appear to increase the risk of amputation or mortality.
Ann Vasc Surg 2013 Sep;doi: 10.1016/j.avsg.2013.03.011

UK Vascular Curriculum Topics: ​Vascular trauma, ​Acute ischemia, ​Outcomes

 

Selected by: Juni Sultan, SpR Vascular Surgery, Yorkshire and Humber Deanery, UK  

 

 

08.10.2013

 

 

 

Endothoracic sympathetic block at the T4 ganglion is safe and effective in patients with upper limb hyperhydrosis 

The authors report 174 patients undergoing endothoracic sympathetic block at T4 (ESB4), 31% palmar hyperhydrosis, 69% palmo-axillary hyperhydrosis, in a tertiary hospital, prospectively followed-up to a median of 92 months with a quality of life questionnaire. ESB4 significantly improved symptoms and quality of life in both groups. Compensatory sweating occurred in 24% of patients and was considered severe in 6.7%. Severe compensatory sweating was twice as common in the palmo-axiliary group than in the palmar group.

 

Br J Surg. 2013 Oct;100(11):1471-7. doi: 10.1002/bjs.9275.

 

Vascular Curriculum Topics: Hyperhydrosis, Evidence Based Vascular Practice

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

 

 

In a fast-track expediated CEA service, the most important cause of delays is a failure to provide specialist staff for weekend operating

Here, the authors sought to identify reasons for delays in patients receiving urgent CEA following admission from the TIA clinic at the Leicester Royal Infirmary, following introduction of a reconfigured “fast track” admission system. Eighty nine patients were included in the audit, 11% suffered recurrent symptoms between admission and surgery. Two recurrent strokes were so severe that surgery was cancelled. 85% underwent CEA within 14 days of index symptom; 45% within 7 days. 51% were worked-up for CEA within 24hours of admission and 83% were ready within 72 hours. The most common reason for delay in CEA was a logisitical failure to plan for weekend CEA operating.  

 

Eur J Vasc Endovasc Surg. 2013 Oct;46(4):404-10. doi: 10.1016/j.ejvs.2013.07.015. Epub 2013 Aug 21.

 

Vascular Curriculum Topics: Carotid Artery Disease, Evidence Based Vascular Practice, Clinical Audit

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

 

Lengthening surveillance intervals for abdominal aortic aneurysm appears safe and more cost effective than those currently employed

The authors undertook a comprehensive systematic literature review and obtained patient level data on 15,475 patients for analysis. Mean growth rate was 2.3mm/year. For each 0.5cm increase in aneurysm size, growth rates increased by 0.5mm/year and rupture rate doubled. On average a patient with a 3cm AAA will take 7 years to reach the intervention threshold with a 10% rupture risk threshold. Growth was increased in smokers and decreased in diabetics. Rupture risk was 4 fold higher in women compared to men and increased in current smokers and hypertensives. The following surveillance intervals are suggested by the authors based on growth and cost effectiveness analysis:

3.0-4.0cm AAA                   Several Years

4.0-4.9cm AAA                   1 Year

5.0-5.4cm AAA                   6 Months

 

Health Technol Assess. 2013 Sep;17(41):1-118. doi: 10.3310/hta17410.

 

Vascular Curriculum Topics: Aneurysm – Elective, Evidence Based Vascular Practice, Clinical Audit

 

Selected by: Marc Bailey, BHF Fellow in Vascular Surgery, University of Leeds

 

 

 

 


 

 

 

03.10.13

 

 

 

Lack of association between inguinal hernia and abdominal aortic aneurysm

Higher prevalence of inguinal hernia is reported in patients with abdominal aortic aneurysms (AAA). Authors explored this relationship in a large sample cohort study of men screened for AAA. Inguinal hernia was not found to be associated with AAA in contrast to the previous inadequate sample sized studies.

BJS, 2013; DOI: 10.1002/bjs.9257

 

UK Vascular Curriculum Topics: Aortic aneurysm, Screening, Outcomes

 

 


           

 

Aortic arch de-branching and thoracic endovascular repair

Authors aimed to evaluate the early and midterm results of arch de-branching and endovascular procedures in this study. 104 consecutive patients undergoing arch endovascular intervention were assessed for outcomes. At 5 years the survival rate was 70.9% with no endoleak in 88.3%. Endovascular arch repair presents a low rate of aorta–related deaths and re-interventions with acceptable midterm survival.

J Vasc Surg, 2013;doi: 10.1016/j.jvs.2013.07.010.

 

UK Vascular Curriculum Topics: Aortic aneurysm, Open and endovascular treatment options, Outcomes, Evidence based vascular practice

 

 

 

 

The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality

Outcomes of the patients after carotid endarterectomy (CEA) was evaluated who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED). Outcomes of 30 day mortality, MI, stroke, cardiac heart failure (CHF), length of hospital stay and 1 year stroke or death were compared between the patients who required post-operative IVMED to treat hyper or hypotension with those who did not. The use of IVMED was found to be associated with higher 30-day mortality, MI, stroke, CHF, longer hospital stay and 1-year death in patients who required treating hyper- or hypotension.

J Vasc Surg, 2013;doi: 10.1016/j.jvs.2013.07.025.

 

UK Vascular Curriculum Topics: Carotid disease, Open and endovascular treatment options, Selection of Patients, Risk factors, Outcome

 

 

 

 

24.09.13

 


Mortality from ruptured AAA is high as some will not have interventions even if they make it to hospital

In this review, population based studies reporting pre-hospital and in-hospital mortality from rAAA were collectively analysed to estimate the total mortality resulting from this surgical emergency. A total of 24 studies were included.

81% (95% CI 78 - 83). Over time, a drop in mortality was noted (P = 0•002); the pooled estimate of mortality <1990 was 86%, compared with 74% since 1990. An estimated 32% of patients died before reaching hospital. The in-hospital non-intervention rate was 40%. Mortality from rAAA remains very high, especially before reaching hospital. A significant number of patients will not have interventions even if they make it to hospital.

BJS, 2013;100(11):1405–1413

 

 

UK Vascular Curriculum Topics: Aortic Aneurysm Disease; Outcomes; Principles of Clinical research; Evidence based vascular practice

 

 


Use of statins may be associated with lower major amputation rates in diabetics

This studies examines the association between statins and other lipid-lowering medications, and the risk of non-traumatic limb amputations in diabetic patients. Over a follow up period of 5 years, many pertinent factors were analysed as variables including patient demographics, medications and established risk factors for amputations. The cohort was a total 83 952 patients. 0.3% of patients (n=217) experienced major lower limb amputation. 14% (n=11,716) of patients experienced an amputation or death (treatment failure). Statin users were found to be 35%-43% less likely to experience a major amputation. Users of other cholesterol-lowering medications were not significantly different in amputation risk, but also had a 41% lower risk of treatment failure.

Journal of Vascular Surgery, 2013;doi:10.1016/j.jvs.2013.06.069

 

 

UK Vascular Curriculum Topics: Vascular Complications of Diabetes; Chronic lower limb ischaemia; Principles of Clinical research; Evidence based vascular practice

 

 


Renal function following AAA interventions deteriorates

In this study, 5-year follow up data from the DREAM trial were used to study the impact of Open repair (OAR) and EVAR on renal function, an important outcome postoperatively. Creatinine levels were available for: 94 patients after OAR and 95 after EVAR. eGFR (CKD-EPI equation) declined over time: mean preoperative value of 80•0 ml/min/1•73 m2 compared with 75•7 ml/min/1•73 m2 after 5 years (mean difference 4•2 (95%CI 3•2-5•3); P < 0•001). 5 years following surgery, the mean eGFR was not significantly different between the OR and EVAR groups (P=0.410).

BJS, 2013;100(11):1465–1470

 

 

UK Vascular Curriculum Topics: Aortic Aneurysm Disease; Open repair infrarenal AAA; Endovascular repair infrarenal AAA; Outcomes; Principles of Clinical research; Evidence based vascular practice

 


 

09.09.13

 

 

AAA rupture after EVAR secondary to an isolated type II endoleak is <1%

This systematic review from the Leicester group in the UK aimed to analyse the risk of rupture and outcomes of interventions in patients with type II endoleak after EVAR. In total 32 studies were included with the majority (n=31) being retrospective in nature, however this incorporated 21 744 patients undergoing EVAR with 1515 type II endoleaks indentified. The authors conclude that ~10% of patients undergoing EVAR will develop type II leak and in the current review these resolved spontaneously in over 35% of patients. Ruptured aneurysm after type II endoleak is rare however this review raises concerns about the use of sac expansion as a surrogate marker of rupture risk as over 1/3 of rupture patients did not demonstrate concurrent sac expansion. In total 393 interventions were undertaken for endoleak, 72% of which were deemed successful. The criteria for intervention appears to be widely variable and the review commented only on translumbar and transarterial embolisation with no study of alternative intervention methods (e.g. direct sac puncture). Translumbar embolisation was associated with a higher success rate and fewer complications than a  transarterial approach however the authors stress the need for a long term prospective study in this area, both to help define the natural history of type II endoleaks and to determine the gold standard for intervention.

BJS Vol 100, issue 10, first published online 12/8/13

 

 

Vascular Curriculum Topics: EVAR/TEVAR and vein graft surveillance; Evidence‐based vascular practice; Ability to recognise/manage postop. complications: bleeding, thrombosis, embolism, organ failure, endoleak, infection; Endovascular repair infrarenal AAA; Correction of endoleak

 

 


Family history may provide insight into the behaviour of the untreated AAA

Family history is an established risk factor for the development of abdominal aortic aneurysm (AAA). Any affect on severity of disease is unknown. The authors obtained family history data from 426 patients with AAA (36% had a positive family history) and correlated aortic morphology with positive or negative family history using a logistic regression model. Patients with a positive family history were younger at the time of diagnosis, were more likely to have proximal disease – 50% of patients with a positive family history developed supra-renal involvement – and had a greater incidence of bilaterial iliac artery aneurysm. The authors suggest a positive family history may point to more anatomically complex disease in addition to its role as a risk factor for AAA.

J Vasc Surg. 2013 Sep;58(3):573-81.doi: 10.1016/j.jvs.2013.02.239.

 

 

Vascular Curriculum Topics: Epidemiology & Interactions of Vascular Risk Factors; Evidence Based Vascular Practice

 

 


High-volume surgeons have significantly better perioperative stroke/death rates for CEA

The volume-outcome relationship is well established for many procedures, including carotid endarterectomy (CEA) when stratified by unit volume. Here the authors report retrospectively on CEA outcomes based on individual surgeon volume and specialty over a two year period, encompassing 953 CEAs by 24 surgeons. Peri-operative stroke/death rate was significantly higher for non-vascular surgeons (3.2% vs. 0.72%) and for surgeons performing less than 30 cases per annum (1.3% vs. 4.1%). These data support unit level data that the best outcomes are found when highly specialised surgeons undertake large numbers of cases themselves.

J Vasc Surg. 2013 Sep;58(3):666-72.doi: 10.1016/j.jvs.2013.02.016.


 

Vascular Curriculum Topics: Principles of Audit & Quality Control; Evidence Based Vascular Practice; Planning & Budgeting Vascular Services

03.09.13 

 


Endovenous microwave ablation is effective for the treatment of varicose veins

In a randomized trial, the authors study the differences between endovenous microwave ablation (EMA) and high ligation-stripping (HLS) for thetreatment of varicose veins in 200 patients. The follow-up was up to 24 months. EMA was associated with shorter operative time, less bleeding, smaller incisions and less sensory alteration and ecchymosis in comparison to HLS. In the EMA group, skin burns were found on 11 limbs (10.2%). The recurrence rate was also relatively lower. Both groups had significant improvement in VCSS and disease-specific quality of life AVV.

EJVES, 2013; doi:10.1016/j.ejvs.2013.07.004

 

 

Vascular Curriculum Topics: Varicose vein surgery, Management options (conservative, sclerotherapy, endovenous thermal ablation, surgery), Outcomes, Principles of Clinical research, Evidence based vascular practice

 


EVAR planning with a 3D workstation reduces type I endoleaks and secondary interventions

In this study, the authors compare their centre’s experience of EVAR planning before they started using the 3D workstation and after that, aiming at evaluating its influence on mid- and long-term outcomes. The workstation is known to allow for multi-planar reconstruction and center-line analysis. In total, 295 patients were included divided in the 2 study groups. All completed the 2 year follow-up. A reduction in the incidence of Type I endoleak and the secondary interventions rate was obvious with using the workstation. No difference was seen in all-cause or aneurysm related mortality.

Journal of Vascular Surgery 2013;doi:10.1016/j.jvs.2013.07.012

 

 

UK Vascular Curriculum Topics: Aortic Aneurysm Disease, Open and endovascular treatment options,
Endovascular planning, Outcomes, Principles of Clinical research, Evidence based vascular practice

 


Co-morbidities rather than interventions in claudication seem to be predictors of inferior long-term outcomes

In patients with intermittent claudication, interventions were thought to adversely affect overall survival or ultimate limb salvage rates. In this retrospective study the authors investigate a variety of variables (including co-morbidities and patient demographics) and the relationship with inferior long-term outcomes. In 262 IC patients, a history of hypertension, hyperlipidaemia and diabetes were obvious predictors of inferior survival and not interventions. It is uncommon for IC to progress to CLI but re-intervention rates remain common in IC patients having either immediate or delayed interventions.

Journal of Vascular Surgery, 2013;doi:10.1016/j.jvs.2013.07.012

 

 

UK Vascular Curriculum Topics: Chronic limb ischaemia, Risk factor modification, Selection of Patients, Outcomes, Principles of Clinical research, Evidence based vascular practice

26.08.2013

 


Combined arch replacement with hybrid stent–graft enables one–stage treatment with acceptable mortality for thoracic aneurysms

Patients with thoracic aneurysmal disease involving the arch and the descending or thoraco-abdominal aorta may require more than one surgical intervention. Authors found that in 113 cases treated for combined arch replacement with antegrade stent grafting distally, the 30-day mortality was 12% with 78% survival at 5 years. No secondary intervention was needed in up to 90% of cases.  In multi-segmental thoracic aneurysmal disease, combined arch replacement with distal repair by a hybrid stent–graft enables one–stage treatment with acceptable mortality.

Eur J Cardiothoracic, 2013;Doi:10.1093/ejcts/ezt374

 

Vascular Curriculum Topics:
Aortic Aneurysm Disease; Open and endovascular treatment options; Selection of Patients; Outcomes; Principles of Clinical research; Evidence based vascular practice

 

 

 

Aggressive treatment of postop troponin elevation is needed after vascular surgery to improve outcomes

Relationship between postoperative troponin elevation and long–term survival following vascular surgery is not known. The authors hypothesize that a postoperative troponin elevation is associated with significantly reduced long–term survival. In a cohort of 16,363, troponin elevation and MI were found to be independent predictors of reduced survival in 5 years. Postoperative troponin elevation and MI predict a 26% or a 55% relatively lower survival in the 5 years following a vascular surgical procedure, respectively, compared with patients who do not experience myocardial ischemia. This highlights the need for more aggressive optimization in patients with postoperative troponin elevation, either alone, or in combination with an MI in hopes of reducing adverse long–term outcomes.

J Vasc Surg, Aug 2013; Doi: 10.1016/j.jvs.2013.06.062

 

 

Vascular Curriculum Topics:
Peripheral vascular disease, Carotid artery disease, Aortic aneurysm disease, Open and endovascular treatment options, Selection of Patients, Outcomes, Principles of Clinical research, Evidence based vascular practice

 

 

 

05.08.13

 


No differences in outcomes between EVAR and open repair for ruptured AAA

This randomised controlled trial compared 30-day morality and severe complications in 116 patients, fit for either OAR or EVAR randomised to either intervention. The primary end point was a composite of 30-day death and severe complications and was 42% in EVAR group and 47% in OAR (ARR=5.4%). 30-day mortality was 21% in EVAR and 25% in OAR group.

Annals of Surgery, 2013;doi: 10.1097/SLA.0b013e31828d4b76

 

 

 

Data from CT can be used to assess the risk of complications after EVAR and guide surveillance

In this study, data for 761 patients who underwent EVAR we used to derive a scoring system for aortic complications postoperatively that can inform rationalized surveillance. Morphological features were the focus of the investigation and models were developed in the first instance to identify predictors of outcomes. This was later re-evaluated at a second study centre. Maximum aneurysm diameter (P< .001) and largest common iliac diameter (P=.004) accurately allocated most patients to a risk group with excellent discrimination between 5-y complication rates.

BJS, 2013;doi: 10.1002/bjs.9177

 

 

Ramipril appears to improve walking distances in claudicants

This is a double-blinded RCT that compared 33 patients with intermittent claudication started on Ramipril (n=14) or placebo (n=19) for 24 weeks in terms of walking distance, arterial stiffness (measured by carotid femoral pulse wave velocity) and quality of life. Those on Ramipril improved their walking distance (adjusted mean=131 m) (P=0.001), treadmill intermittent claudication distance by 122 m (P=0.001) and self-reported walking distance by 159 m (P=0.043). Ramipril reduced carotid femoral pulse wave velocity by –1·47 m/s compared with placebo (P=0·002). The differences in ABPis did not reflect the abovementioned improvements and there was no significant improvement in quality of life measures.

BJS, 2013; DOI: 10.1002/bjs.9198

 

 

 

29.07.13

 

Drug–coated balloons provides a cost–effective alternative to PTA with bare metal stents in PAD

The aim of this study was to perform an economic evaluation of the cost–effectiveness of endovascular enhancements to percutaneous trans-luminal balloon angioplasty (PTA) with bail–out bare metal stents for infra-inguinal peripheral arterial disease. The use of drug–coated balloons represents a cost–effective alternative to the use of PTA with bail–out bare metal stents.

Br J Surg, 2013;100(9):1180-8

 

 

 

Duplex USS correlates with intraoperative findings in diagnosing popliteal artery entrapment syndrome

The purpose of this study was to report the authors' experience with popliteal artery entrapment syndrome (PAES) with special emphasis on the applicability of duplex ultrasound scanning (DUS) when diagnosing PAES. In addition to examining the correlation between DUS and intraoperative findings in symptomatic limbs, the ultrasonic effect of plantar flexion in healthy volunteers were also evaluated. In this series of patients with surgically confirmed PAES, the authors found preoperative DUS to have perfect agreement with the intraoperative findings in diagnosing PAES. The applicability of the method seems to be emphasized by the restoration of popliteal flow and relief of arterial insufficiency after surgical release in all patients, and by the fact, that none of the healthy volunteers were able to compress the popliteal artery during plantar flexion.

Vascular and Endovascular Surgery, 2013; 2013, doi: 10.1177/1538574413495466

 

 

 

Hypertensive extracorporeal limb perfusion (HELP) may prevent major limb amputation due to ischemia

This article reports the early results in humans of hypertensive extracorporeal limb perfusion (HELP) technology in the prevention of major limb amputation due to ischemia. The short–term aim was to dilate pre–existing collateral channels, and the long–term aim was to stimulate remodeling and new collateral development by increasing endothelial shear stress and wall tension. The collateral circulation of ischemic limbs can be augmented and regulated by a connection to an extracorporeal centrifugal pump, with isolation from the systemic circulation provided by balloons and with an access system providing repeatable pump connections. Major amputation may be avoided in selected cases.

JVS, 2013; doi:10.1016/j.jvs.2013.05.004

 

 

 

09.07.13

 


First postop CT provides valuable information that can be used to choose patients who need CT surveillance following EVAR

This study investigates the predictive value of the first postop CT as means for selecting patients who need ‘adapted’ surveillance following EVAR. 131 patients were included, with first CT scans analysed for evidence of endoleak, kinking, distances relative to renal arteries and proximal/distal seal. The median follow-up was 4.1 years. 30 patients (23%) sustained aneurysm-related adverse events with seal length <10 mm & presence of endoleak as significant risk factors depending on which patients were classified in either high or low risk groups.  4 low-risk patients (3%) and 26 high-risk patients (19%) sustained events (P < .001), similar differences were also obvious in terms of sac growth and secondary interventions. 5-year freedom from aneurysm-related adverse events were 98% for the low-risk group and 52% for the high-risk group.

Journal of Vascular Surgery, June 2013;doi:10.1016/j.jvs.2012.11.085

 

 

  

Proximal migration is seen in1/4 cases using Zenith’s fenestrated graft system at 4 years

This prospective study identified 55 patients who underwent EVAR using Zenith fenestrated systems. The idea was to study the incidence, timing & sequelae of graft migration (defined as stent graft movement ≥4 mm) postoperatively, so, at least 1 postop (< 6wk) and 1 follow-up CT (> 5 months) were available to be assessed. 12 iliac limbs in 11 patients were excluded from assessment due to occlusion of one internal iliac artery or image quality issues.
Kaplan-Meier analysis for proximal migration revealed migration rates of 14% & 22% at 12 and 36 months, respectively. Distal migration rates were lower at 3% and 8%, respectively. There were no late ruptures or open conversions. Of the patients with proximal migration, two patients lost a single target vessel (2 Renal arteries) & 3 patients were reported to have target vessel stenosis (2 SMAs, one RA). These cases did not require re-intervention.

Journal of vascular surgery, June 2013;doi:10.1016/j.jvs.2012.12.035

 

 

 


27.05.13

 


Time to healing is influenced by the quality of the pedal arch in critical limb ischaemia

This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI). Patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. The pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264).

Journal of Vascular Surgery, 2013;57(5):1219-1226

 

 

 

Following TEVAR type 2 endoleaks are associated with a reintervention rate

This retrospective study evaluated the clinical significance of type II endoleaks (ELII) after thoracic endovascular aortic repair (TEVAR). ELII was diagnosed in 30 patients (8.7%; 13 males; median age: 65 years, range: 24 to 84 years) in a total of 344 patients who received TEVAR. Primary ELII was observed in all but two cases (28/30; 93.3%). The most common sources of ELII were the left subclavian artery (LSA; 13/30; 43.3%) and intercostal/bronchial vessels (13/30; 43.3%), followed by visceral arteries (4/30; 13.4%). Overall mortality was 33.3% (10/30). ELII-related death (secondary rupture) was observed in 20% (2/10). Reintervention (RI) procedures for ELII were performed in 9 of 30 patients (30.0%); 5 of 9 (55.6%) in cases with ELII via the LSA. Indications for RI were diameter expansion in five and extensive leakage in four cases. Treatment was successful in five patients (55.6%) but failed in four cases (44.4%). In 12 of 21 (57.1%) untreated patients, ELII sealed during follow-up. In conservatively treated patients, an increase in aortic diameter has been only observed in a patient with secondary ELII.

Journal of Vascular Surgery, May 2013;doi:10.1016/j.jvs.2013.03.026

 

 

 

 

Omental wrapping of artificial aortic grafts may reduce subsequent infection

Postoperative infection control is one of the most important issues for infected aortic aneurysms, and the methods of preventing recurrent infection remain controversial. Authors evaluated if omental flaps could prevent or reduce the occurrence of infection after implanting an artificial aortic graft. 521 patients were treated with thoracic aortic aneurysm (TAA), of these, 22 (3.9%) (male, n = 17; mean age, 68.2 ± 11.4 years) had infectious TAA. All infectious aneurysms were resected, all patients received in-situ grafts and 16 grafts were wrapped with omentum. Survivors were followed up annually using computed tomography. Five patients died in-hospital (operative mortality, 26.3%). The operative mortality rates of patients with and without omental wrapping were 12.5 and 50.0%, respectively (P = 0.06, NS), and the 5-year event-free survival rates were 84.6 and 33.3% (P = 0.025), respectively. Omental flaps around prosthetic grafts and their blood circulation were well-preserved over the long-term.

European Journal of Cardio-thoracic surgery, 2013;43 (6): 1177-1182.

 

 

 

 

Antegrade eversion endarterectomy of the external iliac shows promising results

Authors describe and present the results of eversion endarterectomy of the external iliac artery (EIA). Antegrade eversion endarterectomy (AEEA) of the EIA was mostly performed as a bail-out procedure, if (endovascular-assisted) remote endarterectomy from the groin had failed. Postoperative clinical and hemodynamic changes were reported according to the recommendations of the Society for Vascular Surgery. Thirty patients (mean age 65.5 years) underwent AEEA on 33 EIAs for atherosclerotic occlusive disease over a 10-year period. The primary technical success rate was 100%. The 30-day mortality was 0. There were no early occlusions. Two patients required redo surgery for retroperitoneal haematomas. Postoperative improvement was marked in 30%, moderate in 64% and minimal in 6%, explained by 21 (64%) concomitant occlusions of the superficial femoral arteries. The 1-, 3- and 5-year primary patency rates were 100%, 96% and 90%, and primary assisted patency rates were 100%, 96% and 96% respectively. Fourteen patients (47%) died during the long follow-up period from unrelated causes.

European Journal of Vascular and Endovascular Surgery, 2013;doi:10.1016/j.ejvs.2013.03.029

 

20.05.13

 


Stable preop BP is associated with better outcomes following EVAR for ruptured AAA

This retrospective study compared outcomes of ruptured AAAs (r-AAAs) who underwent EVAR categorized into two groups based on systolic blood pressure (SBP) measurements before EVAR: 92 (68%) Hd-stable (SBP ≥80 mm Hg) and 44 (32%) Hd-unstable (SBP <80 mm Hg for >10 minutes). Of the 136 r-AAA patients with EVAR, the Hd-stable and Hd-unstable groups had similar comorbidities, mean AAA maximum diameter, need for on-the-table conversion to open surgical repair and incidences of nonfatal complications and secondary interventions. Compared with Hd-stable patients, the Hd-unstable patients had a significantly higher intraoperative need for aortic occlusion balloon, mean estimated blood loss, incidence of developing abdominal compartment syndrome and death. Abdominal compartment syndrome was a significant predictor of death.

JVS,  2013; 57(5): 1255-1260.

 

 

 

 

Ethnicity is an independent risk factor for 30-day mortality after CEA

The objective of this study was to investigate the relationship between race and outcomes after CEA. CEA was performed on 29114 white patients and on 1316 black patients; the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks. The 30-day mortality rate was 0.7% for whites and 1.4% for blacks. There was a longer operating time and total length of stay, more postoperative pneumonias, unplanned intubations, ventilator dependence, cardiac arrests, bleeding requiring transfusions and reoperations within 30 days among black patients. Multivariate logistic regression analysis identified black race as an independent risk factor for 30-day mortality. Black patients also had a greater proportion of in-hospital deaths than white patients. There was no between-group difference in the rate of post-discharge strokes.

JVS, 2013; 57(5): 1325-1330.

 

 

 

 

No longterm survival benefit of EVAR compared with open repair of AAA

The long‐term benefit from EVAR vs. open surgical repair for AAA was analysed in this met-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30‐day or in‐hospital mortality rate. By 2‐year follow‐up there was no difference in all‐cause mortality, which was maintained after at least 4 years of follow‐up. There was no significant difference in aneurysm‐related mortality by 2 years or longer follow‐up. A significantly higher proportion of patients undergoing EVAR required reintervention and suffered aneurysm rupture.

BJS, 2013; DOI: 10.1002/bjs.9101.

 

 

 

06.05.13

 


Critical limb ischaemia model to predict morbidity and mortality following surgical interventions

The aim of this study was to develop a specific risk assessment tool to predict 30-day major morbidity and mortality (M&M) after bypass surgery for critical limb ischaemia (CLI) using data from 4985 individuals.  30-d mortality was 2.9%, major morbidity - 19.1%. The composite end point M&M occurred in 10.1%. Significant predictors of M&M included age >75 years, prior amputation or revascularization, tissue loss, dialysis dependence, severe cardiac disease, emergency operation, and functional dependence. These were assigned integer values (points) added to calculate a patient's Comprehensive Risk Assessment For Bypass (CRAB) score which was significantly associated with mortality and M&M (P<0.0001). This was more accurate than other commonly used models.
Journal of Vascular Surgery, 2013; doi:10.1016/j.jvs.2012.09.083

 



Higher incidence of persistent greater saphenous vein reflux with laser treatment

The initial results of a multicentre, 3-arm RCT that compares main outcomes following EVLA +/- high ligation (HL) against high ligation and stripping (ST) of the GSV in 449 patients are presented with 2 months follow up. Inguinal venous reflux IVR persisted in 8.5% in the laser group, in 2.2% in the EVLA/HL group and none in the HL/ST group. Postoperative ecchymosis was more common in the surgical group. Postoperative pain after one day occurred in 32.7% in the HL/ST group and ‘discomfort’  was higher in the EVLA/HL group. Early postoperative nervous saphenous syndrome developed in 0.6% in the HL/ST group, in 3.7% in the EVLA group and in 6.1% in the EVLA/HL group.

Phlebology, 2013;doi:10.1258/phleb.2011.011147 



 

 

Lap aortic surgery can be considered a minimally invasive alternative for AAA repair

This study aimed to investigate the value of aortic laparoscopy as a minimally invasive alternative to open surgery. Prospectively collected data for 99 patients with standard surgical risk with AAAs compatible with EVAR were retrospectively examined. The authors report frequencies on a variety of complications including: 5% conversion to open, 3 patients developing severe systemic complications (arrest, colonic ischaemia and febrile atelectasis) and 10 developing moderate complications (pneumonia, arrhythmias, U&E disturbances). Multivariate analysis showed that procedure time was predictive of severe systemic complications. Two patients required late surgery (2%): 1 for limb thrombosis after neuroendovascular procedure and 1 for iliac thrombosis. The only abdominal complication was a rupture at the level of a laparotomy conversion. 6 late deaths occurred (6%) and were not related to the AAA.
Annals of Vascular Surgery, 2013; doi:10.1016/j.avsg.2012.07.006

 

 

 

16.04.13

 

Aggressive volume resuscitation in ruptured AAAs increases perioperative risk of death

This retrospective study analysed prospectively collected and validated data of a consecutive patients with ruptured AAAs (n=248, of whom 237 underwent open repair). A median of 0.9 L of total volume per hour had been administered preoperatively to these patients. The postoperative 30-day mortality rate was 15.3%. The preoperative rate of fluid infusion correlated with 30-day mortality after adjustment for confounding factors, and the association persisted robustly through sensitivity analyses so that each additional liter per hour increased the odds of perioperative death by 1.57.

 JVS, 2013;57(4):943-50.

 


 

 

Large proportions of PAD patients don’t have ABI improvement of 0.15 following revascularization

In a cohort of patients with peripheral arterial disease, authors compared annual change in 6-minute walk performance between participants who neither underwent lower extremity revascularization nor walked for exercise (group 1), those who walked regularly for exercise (group 2), and those who underwent lower extremity revascularization (group 3) in 348 participants, 43 underwent revascularization. Adjusted annual declines in 6-minute walk were −96.6 feet/year for group 1, −49.9 feet/year for group 2, and −32.6 feet/year for group 3. Forty-one percent of revascularizations were not associated with ABI improvement. When group 3 was limited to participants with ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were −97.7 feet/year for group 1, −46.5 feet/year for group 2, and +68.1 feet/year for group 3. When group 3 was limited to participants without ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were −99.2 feet/year for group 1, −48.0 feet/year for group 2, and −61.7 feet/year for group 3.

JVS. 2013; 57(4): 990-996.

 


 

 

Early repair of smaller AAA with EVAR is associated with no difference in total medical costs vs surveillance

This was a cost effectiveness analysis of the Positive Impact of EndoVascular Options for Treating Aneurysms Early (PIVOTAL) trial which enrolled individuals with small AAA and reported no difference in rupture or aneurysm-related death for patients who received early endovascular repair (EVAR) vs surveillance with serial imaging studies. After 6 months, the rate of aneurysm repair was 96 vs 10 per 100 patients in the early EVAR and surveillance groups, respectively and total medical costs were greater in the early EVAR group. In months 7 through 48, however, the rate of aneurysm repair was 54 per 100 patients in the surveillance group, and total medical costs were higher for patients in the surveillance vs the early EVAR group. At 48 months' follow-up, early EVAR patients had greater cumulative use of AAA repair but there was no difference in total medical costs. After discounting at 3% per annum, total medical costs for early EVAR and surveillance patients remained similar. There were no treatment-related differences in quality of life at 24 months.

JVS, 2013: doi:10.1016/j.jvs.2013.01.038.




09.04.12

 

Ruptured AAA is most common cause of death in those declined from operative treatment
The authors retrospectively analysed the course of patients who had AAAs that meet common treatment criteria (i.e. >55mm diameter, &/or >5mm increase in size over 6 months) but not the operative criteria. 154 patients were declined from operative care of AAA due to cardiorespiratory co-morbidities (33%), cancer (8%), overall condition (33%) and patient's choice (21%).Regardless of the size of the aneurysm, the cause of death was aneurysm rupture in 43%, which was confirmed either in hospital or in autopsy for 76% of the patients. Of the ruptured aneurysms, 12 were operated of which five survived.

European Journal of Vascular & Endovascular Surgery, 2013;45(4):326-331

 


 

  
Branched and fenestrated endografts for complex AAAs appear durable

This study aimed at studying the durability of branched and fenestrated grafts used in aortic aneurysm repair by analysing any graft-related complication and secondary interventions. 650 prospective patients were included and secondary procedures were performed for 0.6% of celiac, 4% of superior mesenteric artery (SMA), 6% of right renal artery, and 5% of left renal artery stents. The 30-day, 1-year, and 5-year freedom from branch intervention was 98%, 94% and 84% respectively. Death from stent complications occurred in 3 patients.

Journal of Vascular Surgery, 2013;57(4);926-933

 



In infected AAA grafts lifelong antimicrobial therapy appears to produce greatest survival

The aim here was to study the treatment and progress of all infected AAA grafts occurring at a single centre. The authors studied records from 18 patients with a compatible clinical presentation, CT imaging and tissue/blood culture results. Staphylococcus aureus was isolated from blood or graft in 6 cases, beta haemolytic streptococci in 2 and enteric organisms in 9 cases. There was no isolate from 2 cases. 1 case had graft explantation and brief antimicrobial therapy. 17 had the graft retained. Of these, 14 received intravenous antimicrobials for 6 weeks and 14 lifelong oral therapy. None died during their initial admission or within 30 days. During the 57 month follow up 10 patients died: 4 had relapsed & had organisms isolated (all enteric).

European Journal of Vascular & Endovascular Surgery, 2013;45(4):373-380

 

 

18.03.13

 

 

Cool excimer laser–assisted angioplasty is superior to angioplasty in tibial artery occlusive disease

The authors aimed to compare cool excimer laser–assisted angioplasty (CELA) versus tibial balloon angioplasty (TBA) in patients with critical limb ischemia (CLI) with tibial artery occlusive disease. Tibial endovascular revascularizations (EVRs) provides exceptional outcome in CLI. A total of 80 patients underwent 89 endovascular revascularizations (EVRs) for tibial occlusions, 47 using TBA and 42 using CELA. The CELA has superior sustained clinical improvement, amputation free survival, and freedom from target extremity revascularization, with improved quality time without symptoms and cost–effectiveness.

Vasc and Endovas Surgery, 2013; doi: 10.1177/1538574413478473

 

 

 

Video motion analysis may be a valuable tool for the objective assessment of endovascular skills

This study assessed the feasibility and role of objective motion analysis of guide-wire/catheter manipulation when assessing proficiency during endovascular interventions. 21 interventionalists (6 cardiologists, 8 interventional radiologists, 7 vascular surgeons were assed. Endovascular instrument video motion analysis is feasible and may represent a valuable tool for the objective assessment of endovascular skill.

European Journal of Vasc and Endovascular Surgery, 2013; doi:10.1016/j.ejvs.2013.02.004

 

 

 

Endovascular ePTFE-covered stents is effective method to treat malignant SVC syndrome

Expanded polytetrafluoroethylene (ePTFE)-covered stents were compared with uncovered stents in 37 patients with malignant superior vena cava (SVC) syndrome to evaluate the outcome. Kaplan-Meier analysis revealed that covered stents had higher cumulative patency than uncovered stents. Clinical success rates did not significantly differ, nor did patient survival. Median survival in the covered stent group was 141 days and 100 days in the uncovered stent. Endovascular placement of ePTFE-covered stents appeared to be a safe and effective method to treat patients with malignant SVC syndrome and seemed to be superior to uncovered stents in terms of stent patency.

Radiology, 2013; doi:10.1148/radiol.12120517

 

 

 

Additional catheter-directed thrombolysis is cost-effective in high proximal DVT

This study aimed to evaluate the cost effectiveness of additional treatment with catheter-directed thrombolysis (CDT) in Post Thrombotic Syndrome. Additional CDT was found to be a cost-effective alternative to standard treatment for patients with high proximal DVT and low risk of bleeding.

Journal of thrombosis and haemostasis, 2013;DOI: 10.1111/jth.12184

 

 

 

11.03.13

 

Model to predict inhospital mortality risk for open AAA repair or EVAR

The objective of this study is to produce a national risk prediction model for elective abdominal aortic aneurysm repair in the UK.  There were 312 inhospital deaths among 11 423 AAA repairs of which 230 after 4940 open AAA repairs and 82 after 6483 EVARs. Variables associated with inhospital death included in the final model were: open repair, increasing age, female sex, serum creatinine level >120 µmol/l, cardiac disease, abnormal electrocardiogram, previous aortic surgery or stent, abnormal white cell count, abnormal serum sodium level, AAA diameter and American Society of Anesthesiologists fitness grade. The area under the receiver operating characteristic curve was 0·781 for the whole model. This multivariable model for elective AAA repair can be used to predict riskadjust outcomes for inhospital mortality risk for open AAA repair or EVAR.

BJS,  2013; 100(5): 645-53.


 

 

Significantly higher risks of reintervention and aneurysm rupture after EVAR for AAA

This systematic review aimed to investigate 30day and longterm mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA. 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA were included. Patients who had EVAR had a significantly lower 30day or inhospital mortality rate. By 2year followup there was no difference in allcause mortality which was maintained after at 4 years followup. A significantly higher proportion of patients undergoing EVAR required reintervention and suffered aneurysm rupture.

BJS, 2013;DOI: 10.1002/bjs.9101

 

 

 

Patients with O2-dependent COPD undergoing AAA repair have poorer long-term survival 

This prospective study analyzed the effect of COPD on patients undergoing AAA repair. Over a period of 8 years, 2043 patients underwent EVAR and 1412 patients underwent open repair with a nearly equal prevalence of COPD. O2-dependent COPD (4%) was associated with significantly increased in-hospital mortality, pulmonary complications, and major postoperative events and was also associated with significantly decreased extubation in the operating room among patients undergoing both EVAR and open repair. Five-year survival was significantly decreased among all patients undergoing AAA repair with COPD. Furthermore, O2-dependent COPD was independently associated with in-hospital mortality and decreased 5-year survival.

JVS, 2013: doi:10.1016/j.jvs.2012.11.132

 


04.03.12

 

EVLA appears better than conventional surgery in the management of small saphenous varicose veins
This randomised trial compares conventional surgery & endovenous laser ablation (EVLA) in the management of SSV incompetence. 56 patients were randomised in each arm, and the results showed significant reduction in SSV reflux, pain, functionality and quality of life/venous clinical severity scores in the EVLA group.

Annals of Surgery, 2013; doi: 10.1097/SLA.0b013e318275f4e4




Severity of chronic venous disease is directly related to patient’s weight

The purpose of this cross-sectional trial was to investigate whether high BMI is related to the clinical (C) category of clinical, etiologic, anatomic and pathophysiologic (CEAP) classification of chronic venous disease (CVD). 1116 subjects with primary CVD were analysed (34.4% men and 65.6% women). 42.7% were overweight (BMI = 25.0–29.9) and 15.8% were obese (BMI ≥ 30.0). CEAP C category of CVD was significantly more advanced in overweight and obese patients. No difference was found in the presence of venous reflux.

European Journal of Vascular and Endovascular Surgery, 2013; doi:10.1016/j.ejvs.2012.12.011

 

 

Technical outcomes following EVAR are similar in both genders despite more complex anatomy in women

This study examined data for 1,262 patients from the ENGAGE registry to compare gender-specific early outcomes after EVAR. Females were older, had smaller aneurysms, narrower aneurysm necks, shorter aneurysm length and greater angulation. Technical success however was similar in both groups with no difference in the incidence of early endoleak. At 1 month of follow-up, there were no significant differences in terms of graft occlusion, or in terms of endoleaks. Survival and main complications were also similar.

Journal of Vascular Surgery, 2013; doi:10.1016/j.jvs.2012.09.075

 


25.02.13

 

 

3D USS can identify local wall strain in AAAs offering prospect of predicting rupture risk

This study aims to establish real-time 3-dimensional (3D) speckle tracking ultrasound to explore local displacement and strain parameters of the whole abdominal aortic aneurysm. Strong local differences in displacement and strain were identified within the aortic aneurysms of patients. Local wall strain of the whole abdominal aortic aneurysm can be analysed in vivo with real-time 3D ultrasound speckle tracking imaging, offering the prospect of individual non-invasive rupture risk analysis of abdominal aortic aneurysms.

European journal of vascular and endovascular surgery, 2013;doi: 10.1016/j.ejvs.2013.01.004

 


 

Next generation of balloon-expandable iliac stent demonstrate sustained patency

This study reports the outcome of the ACTIVE (Use of the Assurant Cobalt Iliac Stent System in the Treatment of Iliac Vessel Disease) study, which was designed to determine the safety and effectiveness of the next-generation Assurant cobalt chromium balloon-expandable stent in symptomatic patients with iliac occlusive disease. There were no device- or procedure-related deaths or target limb amputations in the treatment of 159 symptomatic lesions. The ankle-brachial index increased by 0.2 at 9 months. There was an improvement in the Fontaine classification of claudication for the majority of patients, accompanied by significant and sustained improvements in walking speed, distance, and stair climbing. The balloon-expandable Assurant cobalt chromium iliac stent demonstrated an excellent safety profile and sustained patency associated with marked improvements in objective and functional measures of patency.

Journal of Endovascular Therapy, 2013;20(1):94-103.

 

 

 

MRI maybe more sensitive compared to CTA for the detection of post-EVAR endoleaks 

This systematic review examined whether MRI or CTA is more sensitive for the detection of endoleaks in patients with AAA after EVAR. Eleven articles were included. The overall methodological quality of the articles was good. In total, 369 patients with 562 MRI and 562 CTA examinations were included. A total of 146 endoleaks were detected by CTA; MRI detected all but two of these endoleaks. With MRI 132 additional endoleaks were found.

European Journal of Vascular and Endovascular Surgery, 2013;doi: 10.1016/j.ejvs.2012.12.014

 

 

 

 

T-shaped Angioplasty with Apex Puncture of Thrombosed Looped Hemodialysis Grafts

This study is a retrospective evaluation of an alternative technique for angioplasty of thrombosed loop hemodialysis grafts through a single vascular access. This technique can provide balloon angioplasty to the puncture site without any additional vascular accesses by using a T-shaped balloon catheter and can simplify thrombectomy procedures.

Journal of Vascular and Interventional Radiology, March 2013 

18.02.13

 

Percutaneous interventions for isolated CFA disease can be effective as surgical endarterectomy
Surgical endarterectomy is the preferred treatment for isolated CFA lesions, so this retrospective study compared the outcomes with percutaneous interventions in 97 cases. The procedure was successful in 89 cases (91.8%). Minor and major vascular complications at 30 days occurred in three (3.1%) and four (4.1%) cases, respectively. At 12 months, restenosis greater than 50% and limb revascularisation were observed in 19.5% and 14.1% of procedures, respectively.

Journal of vascular and interventional radiology, 2013; doi:10.1016/j.jvir.2012.10.020

 


Significant ambiguity exists regarding the indications for re-intervention for recurring carotid stenosis
This systematic review examined the indications for intervention in patients with recurrent carotid artery stenosis.
50 studies were found including re-intervention by CEA in 2403 patients and by CAS in 1121. 55% of patients were treated for symptomatic disease but only 23% of symptomatic patients underwent intervention for documented ipsilateral symptoms. None of the studies reported whether the patients were evaluated for other sources of emboli. The remaining 45% of patients had asymptomatic restenosis and were treated when the degree of stenosis exceeded 80%. The time to repeat intervention was significantly longer in patients with recurrent atherosclerosis, in asymptomatic patients and in patients undergoing CEA.
British Journal of Surgery, 2013; DOI: 10.1002/bjs.9027

 



Online questionnaire is acceptable to patients and correlates with clinical findings
This qualitative/quantitative study aimed at assessing the feasibility and reliability of an online patient completed Aberdeen Varicose Vein Questionnaire (AVVQ) as a tool to guide specialist referral. 106 patients completed AVVQ, Venous Clinical Severity Score (VCSS) grade was assigned by a consultant vascular surgeon. The AVVQ correlated with the specialist's VCSS grade. It was reproducible with close agreement and received positive feedback from patients.

Eur J Vasc Endovasc Surg, 2013; doi:10.1016/j.ejvs.2012.11.016



14.02.13

 

EVAR reduces the 30-day mortality and improves long-term survival at 5 years in ruptured AAA

The aim of this study was to determine the long term survival of patients following endovascular repair in ruptured AAA (r-AAA). Over a 9 year period, 283 patients with r-AAA underwent EVAR (n = 120) or open surgical repair (n = 163).

The EVAR patients had a significantly lower 30-day mortality than did the open repair patients and better cumulative 5-year survival. Men benefited more from EVAR than women. An age ≥80 year is a significant predictor of death for EVAR but not for open repair. Almost one fourth of EVAR patients required secondary interventions. Survival advantage was maintained for EVAR patients to 5 years.

JVS; 2013:57(2); 368-375.


 

 

Preop serum BNP concentration predicts postoperative cardiac events following AAA repair

This prospective observational study aimed to determine if a single preoperative B-type natriuretic peptide (BNP) level correlated with perioperative cardiac events, cardiac death, and all-cause mortality in elective open AAA repair in the short term, intermediate term, and long term. All patients who were admitted for elective open AAA repair were recruited (n=106). Median BNP concentrations were higher in the 16 patients (15%) with immediate postoperative cardiac events and the five with cardiac death. Area under the receiver-operating characteristic (AUC) curve analysis indicated BNP concentrations of 99.5 pg/mL best predicted cardiac events, and 448 pg/mL predicted cardiac death. BNP also predicted all-cause mortality in the short-term, intermediate-term, and long-term.

JVS. 2013; 57(2): 345-353.





04.01.13

 

Tibial artery endovascular interventions can be used in critical limb ischemia with acceptable limb salvage rates

Restenosis following tibial artery endovascular interventions (TAEIs) is thought to be benign but is not well characterized. This study examines the consequences and predictors of recurrent stenosis of TAEIs for critical limb ischemia. TAEIs can be used successfully to treat patients with critical limb ischemia with acceptable limb salvage rates. Special attention should be given to patients with extensive tissue loss or gangrene because they are at risk for early restenosis and subsequent limb loss. Strict wound and hemodynamic surveillance, wound care, and timely reinterventions are crucial to achieve successful outcomes in this patient population. Amputation or alternative revascularization options, when feasible, should be considered in patients with restenosis and tissue loss given the high rate of limb loss with tibial reinterventions.

Journal of Vascular Surgery, 2013;doi:10.1016/j.jvs.2012.08.115.

 

 

 

Indocyanine green angiography provides quantitative information about regional foot perfusion 

Traditional means of evaluating perfusion before and after revascularization are often limited by the presence of medial calcinosis, open wounds, prior toe or forefoot amputations, and infection. Indocyanine green angiography (ICGA) provides rapid visual and quantitative information about regional foot perfusion. This study is the first report describing quantification of foot perfusion before and after lower extremity revascularization for severe limb ischemia. Further study is warranted to help define the utility of this intriguing new technology to assess perfusion, response to revascularization, and potentially, to predict likelihood of wound healing.

Journal of Vascular Surgery, 2013;doi:10.1016/j.jvs.2012.10.113

 

 

 

Carotid plaque progression was positively related to growth in infrarenal aortic diameter 

This research study showed that carotid plaque progression was positively related to growth in infrarenal aortic diameter and aortic diameter at follow-up. Whether this co-variation between plaque growth and aortic diameter growth is causally related or independent events is still an open question.

European Journal of Vascular and Endovascular Surgery, 2013;doi:10.1016/j.ejvs.2012.11.019

 

 

 

‘Sandwich’ technique facilitates safe and effective aneurysm exclusion in complex AAAs 

This study assessed the safety and efficacy of the sandwich technique for complex aortic aneurysms. 78 patients undergoing complex thoracic or abdominal endovascular aneurysm repairs were treated with the sandwich technique when the aneurysm features did not fulfill the requirements for standard endovascular techniques or total aortic arch replacement. Overall, only 4 (5.1%) type II endoleaks persisted: 3 early with no sac increase and 1 late with sac increase that was managed conservatively on patient demand (stable at 9 months). In all other aneurysms except the 3 in the arch, there was a 5-mm reduction in size achieved by the end of the second year of follow-up, though this was significant only in the aortoiliac aneurysm group (p<0.005). The sandwich technique facilitates safe and effective aneurysm exclusion and target vessel revascularization in adverse anatomical scenarios, with sustained durability in midterm follow-up.

Journal of Endovascular Therapy, 2012;19(6):691-706.

 

 

 

28.01.13

 

Treating an AAA has a harmful affect on patient-reported quality of life
This meta-analysis of 16 published studies assessed the effect of either EVAR (n=2) or open repair (n=14) on quality of life (QoL) in patients with a AAA. The results showed that treating AAA had a negative effect on mainly physical ability and pain patient-reported QoL within the first 3 postoperative months and were more pronounced following open repair.

BJS, 2012; DOI: 10.1002/bjs.9018


Carotid artery stenting and endarterectomy have similar outcomes when performed by surgeons

This study examined the differences in outcomes following carotid artery stenting (CAS) and endarterectomy (CEA) performed by vascular surgeons in a subgroup analysis of the CREST trial. Vascular surgeons performed 21% of the CAS procedures and 65% of the CEA procedures among 2320 patients in the CREST trial. For procedures performed exclusively by vascular surgeons, the primary end point did not differ between CAS and CEA at 4-year follow-up. However, the periprocedural stroke and death rates were higher after CAS than CEA for symptomatic patients.

Journal of vascular surgery, 2013;doi:10.1016/j.jvs.2012.09.014

 

 

 

Risk model maybe able to calculate in-hospital mortality following open repair of AAA and EVAR

The objective of this study was to develop a national risk prediction model for elective AAA repair using data from the National Vascular Database (n=11 423). In-hospital mortality occurred in 230 patients following 4940 open repair and 82 after 6483 EVARs. On multivariate analysis: variables associated with in-hospital death were: open repair, increasing age, female sex, serum creatinine level over 120 µmol/l, cardiac disease, abnormal electrocardiogram, previous aortic surgery or stent, abnormal white cell count, abnormal serum sodium level, AAA diameter and ASA grade. This model maybe able to calculate in-hospital mortality risk for OR and EVAR.

BJS, 2013;DOI: 10.1002/bjs.9047

 

 

 

 

 

 21.01.13

 

Thoracic endovascular aortic repair in blunt thoracic aortic injury is associated with better early outcomes

This report shares the experience of blunt thoracic aortic injury at a level 1 trauma center over the past 15 years (n=338). A total of 175 patients underwent thoracic aortic repair; 29 had open repair with aortic cross-clamping, 77 had open repair with distal aortic perfusion, and 69 had thoracic endovascular aortic repair during this time. The early mortality for all patients with blunt thoracic aortic injury was 41%. Early mortality was 17% for operative aortic interventions, 4% for thoracic endovascular aortic repairs, 31% for open repairs with aortic crossclamping, and 14% for open repairs with distal aortic perfusion.

J Thorac Cardiovasc Surg, 2012;doi:10.1016/j.jtcvs.2012.11.074

 

 

 

Re-operative aortic surgery is associated with satisfactory short- and long-term results 

This study reports short and long-term results after reinterventions on the thoracic aorta. Authors performed 224 reoperations on the proximal thoracic aorta after previous aortic surgery between 1986 and 2011. Surgical procedures involved the aortic root in 40.6% of patients, the ascending aorta in 9.4%, the aortic arch in 24.6%, and the entire proximal thoracic aorta in 25.4%. Hospital mortality was 12.1%. On multivariate analysis, cardiopulmonary bypass time, and urgent/emergency status emerged as independent predictors of hospital mortality. Estimated 1-, 5-, and 10-year survival rates were 84.4%, 72.5%, and 48.5%, respectively. Freedom from reoperation at 1, 5, and 10 years was 95.6%, 90.2%, and 81.5%, respectively, especially if carried out on an elective basis. The progressive nature of aortic disease and the favorable results of elective primary aortic interventions suggest favoring aggressive aortic resections at initial surgery.

J Thorac Cardiovasc Surg, 2012; doi:10.1016/j.jtcvs.2012.11.055

 

 

 

Preop IMA embolization is associated with reduced incidences of type II endoleak

This study reviews the effect of preoperative embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR) on subsequent endoleaks and aneurysm growth. 108 patients underwent IMA embolization before EVAR and were compared with a group of 158 consecutive patients with a patent IMA, who did not undergo preoperative embolization for type II endoleaks. The incidence of type II endoleak and subsequent intervention was significantly higher in patients not treated with embolization. Similarly at 24 months, a significant increase in aneurysm sac volume was observed in patients in the non-embolized cohort.

Journal of Vascular and Interventional Radiology, 2013;24(1):49-55

 

 

 

BASIL survival prediction model can predict short- and medium-term mortality in limb ischemia

The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial investigators developed a model to predict death in this study. Data was collected prospectively on 342 patients. Patients with isolated iliac disease or claudication were excluded. The 6-, 12-, and 24-month all-cause mortality rates were 11.6%, 17.9%, and 26.8%, respectively. The area under the ROC curve (95% confidence interval) using the BASIL score to predict mortality at 6, 12, and 24 months was 0.700 (0.60-0.80; P < .001), 0.651 (0.56-0.74; P < .003), and 0.681 (0.59-0.74; P < .001), respectively. The BASIL survival prediction model can predict short-term and medium-term mortality in patients with limb ischemia.

Journal of Vascular Surgery, 2013;57(1):1-7.

 

 

 

 14.01.13

 

Validated risk model predicts perioperative mortality after elective AAA repair

The aim of this study was to develop and validate an internal risk model for predicting perioperative mortality following elective AAA repair and to compare this with other well-known models. Elective open (n=564) and endovascular (n=589) AAA repairs from 2000 to 2010 were split randomly into development and validation data sets. Variables associated with perioperative mortality included: increasing age, myocardial infarct within last 10 years, raised serum creatinine and open surgery. The areas under the receiver operating characteristic curve for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. Other models such as Glasgow Aneurysm Score and Modified Customised Probability Index did not perform as well.

EJVES; 2012:44(6); 549-554.  

 

 

 

Cilostazol reduces restenosis and reocclusion rates following infrapopliteal angioplasty

This retrospective study investigated whether cilostazol reduces restenosis and revascularization after infrapopliteal angioplasty. 68 limbs with critical limb ischemia were enrolled. 32 were cilostazol treated and 31 were the non-cilostazol-treated group. Procedural success was obtained in all patients. The backgrounds and lesion characteristics of patients with isolated tibial artery disease and critical limb ischemia did not differ significantly between the two groups. In a lesion-based analysis, binary restenosis,  reocclusion and target lesion revascularisation were significantly lower in the cilostazol group than in the non-cilostazol group.

EJVES. 2012;44(6): 577-581.

 

 

 

Early remodeling of the arterialized vein appears to predict midterm lower limb bypass graft patency

This prospective study investigated whether early vein graft remodeling is predictive of subsequent patency. 67 patients undergoing lower extremity bypass with autogenous vein were studied. Patients had a median age of 70 years , 40% had diabetes mellitus, 49% had critical limb ischemia, 75% were taking a statin, and 91% were taking an antiplatelet medication. Median follow-up was 32 months. The average intraoperative, postimplantation vein lumen diameter was 3.9 ± 1.0 mm, increasing to 4.7 ± 1.1 mm at 1 month. By 3 months, the average lumen diameter was 5.1 ± 1.6 mm, with little subsequent change observed to 12 months. Nonwhite race, baseline high sensitivity CRP ≥5 mg/L, statin use, and initial lumen diameter were significantly associated with early vein remodeling. The primary patency rate for the cohort was 60% at 2 years. Initial lumen diameter of the index segment was not associated with primary patency, whereas larger lumen diameter achieved at 1 month (≥5.1 mm) was positively associated with primary patency.

JVS, 2013;57(1):9-18. 

 

 

 

 08.01.13

 

Low ankle-brachial index is associated with reduced bilateral hip extensor strength in PAD

This study evaluated if the severity of symptomatic Peripheral arterial disease (PAD) is associated with lower levels of muscle mass, strength, endurance, and if these musculoskeletal abnormalities in turn impair functional performance and walking ability in patients with PAD. 22 subjects with intermittent claudication from PAD were assessed and outcome assessments included initial claudication distance and absolute claudication distance via treadmill protocols and outcomes from the 6-minute walk (6MW). Lower resting ABI was significantly associated with reduced bilateral hip extensor strength and reduced whole body strength. In addition, lower ABI was associated with a shorter distance to first stop during the 6MW and poorer single leg balance. This series suggest the existence of a causal pathway from a reduction in ABI to muscle atrophy and weakness, to whole body disability represented by claudication outcomes and performance-based tests of functional mobility in an older cohort with symptomatic PAD.

Journal of Vascular Surgery, 2012; doi:10.1016/j.jvs.2012.08.103

 

 

 

Single center experience of treating extended thoracic aortic aneurysms with graft replacement

This is case series of 29 patients with extended thoracic aortic aneurysms, who underwent graft replacement treated at one centre. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. The operative mortality, 30-day mortality and hospital mortality was 1/29 (cardiac arrest due to aneurysm rupture), 1/29 (rupture of infected aneurysm) and 1/29 (brain contusion), respectively. Survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years.

Eur J Cardiothorac Surg, 2012;doi: 10.1093/ejcts/ezs200

 

 

 

 

 17.12.12

 

Moving vascular operations to theatres with laminar flow ventilation may reduce infective complications

This study compared airborne contamination during insertion of vascular prosthesis (n=21) and major joint replacement procedures (n=24) in conventional and laminar flow ventilated theatres respectively. Airborne contamination was measured by exposing agar plates throughout instrument preparation, patient transfer and procedure and compared to control plates which remained covered though out. Duration of exposure was recorded. After 24 hours incubation bacterial colonies were counted by an independent assessor. Airborne contamination in the vascular group in which procedures were performed in conventional theatres was 15 fold greater than in the orthopaedic laminar flow theatres.

Presented at the Vascular Society 2012

 

 

Over a third of patients on an antiplatelet do not experience effective platelet inhibition

This study analysed the response to antiplatelet therapy in 30 carotid artery disease (CAD) patients taking Aspirin and/or Clopidogrel using Multi-plate Impedance Aggregometry. 37% of patients did not experience effective platelet inhibition despite treatment. Resistant patients were more likely to have large carotid plaque volumes, increased frequency of microembolic signals in the middle cerebral artery and more commonly suffered cerebrovascular events such as stroke, TIAs and amaurosis fugax than antiplatelet responders.

Presented at the Vascular Society 2012

 

 

Risk score can discriminate between 5-year rates of EVAR complications into low-risk and high-risk groups

This study aimed to develop and validate a scoring system for aortic complications after EVAR. Pre-operative morphology was quantified using CT. Images were studied by investigators blinded to outcomes. Proportional hazards modelling were used to identify factors predicting aortic complications to derive the risk score and patients were divided into low or high-risk groups. 761 patients were included. A morphological risk score incorporating maximum aneurysm diameter and largest common iliac diameter allocated 75% of patients to a low-risk group, with excellent discrimination between 5-year rates of aortic complication in low-risk and high-risk groups.

Presented at the Vascular Society 2012

 

 

11.12.12

 

Aneurysmal disease is associated with lower carotid intima-media thickness than occlusive arterial disease

This prospective cohort study aimed to investigate whether there is a difference in atherosclerotic burden as measured by carotid intima media thickness between patients with aneurysmal and those with occlusive arterial disease. Overall, 904 patients were included in the study: 502 patients with aneurysmal disease and 402 patients with occlusive arterial disease. The mean carotid intima-media thickness in patients with aneurysmal disease was significantly lower in patients with aneurysmal disease compared with those with occlusive arterial disease.  This difference remained significant after adjustment for cardiovascular risk factors, comorbidities, and medications. This study shows a lower intima thickness in patients with aneurysmal disease than in those with occlusive arterial disease, suggesting a lower atherosclerotic burden in patients with aneurysmal disease. These findings support the idea that additional pathogenic mechanisms are involved in aortic aneurysm formation.

Journal of Vascular Surgery, 2012;doi:10.1016/j.jvs.2012.09.015

 

 

 

Kidney injury following TEVAR is associated with blood transfusions and extent of thoracoabdominal disease

This prospective study analyzed the incidence and the predictive factors of postoperative acute kidney injury after thoracic endovascular aortic repair (TEVAR) and evaluated the effect of acute kidney injury (AKI) on postoperative survival. Out of 171 patients who underwent TEVAR, acute kidney injury occurred in 14%. Predictors of AKI were preoperative low eGFR, thoracoabdominal extent, and postoperative blood transfusion. Patients with acute kidney injury had major postoperative events, longer hospitalization, and higher hospital mortality. Survival for patients who developed kidney injury was significantly worse than for patients who did not experience kidney injury.

Journal of Vascular Surgery, 2012 December;56(6): 1527-1534.

 

 

 

Endovenous laser ablation is associated with less periprocedural morbidity in short saphenous vein reflux

This trial randomised 106 patients to either surgery or endovenous laser ablation. Abolition of short saphenous vein reflux was significantly higher after laser treatment than surgery. Postoperative pain was significantly lower after laser ablation, allowing an earlier return to work and normal function. Both groups demonstrated similar improvements in Venous Clinical Severity Score and quality of life.

Annals of Surgery, 2012; doi: 10.1097/SLA.0b013e318275f4e4. 

 

 

 

 04.12.12

 

In fem-pop disease, a bypass procedure may be offered as a first-line treatment in fit patients

This systematic review compared open surgical and percutaneous transluminal methods for the treatment of femoropopliteal arterial disease. Four randomized controlled trials and six observational studies reporting on a total of 2817 patients (1387 open, 1430 endovascular) were included. 30-day morbidity was lower in the endovascular group (odds ratio [OR], 2.93) but higher technical failure (OR, 0.10) than bypass surgery, whereas no differences in 30-day mortality between the two groups were identified (OR, 0.92). Higher primary patency in the surgical treatment arm was found at 1 (OR, 2.42), 2 (OR, 2.03), and 3 (OR, 1.48) years of intervention. Progression to amputation was found to occur more commonly in the endovascular group at the end of the second (OR, 0.60) and third (OR, 0.55) year of intervention. Higher amputation-free and overall survival rates were found in the bypass group at 4 years (OR, 1.31 and OR, 1.29, respectively).

High-level evidence demonstrating the superiority of one method over the other is lacking. An endovascular-first approach may be advisable in patients with significant comorbidity, whereas for fit patients with a longer-term perspective a bypass procedure may be offered as a first-line interventional treatment.

Journal of Vascular Surgery, Nov 2012; doi:10.1016/j.jvs.2012.07.038

 

 

PTA of small cephalic veins improves primary patency of AV fistulae and decreases reintervention rates

This study evaluated the effect of primary balloon angioplasty (PBA) of cephalic veins with diameter ≤2 mm on patency and maturation time of autogenous radiocephalic arteriovenous fistulae (AVF) for hemodialysis. Forty candidates for distal AVF, with a cephalic vein ≤2 mm, were randomized to two different surgical procedures: (1) PBA of a long segment of the cephalic vein from the wrist up to the elbow (n = 19); and (2) hydrostatic dilatation (HD) of a short venous segment (5 cm) at the level of the anastomosis (n = 21).  Immediate success rate was 100% for PBA and 67% for HD groups (P = .04). Causes of failure in the HD group included early vein thrombosis in seven patients (33%). Mean fistula maturation time was 32 days in the PBA group and 55 days in the HD group (P = .04). During the mean follow-up of 7 months, three patients underwent drug-eluting balloon angioplasty for failure of AVF to mature due to stenosis (1 in the PBA group and 2 in the HD group). Six-month reintervention rate was significantly lower in the PBA group (5%) compared with the HD group (43%) (P = .02). At 6 months, primary patency rates were 95% in the PBA group and 57% in the HD group (P = .01). Working AVF rate was 100% in the PBA vs 90% in the HD group.

PBA of very small cephalic veins during the creation of a distal AVF for hemodialysis is a safe and feasible procedure. This technique assures excellent primary patency, maturation time, and dramatically decreases reintervention rate.

Journal of Vascular Surgery, Nov 2012;doi: 10.1016/j.jvs.2012.07.047.

 

 

 

 27.11.12

 

Long-term outcomes are similar for EVAR and open repair in patients > 70 years old
The OVER study aimed to compare long-term morbidity and mortality in patients treated with EVAR or Open repair of AAA. 881 were randomised to either of the treatments and followed up to 9 years. The primary outcome was: all-cause mortality. Lower perioperative mortality was demonstrated in the EVAR group up to 3 years but not after. 10 aneurysm-related mortalities occurred in the EVAR group versus 16 in the OAR (P=0.22).  6 ruptures were reported in the EVAR group as this remains the main concern. Survival was increased among patients less than 70 years of age in the EVAR group but tended to be better among those 70 or older in the open-repair group.

N Engl J Med, November 2012;367:1988-1997

 

 

Patient reported improvements following interventions for varicose veins were variable in the UK 

This report investigates the potential impact of patient-reported outcome measures (PROMs) following interventions for varicose veins in the NHS on the provision of service. Data from 37,521 varicose vein operations and 15,808 preoperative questionnaires were included.  53% of patients had improved postoperative scores, 33% reported no change, while 14% reported a reduction in their postoperative EQ-5D score. Pain/discomfort was the only domain where patients reported any negative symptoms; 72% reported pain/discomfort preoperatively and 37% postoperatively. The average Aberdeen Varicose Vein Questionnaire (AVVQ) preoperative score was 18.75 and postoperatively 10.76 showing a reduction in symptom scores of one-half following intervention. 90.3% of patients reported an improvement in their problems from varicose veins following surgery and 85% describing their operative results as excellent, very good or good.

Phlebology, June 2012;27(4):173-178

 

 

Risk index can be useful in classifying asymptomatic patients undergoing CEA

This study that aimed to develop and validate a risk index to estimate the combined risk of perioperative stroke, MI, or death in asymptomatic patients undergoing elective CEA. 17,692 patients with asymptomatic carotid stenosis were included. The combined 30-day stroke, MI, or death incidence was 1.8%. Age, dyspnea, COPD, PVD, recent angina and functional status were all predictors and could be used to divide patients in 3 different risk groups: low-, intermediate- and high-risk with a <3%, 3%-6% or >6% risk of combined 30-day stroke, MI, or death respectively.

Journal of vascular surgery, 2012;doi:10.1016/j.jvs.2012.08.116

 

 

19.11.12

 

Ablation of perforator vein reflux in chronic ulcers improves healing and decreases recurrence

This retrospective study compared the treatment of chronic venous ulcers (CVU) by compression alone with compression plus minimally invasive interventions (e.g. thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities). Compared with the compression group, the ulcers in the intervention group healed faster and showed fewer recurrences at 1-year follow-up. Multivariate analysis showed use of interventions were the strongest determinant of healing.

Annals of Vascular Surgery, October 2012;doi:10.1016/j.avsg.2012.06.002

 

 

Similar limb salvage results after tibial bypass can be achieved using Distaflo and Propaten plus distal vein patch

This retrospective study evaluated early and midterm results of tibial bypasses comparing precuffed expanded polytetrafluoroethylene (PTFE) graft (Distaflo) vs. heparin-bonded PTFE graft (Propaten) with a distal vein patch. At 24 months, the two groups were equivalent in terms of primary patency, secondary patency and limb salvage. At 24 months, the two groups were equivalent in terms of primary patency, secondary patency, and limb salvage. In addition, in this study postoperative treatment with warfarin therapy compared with antiplatelet therapy was independently associated with better secondary patency.

Ann Vasc Surg, October 2012;doi:10.1016/j.avsg.2012.04.015

 

 

AAAs with hostile aneurysm neck anatomy can be successfully treated with EVAR

This study evaluated outcomes following EVAR in patients with hostile aneurysm neck anatomy (HNA). 552 patients underwent EVAR, of which 199 patients had HNA and 353 had favourable neck anatomy (FNA). There was a significant increase in late type I endoleaks, total reinterventions, and a significant decrease in late type II endoleaks in patients with HNA. There was no significant difference in technical success, 30-day re-intervention, 30-day mortality, 30-day type I endoleaks, 5-year mortality, aneurysm-related mortality, stent-graft migration, sac expansion, or graft rupture.

European Journal of Vascular & Endovascular Surgery, Nov 2012;doi:10.1016/j.ejvs.2012.10.003

 

05.11.12

 

The most cost-effective treatment of carotid artery stenosis is surprisingly still unknown

This systematic review assesses the availability and validity of economic evaluations of carotid artery stenosis (CS) diagnosis and treatment.Twenty-three studies were identified of which seven studies were of high, eight of medium and eight of low quality. There were no comparisons made between carotid angioplasty versus stenting versus best medical treatment. For subjects with severe stenosis, comparisons of carotid endarterectomy and best medical treatment were surprisingly missing. Three of five studies dealing with pre-operative imaging found that duplex Doppler ultrasound was cost-effective compared with carotid angiogram.

EJVES. 2012; Oct;44(5): 505-513.

 

 

Diabetes is a major predictor of risks following lower extremity bypass surgery

This was a retrospective analysis of 1977 infrainguinal bypass operations performed for critical limb ischemia between 2003 and 2010. 41% of patients were non diabetic, 28% were non-insulin dependent diabetics, and 31% were insulin dependent diabetics. In-hospital mortality rates were similar across these groups. Adjusted analyses accounting for differences in patient characteristics showed that diabetes is not associated with increased risk of in-hospital mortality. However, type of diabetes was associated with a higher risk of major adverse events (odds ratio for non-insulin DM, 1.41; odds ratio for insulin-dependent DM, 1.53 comapred to non-DM).

Journal of Vascular Surgery. 2012 Oct; 56(5): 1317-1323.

 

 

Presence of chronic kidney disease in AAA repair is associated with significantly increased mortality

This study reported the outcomes of 8701 patients who were treated with EVAR or open aneurysm repair of intact AAAs. Mild, moderate, and severe CKD was present in 63%, 30%, and 7%, respectively. The overall mortality increased in the presence of CKD, with rates of 1.7% (mild), 5.3% (moderate), and 7.7% (severe) in unmatched patients undergoing EVAR or open repair. Operative mortality rates in patients with severe CKD were 6.2% for EVAR and 10.3% for open repair. In propensity-matched cohorts, moderate CKD increased the risk of 30-day mortality for EVAR and open repair. Moderate CKD was also associated with increased morbidity in patients treated with EVAR or open repair. Similarly, severe CKD increased the risk of 30-day mortality for EVAR and open repair. Severe CKD was also associated with increased morbidity in patients treated with EVAR or open repair.

Journal of Vascular Surgery. 2012 Oct; 56(5): 1206-1213.

 

23.10.12

 

Systematic review of the efficacy of cilostazol, naftidrofuryl oxalate and pentoxifylline for the treatment of intermittent claudication
This review considers the efficiency of the main pharmaceutical agents used in the management of intermittent claudication. RCTs and published systematic reviews of patients with intermittent claudication due to PAD and whose symptoms persisted despite conservative management were searched for inclusion in a meta-analysis and systematic review. Outcome measures were maximum walking distance (MWD) and pain-free walking distance (PFWD). Naftidrofuryl oxalate was ranked best for both MWD and PFWD (probability of 0·947 and 0·987, respectively, of being the best treatment) followed by cilostazol and pentoxifylline.
Br J Surg Oct 2012; DOI: 10.1002/bjs.8895



Availability of Supervised Exercise Programs and the Role of Structured Home-based Exercise in Peripheral Arterial Disease
This international survey and systematic review evaluates the evidence regarding supervised exercise programs (SEPs) and alternative approaches in terms of practicality and outcomes. 378 responses from 43 countries were collected. 30.4% of the participants had access to SEPs and within this group there was significant heterogeneity on the way SEPs were implemented. 12 studies on the effectiveness of Home-based Exercise Programs (HEPs) were included in the review as well. SEPs were superior to HEPs in improving functional capacity or equivalent in improving quality of life (QoL). HEPs significantly improved most of the functional capacity and QoL markers when compared to the “go home and walk” advice and baseline measurements.
Eur J Vasc Endovasc Surg Oct 2012; DOI: 10.1016/j.ejvs.2012.09.009
 


17.10.12

 

Abdominal Aortic Endografting Beyond the Trials

In this study, 1400 patients undergoing EVAR since 1997 were divided in two groups according to the device used: Old devices and New ones (i.e. those introduced after 2004). The New-device group participants were significantly older, had larger AAAs and higher rates of hypertension and diabetes. They were also less frequently smokers and had lower incidence of pulmonary disease. The reported 30-day mortality was similar in the 2 groups (0.8% in the New-device group vs. 1.1% in Old-device group) and the long term survival was 61% in the New-device group and 58% in the old device group. Freedom from late conversion (p<0.001) and reintervention (p=0.01) were higher in patients treated with new devices.

Presented at ESVS XXVI Annual Meeting – Bologna: September 2012

 

 

Reduced Nitric Oxide Bio-availability Post-surgery Pre-disposes to Myocardial Injury and Predicts all-Cause Mortality in Medium Term

In this study, the group showed a reduction in nitric oxide availability in patients undergoing major vascular surgery, particularly in those with a post-operative myocardial injury. Their analysis showed that elevated serum symmetrical dimethylarginine levels predicts adverse outcome in the immediate post-operative phase and on the long term in these patients.

Presented at ESVS XXVI Annual Meeting – Bologna: September 2012

 

 

Infected Abdominal and Thoracic Aortic Endografts: Improved Medium-term Survival with Explantation vs. Re-lining and Sac Drainage

This case-series of 21 consecutive patients with infected abdominal or thoracic grafts. The authors describe explantation with extra-anatomic reconstruction was associated with improved medium-term survival. Thoracic device infection can be initially controlled by antibiotic therapy, drainage and re-lining/extension, but prognosis remains poor.

Presented at ESVS XXVI Annual Meeting – Bologna: September 2012


 

15.10.12

 

Outcomes of angiosome and non-angiosome targeted revascularization in critical lower limb ischemia

Ischemic ulceration of the foot is the most common cause for major amputations in vascular surgical patients. This prospective study on 64 patients compared direct revascularization (DR) of the ischemic angiosome in 39 patients to indirect revascularization (IR) in 25 patients. Open surgery was performed in 60.9% and endovascular interventions in 39.1%. Ulcer healing at 1, 3, and 6 months for DR vs IR were 7.9% vs 5%, 57.6% vs 12.5%, and 96.4% vs 83.3%, respectively. This difference in the rates of ulcer healing between the DR and IR groups was statistically significant (P = .021). The limb salvage in the DR group (84%) and IR group (75%) was not statistically significant (P = .06). The mortality for IR group was two times higher than the DR group at 6 months.

Journal of Vascular Surgery 2012;doi:10.1016/j.jvs.2012.07.042

 

 

Neointimal Hyperplasia after Silverhawk Atherectomy versus Percutaneous Transluminal Angioplasty (PTA) in Femoropopliteal Stent Reobstructions: A Controlled, Randomized Pilot Trial

This randomized, controlled, pilot trial compared Silverhawk atherectomy with percutaneous transluminal angioplasty (PTA) in patients with a first in-stent re-obstruction in the femoropopliteal arterial segment. A total of 19 patients were included: 9 patients in the atherectomy device and 10 patients in the PTA arm. Intima media thickness (IMT) within the treated segment was statistically significantly elevated in all patients treated with the Silverhawk device versus the patients treated with PTA. The obvious differentiation in elevation of IMT in patients treated with the Silverhawk device started at month 2, with a spike at month 5 and a decline again at month 6 (max IMT SH 0.177 mm vs. IMT PTA 0.121 mm, p = 0.02).

Cardiovascular and Interventional Radiology 2012;DOI:10.1007/s00270-012-0479-9

 

 

Aortic rupture and sac expansion after endovascular repair of abdominal aortic aneurysm

Patients undergoing infrarenal EVAR between 2004 and 2010 were studied prospectively to evaluate the long term efficacy of EVAR. The 30-day mortality rate was 2·1 per cent (10 of 478 patients). Aneurysm-related mortality was 0·897 deaths per 100 person-years and all-cause mortality was 8·558 deaths per 100 person-years. Primary sac expansion occurred in 6·721 per 100 person-years and secondary sac expansion in 4·142 per 100 person-years. This case series demonstrates that EVAR had a lower aneurysm-related mortality rate than demonstrated in early controlled trials, and with lower sac expansion rates than reported from image repositories.

British Journal of Surgery 2012;DOI:10.1002/bjs.8938


 

10.10.12

 

Patients with chronic obstructive pulmonary disease have shorter survival but superior endovascular outcomes after endovascular aneurysm repair

This prospective study compared clinical and endovascular outcomes of patients with (group 1) or without (group 2) COPD undergoing endovascular abdominal and thoracic aneurysm repair (EVAR and eTAAA respectively). Of the 905 patients analyzed, 289 (32%) had COPD (group 1). EVAR was performed in 334 patients (37%), and fenestrated or branched devices were used in the remaining 571 (63%). Group 1 patients were younger, had a better glomerular filtration rate, had higher hematocrits and had more extensive aneurysms. Mean follow-up was 39.5 months. Early and late aneurysm-related deaths were similar between the two groups. Survival in patients with Global Initiative for Chronic Obstructive Lung Disease classification I and II was similar to group 2. Those with classifications III and IV demonstrated lower survival rates. Relevant pulmonary function test variables included a lower forced expiratory volume in 1 second and forced expiratory flow in the middle 50%, which were associated with decreased survival. Surrogate endovascular outcome analyses demonstrated that group 1 patients had fewer endoleaks and more rapid sac shrinkage rate.

Journal of Vascular Surgery. 2012 Oct; 56(4): 911-919.

 

 

Estimating the risk of solid organ malignancy in patients undergoing routine computed tomography scans after endovascular aneurysm repair

This study reported on the risk of solid organ malignancy caused by routine surveillance CT after EVAR using the Biological Effects of Ionizing Radiation (BEIR VII) model. Significant differences found an increased excess relative risk of solid organ malignancy in patients who would undergo routine surveillance CTs as follow up vs those whose surveillance consisted of alternative modalities at some time points. The cumulative relative risk of cancer from radiation was higher in those exposed to contrast-enhanced CT scans, younger people, with highest in the group aged 50 to 55 years and lowest in patients aged ≥80 years.

Journal of Vascular Surgery. 2012 Oct; 56(4): 929-937.


02.10.12

 

Changes in Abdominal Aortic Aneurysm Rupture and Short-Term Mortality, 1995–2008: A Retrospective Observational Study
In this retrospective study, admissions for elective AAA and ruptured AAA (rAAA) were examined to assess possible changes in epidemiology and short-term mortality. 338,278 patients underwent elective repair of AAA and 47,524 (out of a total of 69,653) underwent repair of rAAA. Elective repair rates increased in those >80 years (57.7–92.3 per 100,000, P < 0.001) but decreased in those 65 to 74 years old (81.8–68.9, P < 0.001). A decline in ruptures with and without repair was seen in all age groups. 77% of elective repairs and 31% of all rupture repairs were performed with EVAR (P < 0.001). Operative mortality declined during the study period for elective (4.9%–2.4%, P < 0.001) and rAAA (44.1%–36.3%, P < 0.001) repairs. Short-term AAA-related deaths decreased by more than half (26.1–12.1 per 100,000, P < 0.001), with the greatest decline occurring in those > 80 years (53.7–27.3, P < 0.001).
Annals of Surgery 2012;256(4):651–658

 

 

Causes and Implications of Readmission After Abdominal Aortic Aneurysm Repair
This study analysed the frequency, causes, predictors, and consequences of 30-day readmission after abdominal aortic aneurysm (AAA) repair. 2481 patients undergoing AAA repair were included (1502 EVAR, 979 open). 30-day readmission rates were equivalent for EVAR (13.3%) and open repair (12.8%). Wound complication were most common reason for readmission after both procedures. The frequency of other causes differed (bowel obstruction was common after open repair, and graft complication after EVAR). Preoperative comorbidities had a modest effect on readmission; however, postoperative factors, including serious complications leading to prolonged length of stay and discharge destination other than home, had a profound influence on the probability of readmission. The 1-year mortality in readmitted patients was 23.4% & 4.5% in those not readmitted (P < 0.001).
Annals of Surgery 2012;256(4):595–605
 


 

Prophylactic Perioperative Anti-Thrombotics in Open and Endovascular Abdominal Aortic Aneurysm (AAA) Surgery: A Systematic Review
This systematic review evaluated the evidence regarding the use of heparin during aorto-iliac arterial surgery. Overall methodological quality of the included studies was poor. From the 6 studies found, harmful effects of heparin were associated with increasing operation time, high blood loss and transfusion requirements. One study compared heparin to a direct thrombin antagonist during EVAR, showing no differences in clinical outcomes.
European Journal of Vascular & Endovascular Surgery 2012;44(4):359-367


10.09.12

Outcome after VAC Therapy for Infected Bypass Grafts in the Lower Limb

The aim of this retrospective study from 2004-2007 was to assess the outcome of vacuum-assisted wound closure (VAC) therapy for infected bypass grafts. 42 wounds and 45 infected bypass (28 synthetic) grafts received VAC treatment for a median of 20 days. Graft preservation rate was 91% and 76% at 3.5 and 15 months respectively. Two serious bleeding episodes from the suture lines occurred. Synthetic graft infection and non-healed wound were associated with mortality.

EJVES 2012;44(3):294-299

 

 

Superior outcomes for rural patients after abdominal aortic aneurysm repair supports a systematic regional approach to abdominal aortic aneurysm care

The purpose of this study was to compare the national experience for treatment of elective AAAs for patients living in rural areas with those living in urban areas. 2616 patients had elective repair of AAAs (40% open, 60% EVAR). Patients from rural and urban areas were equally likely to receive EVAR and be treated by a specialist vascular surgeon. Interestingly, rural residence was independently associated with treatment at high-volume centers, decreased death and rehospitalization.

Journal of Vascular Surgery 2012;56(3):608-613

 

 

Regional use of combined carotid endarterectomy/coronary artery bypass graft and the effect of patient risk

This paper studied the in-hospital stroke or death rate in combined use of CEA/CABG from 2003 to 2009. When compared to patients undergoing isolated CEA (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes, renal failure and congestive heart failure. Patients undergoing CEA/CABG were more likely to take preop beta-blockers, but less likely to take preop clopidogrel. Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion, increased risk of stroke, death and return to the operating room for any reason.

Journal of Vascular Surgery 2012;56(3):668-676


 

03.09.12

Volume-Outcome Relationships in Lower Extremity Arterial Bypass Surgery

In this large analysis, all lower extremity arterial bypass surgeries in England were included to study a possible volume-outcome relationship. A total of 27,660 femoropopliteal bypass and 4161 femoro-distal bypass procedures were identified. In-hospital mortality after popliteal bypass decreased from 6.5% to 4.9% (P = 0.0045) as volume increased. Related major amputation decreased from 4.1% to 3.2% (P = 0.006). For distal bypass, in-hospital mortality decreased from 9.8% to 5.5% (P = 0.004) and 1-year major amputation decreased from 25.4% to 18.2% (P < 0.001) as the volume increased. An increase in the chance of revision surgery (10.6% vs 8.2%, P < 0.001) was seen with higher volume.

Annals of Surgery 2012;DOI:10.1097/SLA.0b013e31825f01d1

 

 

Patient education level affects functionality and long term mortality after major lower extremity amputation
In this retrospective series, the authors review the possible relationship between the level of patient education and the outcome following major lower limb amputations. 245 primary major lower extremity amputations (above and below the knee) were analysed. Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors.

American Journal of Surgery 2012;DOI:10.1016/j.amjsurg.2012.07.018

 

 

Three-Dimensional Ultrasonography Measurements After Endovascular Aneurysm Repair
This study compared the variability in measurements of abdominal aortic aneurysms obtained using a 3D-US imaging with CT angiography and to determine the reliability of these measures following EVAR. Seven patients were analysed. The average aneurysm measured 57.2 mm on CT and 56.2 mm on US (P = 0.14). Correlation coefficients for diameter, CSA, and volume were 0.88, 0.90, and 0.93, respectively (all P values < 0.001). A Bland–Altman analysis demonstrated a strong agreement between 92% of the diameter, 96.4% of the CSA, and 100% of the volume measurements. The inter-rater reliability was remarkably high comparing the modalities (CT vs. US). There was a strong reliability when the tests were reviewed 6 to 8 weeks later.

Annals of Vascular Surgery 2012; doi:10.1016/j.amjsurg.2012.07.018

 

28.08.12

Role of patient-specific virtual reality rehearsal in carotid artery stenting

This study aimed to evaluate how effectively carotid artery stenting are replicated by patient-specific rehearsal technology. Each team member rehearsed the virtual procedure in the laboratory, simulated operating theatre or angiography suite environment immediately before treating the real patient. In 11 of 15 and 13 of 15 patients respectively endovascular tool use and fluoroscopy angles were identical during rehearsal and the real procedure. In a third of patients, the simulator did not adequately predict difficulties in cannulating the stenotic internal or common carotid arteries. The procedure realism, value in evaluating the case, increase in efficiency in tool use, and potential to increase communication, confidence and team performance were all rated highly.

British Journal of Surgery 2012:DOI;10.1002/bjs.8858

 

 

Submaximal exercise testing predicts perioperative hospitalization after aortic aneurysm repair

This study assessed whether preoperative cardiopulmonary exercise testing (CPET) could be used to predict morbidity and hospital length of stay (LOS) after aortic aneurysm repair. A total of 185 patients underwent surgical repair (84 open repairs, 101 EVAR) and had adequate determination of a submaximal CPET parameter (anaerobic threshold). Patients undergoing EVAR had fewer complications (10% vs 32%) and shorter mean (5.7 vs 14.4 days) compared with open repair. In the open repair group, the level of fitness, as defined by anaerobic threshold, was an independent predictor of postoperative morbidity and hospital LOS. When the optimal anaerobic threshold (10 mL/min/kg) derived from receiver operator curve analysis was used as a cutoff value, unfit patients stayed significantly longer than fit patients in critical care and in the hospital. In contrast, fitness in the EVAR group was not predictive of postoperative morbidity but did have predictive value for hospital LOS.

Journal of Vascular Surgery 2012;DOI:10.1016/j.jvs.2012.05.097

 

 

Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery

In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization. The number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. A review of published research identified a total of 2,687 patients who underwent preop coronary angiography before elective PAD surgery. 55% had ≥1 epicardial coronary artery with ≥70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%).

American Journal of Cardiology 2012;110(5):736-740


 

21/08/12

Cost effectiveness of abdominal aortic aneurysm screening and rescreening in men in a modern context: evaluation of a hypothetical cohort using a decision analytical model

This study aimed to assess the cost effectiveness of different screening strategies for abdominal aortic aneurysm in men. In a model of 100000 men over 65 years, screening was found to be highly cost effective compared with not screening. The model estimated a 92% probability that some form of screening would be cost effective at a threshold of £20000 (€24790; $31460). If men with an aortic diameter of 25-29 mm at the initial screening were re-screened once after five years, 452 men per 100000 initially screened would benefit from early detection, whereas lifetime rescreening every five years would detect 794 men per 100000. We estimated the associated incremental cost effectiveness ratios for rescreening once and lifetime rescreening to be £10013 and £29680 per QALY, respectively. The individual probability of being the most cost effective strategy was higher for each rescreening strategy than for the screening once strategy (in view of the £20000 threshold).

BMJ 2012;345:e4276

 

 

Calf muscle oxygen saturation and the effects of supervised exercise training for intermittent claudication

Case controlled study of 42 individuals with claudication. After an initial control period of exercise advice, participants undertook a 3-month supervised exercise program. Spatially resolved near-infrared spectroscopy monitored calf muscle oxygen saturation (Sto(2)) during exercise and after a period of cuff-induced ischemia was measured. Comparison was made with 14 individuals undergoing angioplasty for calf claudication. Clinical outcomes of claudication distance and maximum walking distance were measured by treadmill assessment. Significant increases occurred in mean [interquartile range] claudication disease (57 [38-78] to 119 [97-142] meters) and maximum walking distance (124 [102-147] to 241 [193-265] meters) after supervised exercise but not after the control period. No change occurred in resting Sto(2) at any interval. Angioplasty (27% [21-34] to 19% [13-29]) but not exercise training (26% [21-32] vs 23% [20-31]) resulted in a reduced Sto(2) desaturation in response to submaximal exercise and an increased hyperemichemoglobin oxygen recovery rate after ischemia (0.48 [0.39-0.55] to 0.63 [0.52-0.69] s(-1)). However supervised exercise reduced the Sto(2) recovery half-time by 17% (82 [64-101] to 68 [55-89] seconds).

J Vasc Surg 2012;56(2):470-5

  

 

General anaesthesia is associated with adverse cardiac outcome after endovascular aneurysm repair

The aim of the study is to compare the incidence of cardiac events after EVAR under general or locoregional anaesthesia. This retrospective cohort study included a 302 patients undergoing infrarenal EVAR. A total of 173 patients underwent general anaesthesia and 129 locoregional anaesthesia. Obesity, aspirin use and therapeutic anticoagulation were more common in patients receiving general anaesthesia. Cardiac events were observed in 13.3% of patients receiving general anaesthesia and in 4.7% of patients receiving locoregional anaesthesia or 6.4% versus 0.8% when asymptomatic troponin release is excluded from the end point. In the general anaesthesia group, two cardiac deaths, six non-fatal myocardial infarctions, two cases of non-fatal heart failure, one non-fatal cardiac arrest and 12 cases of troponin T release were observed, compared with one myocardial infarction and five cases of troponin T release in the locoregional anaesthesia group. In multivariable analysis, general anaesthesia was associated with adverse cardiac events (odds ratio (OR) 3.8; 95%-confidence interval (CI) 1.1–12.9). Non-cardiac complications occurred in 11.6% of patients in both groups (P = 1.00).

EJVES 2012;(44)2:121-5.


 

15.08.12

Spray-applied cell therapy with human allogeneic fibroblasts and keratinocytes for the treatment of chronic venous leg ulcers: a phase 2, multicentre, double-blind, randomised, placebo-controlled trial

Healing can be lengthy and costly in many patients with venous ulcer disease.  This multicentre trial in the US and Canada aimed at comparing the efficacy of spray-applied cell therapy with human allogeneic fibroblasts and keratinocytesin different doses and frequencies. The trial included 205 patients (all with at least one ulcer measured 2—12 cm2 in area and had persisted for 6—104 weeks), in 5 different groups: 1:1:1:1:1 ratio to 5·0×106 cells per mL every 7 days or every 14 days, or 0·5×106 cells per mL every 7 days or every 14 days, or to vehicle alone every 7 days.The primary endpoint was mean percentage change in wound area at the end of 12 weeks. Results showed significantly greater mean reduction in wound area associated with active treatment compared with vehicle (p=0·0446), with the dose of 0·5 ×106 cells/mL every 14 days showing the largest improvement, so the authors conclude that a spray formulation of allogeneic neonatal keratinocytes and fibroblasts is effective in chronic venous ulcer management in the optimum dose of 0·5×106 cells per mL every 14 days.
The Lancet 2012;doi:10.1016/S0140-6736(12)60644-8
 

 

Factors Related to Postoperative Delirium in Patients with Lower Limb Ischaemia: A Prospective Cohort Study
Postoperative confusion and delirium is a common problem we all face on the surgical wards.

This study aimed at studying what factors might be related to the development of postoperative delirium in patients with lower limb ischaemia. This was a prospective cohort in which 299 patients undergoing bypasses were included. The scale and severity of cognitive impairment was recorded in 88 patients and the study identified 5 risk factors (by multiple logistic regression analysis): Age > 72 years, end-stage renal disease, multiple occlusive lesions, cognitive impairment and critical limb ischaemia. Long-term outcomes were similar when comparing the patients who experienced delirium postoperatively with those who did not.
EJVES 2012; In Press

 

Effect of Supervised Exercise Therapy for Intermittent Claudication in Patients With Diabetes Mellitus
Supervised exercise is now a useful therapy for many patients with Intermittent Claudication. This study aimed at assessing the efficacy of exercise therapy specifically in diabetic claudicants; who generally have decreased exercise tolerance. 775 patients were included (29.7% , 230 with diabetes). Assessment on baseline and at 1, 3, and 6 months of follow-up was done using a standardized treadmill test. The primary outcome measurement was the absolute claudication distance (ACD). Both ACD at baseline and at 6 months of follow-up were significantly lower in patients with DM (P < 0.001). However, increase in ACD after 6 months of SET did not differ significantly (P = 0.48). Supervised exercise was equally effective in improving walking distance for patients with and without DM, although ACD remains lower in patients with DM.

Annals of Vascular Surgery 2012;doi:10.1016/j.avsg.2012.04.008

 

 

Quality of vascular surgery Web sites on the Internet
In this day and age, our patients refer to the internet continuously for more information. This study evaluated the usability and reliability of vascular surgery information on the Internet in the English language by appraising the search findings of different vascular surgical titles using Google, Yahoo, and MSN/Bing search engines. The Flesch Reading Ease Score and Gunning Fog Index were calculated to assess readability. The LIDA tool (Minervation Ltd, Oxford, UK) was used to assess accessibility, usability, and reliability. The authors summarize their findings here and conclude that Internet information on vascular surgical conditions and procedures is poorly written and unreliable. The also suggested that health professionals should recommend Web sites that are easy to read and contain high-quality surgical information. Medical information on the Internet must be readable, accessible, usable, and reliable.

Journal of Vascular Surgery 2012; doi:10.1016/j.jvs.2012.04.058


 

08.08.12

Cumulative radiation exposure during thoracic endovascular aneurysm repair and subsequent follow-up

Thoracic endovascular aneurysm repair (TEVAR) is an appealing alternative to the standard surgical approach, but requires rigorous radiological follow-up. The cumulative radiation exposure (RE) of patients undergoing TEVAR-including pre-operative workup, the procedure and subsequent follow-up computed tomography (CT) imaging was investigated. 48 patients underwent TEVAR. The average screening time was 15.7 ± 11.4 min, with an RE of 11.3 ± 9 mSv. Obese patients had significantly higher RE during TEVAR (Pearson's coefficient = 0.388, P = 0.019). The RE dropped from 14.9 ± 9.4 mSv to 8.6 ± 7.9 mSv (P = 0.033) after a hybrid suite was established. TEVAR protocolin the study involved one pre-operative thoracoabdominal CT scan and three follow-up thoracic CT scans for the first year, with a yearly evaluation thereafter. The life expectancy of an age- and sex-matched population was 17 years. A patient adhering to study’s surveillance protocol would be subjected to an overall exposure of 89 mSv at 1 year and 161 mSv at 5 years, with a projected lifetime RE >350 mSv. A 2-year RE exceeding the threshold of 100 mSv with a life expectancy >15 years can be estimated to lead to a lifetime risk increase in radiation-induced leukaemia and solid-tumour cancer >2.7%.

Eur J Cardiothorac Surg 2012;42(2):254-60

 

 

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Colonic surgery enhanced recovery after surgery (ERAS) protocol was applied for the perioperative management of open AAA surgery to achieve early recovery and early discharge from the hospital. The ERAS protocol was used for 127 AAA surgery cases from April 2008 onward, and compared them with conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs. The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n = 52) compared to the conventionally managed group (n = 75); with values of 59 ± 15 and 93 ± 25 h (p = 0.021), 9 ± 3 and 16 ± 5 days (p = 0.001), respectively. The medical costs for the ERAS group were 92 % of the costs of the conventionally managed group. Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.

Surg Today 2012;Epub ahead of print

 

 

Risk factors of incomplete thrombosis in the false lumen after endovascular treatment of extensive acute type B aortic dissection

This study evaluated the risk factors of incomplete thrombosis in the false lumen after thoracic endovascular aortic repair (TEVAR) in patients with extensive acute type B aortic dissection. Univariate analysis showed that the age at TEVAR, hypertension, maximum diameter of the abdominal aorta and false lumen at the abdominal level, re-entry tears, and visceral branches that arose partially or totally from the false lumen had a P < .20. Regression model showed that the visceral branches that arose partially or totally from the false lumen (odds ratio [OR], 10.054; P < .001), re-entry tears (OR, 30.661; P < .001), and maximum diameter of the false lumen on the abdominal aorta (OR, 1.265; P = .004) were the significant risk factors of incomplete thrombosis in the false lumen after TEVAR. Visceral branches that arose partially or totally from the false lumen, re-entry tears, and maximum diameter of the false lumen on the abdominal aorta were the risk factors of incomplete thrombosis in the false lumen after TEVAR in extensive acute type B dissection.

J Vasc Surg 2012;Epub ahead of print

 

 

Outcomes of Venoplasty with Stent Placement for Chronic Thrombosis of the Iliac and Femoral Veins: Single-Center Experience

Patency of chronically occluded iliofemoral venous thrombotic lesions treated with stent placement was assessed retrospectively at 30-day, 1-year, and 3-year. A total of 89 patients (27 men; median age, 46.2 y) with chronic iliac or iliofemoral deep vein thrombosis without involvement of the inferior vena cava met criteria for analysis. All patients (91 limbs) successfully underwent placement of venous self-expanding stents. Patency rate at discharge was 100%. Following the index procedure, mean pressure gradient across the lesion decreased from 5.63 mm Hg (95% CI, 3.51–7.75) to 0.71 mm Hg (95% CI, 0.08–1.34; P< .0001). Follow-up at 30 days demonstrated 90 of 91 limbs to be patent. Primary patency rates of treated limbs at 1 and 3 years were 81% and 71%, respectively. Primary patency was lost in 17 cases (19.1%); interventions to maintain or restore stent patency were performed in 13 cases (14.6%). Primary assisted limb patency rates at 1 and 3 years were 94% and 90%, respectively; secondary patency rate was 95%. Angioplasty with stent placement for treatment of chronically thrombosed iliofemoral veins is a low-risk procedure with acceptable patency rates for as long as 3 years.

Journal of Vascular and Interventional Radiology 2012;23(8):1009-1015


 

30.07.12

Prediction of asymptomatic abdominal aortic aneurysm expansion by means of rate of variation of C-reactive protein plasma levels

C-reactive protein (CRP) is an independent risk factor for arteriosclerosis, but its role in abdominal aortic aneurysm (AAA) expansion remains unverified. There are no data about the prognostic significance of rates of variation in the CRP levels  with regard to asymptomatic AAAs. This study investigated the association between plasma CRP levels and AAA diameter, and assessed the relationship between the gradient of CRP levels and rates of expansion in asymptomatic AAAs. Plasma levels of high-sensitive CRP (hs-CRP) were measured using a high-sensitivity technique and AAA size was determined by computed tomography in 435 patients with asymptomatic AAAs followed up in the authors outpatient department. Authors concluded that there is a statistical association between AAA diameter and hs-CRP plasma levels. This study contributes information about the value of the hs-CRP plasma level gradient as a marker of disease progression and rate of expansion.

Journal of Vascular Surgery, July 2012, volume 56, 45-52.

 

 

Variation in Clinical Practice in Carotid Surgery in Nine Countries 2005–2010. Lessons from VASCUNET and Recommendations for the Future of National Clinical Audit

This study analysed the variation in carotid surgical practice, results and effectiveness in nine countries. A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. 92.6% of the CEAs were performed based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. Authors concluded that there is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.

European Journal of Vascular and Endovascular Surgery, July 2012, Volume 44, 11-17.


18.07.12

l-Carnitine plus cilostazol versus cilostazol alone for the treatment of claudication in patients with peripheral artery disease: A multicenter, randomized, double-blind, placebo-controlled trial

Large resources are directed at studying noninvasive management modalities for intermittent claudication (IC). The authors here evaluated the effect of cilostazol + l-carnitine versus cilostazol alone on exercise performance, quality of life (QOL), and safety  in a double-blind, placebo-controlled trial. Patients were randomized to either l-carnitine 1 g or matching placebo twice-daily, on a background of cilostazol. Treadmill and QOL assessments were performed at baseline, 90, and 180 days. The primary endpoint was the difference between groups in the natural-log-transformed (ln) ratio in peak walking time (PWT) between baseline and 180 days. The results presented, show general improvement in both mean ratio in PWT and in QOL measures. The findings in this trial support larger trials of l-carnitine in combination with cilostazol in the treatment of IC.

Vascular Medicine 2012;17(3):145-154

 

 

Evaluation and Treatment of Suspected Type II Endoleaks in Patients with Enlarging Abdominal Aortic Aneurysms
Endoleaks are common following endovascular abdominal aortic aneurysm repairs (EVAR). In this retrospective study, the authors evaluate angiographic diagnosis and embolotherapy of patients with enlarging abdominal aortic aneurysms and computed tomographic (CT) diagnosis of type II endoleak. Twenty-five patients underwent 40 procedures between 12 and 82 months after endograft insertion (mean, 48 mo) for diagnosis and/or treatment of endoleaks. Type II endoleaks were treated with cyanoacrylate, coils, and ethylene vinyl alcohol copolymer in 16 patients. Technical success rate was 88% (14 of 16 patients) and clinical success rate was 100% (16 of 16 patients). Aneurysm growth was arrested in all cases over a mean follow-up of 27.5 months (range, 6–88 mo).  Endoleaks in nine patients were misclassified on CT; two had type I endoleaks and seven had type III endoleaks. Four of the nine patients (two type I endoleaks and two type III endoleaks) were correctly classified after initial angiography. Following EVAR, aneurysm growth caused by type II endoleaks was arrested by embolization. Initial CT misclassification of endoleaks remains common.

Journal of Vascular and Interventional Radiology 2012;23(7):866-872


08.07.12

Twenty-year review of abdominal aortic aneurysm screening in men in the county of Gloucestershire, United Kingdom

In this series, a cohort of more than 50,000 patients attending for AAA ultrasound screening in Gloucestershire was reviewed aiming to assess the attendance rates, screening and surveillance outcomes, intervention rates and outcomes over the 20 years of the study. Screening for AAA is a widely spread programme in the UK today: men over 65 years were invited; those with an aorta <2.6 cm were reassured and discharged; men with an aorta between 2.6 cm and 5.4 cm were offered follow-up surveillance; men with an aorta >5.4 cm were considered for intervention. The overall mean aortic diameter on initial scan fell from 2.1 cm to 1.7 cm during the study (reduction 0.015 cm/y, P < .0001). 631 patients with AAAs had interventions with a perioperative mortality rate of 3.9%. 372 AAAs detected incidentally were treated, with a mortality rate of 6.7%. The number of ruptured AAAs treated annually in Gloucestershire fell during the study (P < .0001). Screening reduced the number of ruptured AAAs in Gloucestershire. And there has been a significant reduction of men with an abnormal aorta, as the mean aortic diameter of the 65-year-old male has reduced over 20 years.

JVS 2012;56(1):8-13

 

 

Benefit of a Single Dose of Preoperative Antibiotic on Surgical Site Infection in Varicose Vein Surgery
This study aims to assess the benefit of a single dose of preoperative antibiotics prior to surgical treatment of varicose veins (specifically SFJ ligation/division with GSV radiofrequency ablation) in reducing surgical site infection (SSI). By retrospectively examining records of 902 patients (953 consecutive operations as described above): the authors compared the outcomes between two groups; those who received antibiotics 1 hour before the procedure (n= 449 extremities) and those who did not (n= 504). Primary outcome measure was SSI categorized based on type of therapy required (1: oral antibiotic, 2: hospitalization for intravenous antibiotic and/or wound debridement), with a secondary outcome measure of VTE. The authors found that administration of an antibiotic was associated with a significantly reduced risk for both overall (P = 0.02) and groin (P = 0.01) SSI. Furthermore, prophylaxis eliminated category 2 infections (P = 0.008) and was associated with a significantly lower risk of VTE (P = 0.01). Diabetes and high body mass index were patient-associated SSI risk factors. This study shows that a single dose of preoperative antibiotic significantly reduces the rate of all infection following surgical ligation of the SFJ and radiofrequency ablation of GSV, it also eliminates the danger of serious infection, and is associated with minimal VTE.

Annals of Vascular Surgery 2012;26(5):612-619
 


Systematic review and meta-analysis of vein cuffs for below-knee synthetic bypass
This review aims to investigate the possible benefit of vein cuffs for femoral to below-knee popliteal and femorodistal vessel synthetic bypass grafts. It was a systematic review and metanalysis that included 5 studies (3 cohorts and 2 RCTs); a total of 885 patients. Meta-analysis of five studies examining below-knee popliteal bypass showed a significant improvement for primary patency in cuffed grafts at 2 years, but not at 1 or 3 years (odds ratio at 2 years 0·46, 95 per cent confidence interval 0·22 to 0·97; P = 0·04). Limb salvage was significantly improved in cuffed grafts up to 2 years. Limb survival was also improved for cuffed distal grafts at 2 years (odds ratio 0·29, 0·11 to 0·75; P = 0·01) but showed no difference at any other time interval. This study shows a small but significant benefit for vein cuffs on synthetic grafts used for femoral to below-knee popliteal anastomoses, but little benefit for femorodistal anastomoses.

BJS May 2012 DOI:10.1002/bjs.8811


 

01.07.12

The influence of neck thrombus on clinical outcome and aneurysm morphology after endovascular aneurysm repair

Suitability of the aneurysm neck anatomy remains an important factor in planning EVAR. This study investigates the effect of aneurysm neck thrombus on morphological and clinical outcomes. The study was conducted from 2004-2008 in two centres in Netherlands and included a total of 389 patients. Patients were divided into 2 groups: those with significant thrombus in the neck (>2 mm in thickness in at least >25% of circumference) and compared to those without neck thrombus. The estimated 5-year clinical success rate was 74% for the thrombus group and 62% for the no-thrombus group (P = 0.23). Endograft migration was more frequent in the thrombus group (P = .02). Multivariable analysis showed a significant association between migration and use of a device without active fixation (hazard ratio, 4.9; 95% confidence interval, 1.31-18.23; P = .018) but not with the presence of neck thrombus (P = .063).
The authors conclude that the presence of aneurysm neck thrombus has no significant influence on short-term and midterm EVAR results.
Journal of Vascular Surgery 2012;56(1):36-44


Outcomes of carotid endarterectomy under general and regional anesthesia from the American College of Surgeons' National Surgical Quality Improvement Program
Using the American College of Surgeons' (ACS NSQIP) database, the authors investigate whether the type of anaesthesia (General vs Regional) independently contributes to the risk of postoperative cardiovascular complications or death. It was a retrospective analysis of prospectively maintained date for 26,070 CEAs over the period 2005 - 2009.

Postoperative stroke, MI, and death occurred in 360 (1.63%), 133 (0.6%), and 154 (0.70%) patients of the general anaesthesia group, respectively, and in 58 (1.44%), 11 (0.27%), and 27 (0.67%) patients of the regional anasthesia group, respectively. Stratification by propensity scores and adjustment for covariates demonstrated GA to be a significant risk factor for postoperative MI with an adjusted odds ratio (OR) and confidence interval (CI) of 2.18 (95% CI, 1.17-4.04), P = .01 in the entire study population. These results further validate the results from the GALA trial. The results indicate that GA for CEA is an independent risk factor for postoperative MI, particularly in patients with preoperative neurologic symptoms.
Journal of Vascular Surgery 2012;56(1):81-88

24.06.12

Efficacy of VBHOM to Predict Outcome Following Major Lower Limb Amputation

This study tests an existing Vascular Biochemistry and Haematology Outcome Model (VBHOM) on independent data and presents further refinements to the model. Data from 306 patients who underwent lower limb amputation over a 4-year period were collated. Urea, creatinine, sodium, potassium, hemoglobin, white cell count, albumin, age, gender, mode-of-admission, and short-term mortality events were extracted from the database. This study tests an existing model and trains a new model for predicting mortality using forward stepwise logistic regression. The existing model suggests a significant lack of fit (c-index = 0.665, P = .04). For the exception of gender and mode-of-admission, all predictor variables had significant univariate associations with short-term mortality (P < .05). The refined model included age, sodium, potassium, creatinine, and albumin and had good discriminatory power (c-index = 0.8, no evidence of lack of fit, P = .616).

VASC ENDOVASCULAR SURG 2012;46(5):369-373

 

 

Deficiencies Persist in the Experience of UK Vascular Trainees: A Survey of Rouleaux Club Members

Authors sent a Web-based questionnaire to 217 members of the Rouleaux Club, which represents UK vascular and endovascular trainees, between May and June 2011. A total of 153 trainees (71% response rate) completed the survey; 52% were in posts that do not offer endovascular training, 88% performed <10 peripheral angiograms, and 67% performed part or all of <10 endovascular aneurysm repairs in the last year. Half had no access to formal ultrasound training; 85% believe that vascular access will play a role in their future practice, but 49% performed no vascular access procedures in the past year. No experience of endovenous laser, radiofrequency ablation, or foam sclerotherapy was reported by 33%, 49%, and 46%, respectively.

VASC ENDOVASCULAR SURG 2012;46(5):358-363

 

 

A Scoring System (DISTAL) for Predicting Failure of Snuffbox Arteriovenous Fistulas

The aim of this study was to determine the relative importance of risk factors for snuffbox fistula failure and create a simple scoring system to aid fistula placement decision making. 218 consecutive patients were examined using Cox regression analysis to determine risk factors for failure. Primary patency was used as the endpoint. Diabetes, IHD, Stroke, Two snuffbox procedures, Age > 70 and Less than 2.0 mm vein (DISTAL, maximum score 6) were significant predictors of primary patency failure. There was a clear decrease in primary patency with increasing DISTAL score (log rank χ2 = 30.3, DF = 5, P < 0.001). Performing snuffbox procedures on patients with a score ≤3 would give a 23% reduction in the number of failures within two months for a 12% reduction in the number of patients offered snuffbox procedures.

European Journal of Vascular and endovascular surgery, 2012;44(1):88-91

 

 

Iliac Artery Stent Placement Relieves Claudication in Patients with Iliac and Superficial Femoral Artery Lesions

Author evaluated the efficacy of iliac artery stent placement for relief of claudication in patients with both iliac and superficial femoral artery (SFA) lesions. Stent placement for only iliac artery occlusive disease was performed in 94 limbs (74 patients) with both iliac and SFA occlusive disease on the same limb. All procedures were performed because intermittent claudication did not improve after continuation of antiplatelet medication therapy and home-based exercise for 3 months.  Primary patency rates of the iliac stent at 1, 3, 5, and 7 years were 97, 93, 79, and 79 %, respectively. The initial clinical improvement rate was 87 %. Continued clinical improvement rates at 1, 3, 5, and 7 years were 87, 81, 69, and 66 %, respectively. SFA Trans-Atlantic Inter-Society Consensus (TASC) II C/D lesion was a significant risk factor for requiring additional SFA procedures.

Cardiovascular and Interventional Radiology 2012;DOI:10.1007/s00270-012-0427-8


 

17.06.12

 

A comparison of total laparoscopic and open repair of abdominal aortic aneurysms

Authors compared the long-term results of these techniques. Thirty patients with AAAs treated by total laparoscopic repair between July 2003 and December 2004 (group I) were matched in a case-control fashion by aneurysm morphology and American Society of Anesthesiologists class with 30 patients who underwent open AAA repair between April 1997 and May 2004 (group II). Patients who survived the intervention were followed up during 5 years. Follow-up consisted of physical examination and duplex ultrasonography at 1 month and yearly thereafter. Group I patients had an additional control computed tomography scan within the first 3 months postoperatively. Five-year cumulative survival rates were similar (group I: 83% ± 7% vs group II: 79% ± 7%; log-rank test, P = .69). No late aneurysm-related death occurred during the follow-up period. Incisional hernias were more likely to occur in group II patients (group I: 0% vs group II: 15.4%; P = .047). Incidence of postoperative sexual dysfunction was similar in both groups (group I: 22.2% vs group II: 25.0%; P = not significant [NS]). No late reintervention was recorded in group I, whereas 2 patients in group II had incisional hernia repair. At 5 years, no graft sepsis or anastomotic pseudoaneurysm was reported. This study suggests that total laparoscopic AAA repair provides good long-term results, comparable to those of open repair in terms of aneurysm-related mortality and morbidity. It may reduce the incidence of laparotomy-related complications.

Journal of Vascular Surgery 2012;55(6):1549-1553

 

 

Management and Outcome of Prosthetic Patch Infection after Carotid Endarterectomy: A Single-centre Series and Systematic Review of the Literature

Authors reported the outcomes following prosthetic patch infection after carotid endarterectomy (CEA) at their center. 22 patients were treated between January 1992 and April 2012. The commonest infecting organism was Staphylococcus. One patient was treated by antibiotic irrigation, one was stented, while 20 underwent debridement and patch excision plus; carotid ligation (n = 3), vein patching (n = 3) or vein bypass (n = 14). There was one peri-operative stroke, but no peri-operative deaths. There were no reinfections at a median follow-up of 54 months. A systematic review identified 123 patients with prosthetic patch infection in the world literature. Thirty-six (29%) presented <2 months, 78 (63%) presented >6 months after the original CEA. Seventy-nine of/87 patients (91%) with a positive culture yielded Staphylococci or Streptococci. Seventy-four patients were treated by patch excision and autologous reconstruction. Four (5%) developed reinfection <30 days, but later reinfections have been reported. Seven of nine patients (78%) undergoing prosthetic reconstruction either died or suffered reinfection. Five patients were treated with a covered stent, none developing reinfection (median followup 12 months). Patch infection following CEA is rare. Few have undergone stenting and long term data are awaited. For now, patch excision and autologous reconstruction remains the ‘gold standard’.

European Journal of Vascular & Endovascular Surgery 2012;44(1);20-26

 

 

Calcium channel blockers enhance sac shrinkage after endovascular aneurysm repair

Sac shrinkage is a surrogate marker of success after endovascular aneurysm repair (EVAR). Authors aimed to determine if any common cardioprotective medications had a beneficial effect on sac shrinkage. This retrospective observational study comprised 149 patients undergoing EVAR. Medication use was recorded at intervention (verified at study completion in only 33 patients) and patients were monitored for 2 years. After exclusions, 112 patients, who were a median age of 78 years (interquartile range, 78-83 years), remained for analysis. At 2 years, mortality was 13.4%, endoleak developed in 37.5%, and significant endoleak developed in 14.3%. Patients taking a calcium channel blocker had enhanced sac shrinkage, compared with those not taking a calcium channel blocker, by 6.6% at 6 months (P = .09), 12.3% at 1 year (P = .008), and 13.1% at 2 years (P = .007) independent of other medication use, graft type, endoleak development, or death. Calcium channel blockers maybe associated with enhanced sac shrinkage following EVAR. This warrants further study.

Journal of Vascular Surgery 2012;55(6):1593-1599


09/06/12

 

Eversion Carotid Endarterectomy is Associated with Decreased Baroreceptor Sensitivity Compared to the Conventional Technique

This study published in the European vascular and endovascular Surgery Journal determined differences in postoperative barorecepter sensitivity (BRS) following eversion CEA (E-CEA) and conventional CEA (C-CEA). Sixty-four patients undergoing E-CEA (n = 37) and C-CEA (n = 27) were prospectively studied. Non-invasive measurements of mean arterial pressure (MAP), cardiac output (CO) and total peripheral resistance (TPR) were taken perioperatively over three 10-min periods. Baroreflex gain was calculated as the sequential cross-correlation between heart rate and beat-to-beat systolic blood pressure. Compared with changes observed after C-CEA, E-CEA was associated with an increase in systolic pressure, diastolic pressure, mean arterial pressure and heart rate on postoperative day 1. BRS decreased after E-CEA significantly onday 1 and 3. By contrast, BRS increased after C-CEA on day 1 and day 3. These findings are likely the result of carotid sinus nerve interruption during E-CEA and preservation with C-CEA.

European Journal of Vascular & Endovascular Surgery 2012;44(1):1-8

  

 

Early Results of Fenestrated Endovascular Repair of Juxtarenal Aortic Aneurysms in the United Kingdom

Fenestrated EVAR for AAAs has been proposed as an alternative to open surgery for juxtarenal and pararenal abdominal aortic aneurysms. This study published in Circulation presents the nationwide early results of fenestrated endovascular repair in the United Kingdom. The GLOBALSTAR database was analysed between 2007 - 2010 identifying 318 patients. Primary procedural success was achieved in 99% with perioperative mortality of 4.1% and early reintervention (<30 days) rate was 7%. Survival by Kaplan–Meier analysis was 94%, 91% and 89% at 1, 2, and 3 years, respectively. Freedom from late secondary intervention (>30 days) was 90%, 86% and 70% at 1, 2, and 3 years respectively. In this national sample, fenestrated endovascular repair has been performed with a high degree of technical and clinical success. Late survival and target vessel patency are satisfactory. These results support continued use and evaluation of this technique for juxtarenal aneurysms, but illustrate the need for a more robust evidence base.

Circulation. 2012;125:2707-2715

 

 

Statin therapy is associated with aneurysm sac regression after endovascular aortic repair

The effects of statin therapy on aneurysm sac size reduction remains controversial. This study published the Journal of Vascular Surgery tested the hypothesis that statin therapy enhances aneurysmal sac regression after EVAR. 166 patients met the inclusion criteria; 120 were identified as statin users and 46 as non-statin users. At 24 months of follow-up, statin group patients had a greater aneurysm sac reduction. Multivariate analysis revealed statin use was an independent predictive factor of sac regression. Statin use was predictive of sac regression after EVAR.

Journal of Vascular Surgery 2012;55(6):1587-1592

 

 

Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein
In view of the developing minimally invasive modalities for the treatment of varicose veins, this randomised controlled trial in the British Journal of Surgery compared ultrasound-guided foam sclerotherapy (UGFS) with surgical stripping and high ligation in terms of effectiveness and coast. 230 patients were recruited in the UGFS group and 200 in the surgical group. The main outcome measure was recurrence (on colour duplex) at 3 months, 1 year and 2 years. Secondary outcomes were recurrent reflux (irrespective of symptoms), reduction of symptoms, quality of life measures, adverse events and direct costs. The 2 year probability of recurrence was 11.3% in UGFS group and 9% in the surgical group, and at 2 years, the reflux (irrespective of symptoms) was significantly higher in the UGFS group (35% vs 21% in the surgical group). The authors conclude that UGFS was not inferior to surgery when reflux associated with venous symptoms was the clinical outcome of interest. UGFS has the potential to be a cost-effective approach to a common health problem.
British Journal of Surgery 2012; DOI:10.1002/bjs.8781

 

 

Delayed open conversions after endovascular abdominal aortic aneurysm repair
Durability of endovascular AAA repairs remains the main disadvantage of these procedures. Open conversions following EVAR are worrisome and carry worse outcomes. This study in the Journal of Vascular Surgery is a retrospective review for a 44 patient series who underwent open conversions following EVAR (ranging from 2-190 months) from a single centre. The indications for open interventions were: Aneurysm expansion (64%), rupture (27%) and infection (9%). The endograft was preserved in situ in 10 patients (23%). The authors also stated details of their management to the different types of endoleaks encountered. The overall morbidity rate was 55% and mortality 18%. No deaths occurred in a subgroup of patients who underwent endograft preservation with selective ligation of culprit vessels for type II endoleak. Intraoperative complications included bowel injury in two, bleeding in two, splenectomy in one, and ureteral injury in one. The conclusion was that open conversions following EVARs is  associated with significant morbidity and mortality, except when electively treating an isolated type II endoleak with ligation of branches and preservation of the endograft.
Journal of Vascular Surgery 2012;DOI:10.1016/j.jvs.2011.12.007

 

 

Laparoscopic versus Open Approach for Aortobifemoral Bypass for Severe Aorto-iliac Occlusive Disease – A Multicentre Randomised Controlled Trial

This multi-center clinical trial was conducted between between January 2007 and November 2009. 28 patients with severe aorto-iliac occlusive disease (TASC II C or D) were randomised between a laparoscopic or open approach at one community hospital and one university hospital. The operation time was longer for the laparoscopic approach (mean 4 h 19 min (2 h 00 min to 6 h 20 min) vs. 3 h 30 min (1 h 42 min to 5 h 11 min); p = 0.101)). Nevertheless, postoperative recovery and in-hospital stay were significantly shorter after laparoscopic surgery. Oral intake could also be restarted earlier (mean 20 h (6 h to 26 h) vs. 43 h (19 h to 77 h); p = 0.00014)), as well as a significant difference in postoperative mobilisation (walking) (mean 46 h (16 h to 112 h) vs. mean 94 h (66 h to 127 h); p = 0.00016)). Length of hospitalisation was shorter in the laparoscopic group mean 5.5 days (2.5–15) vs. mean 13.0 days (7–45); p = 0.0095)). Visual pain scores and visual discomfort scores were both lower after laparoscopic surgery. Also return to normal daily activities was achieved earlier. Laparoscopic aortobifemoral bypass surgery for aorto-iliac occlusive disease is a safe procedure with a significant decrease in postoperative morbidity, in-hospital stay, and earlier recovery.

European Journal of Vascular and Endovascular Surgery 2012;43(6):711-715

 

 

Endovascular aortic aneurysm repair with carbon dioxide-guided angiography in patients with renal insufficiency

Renal dysfunction following endovascular abdominal aortic aneurysm repair (EVAR) remains a significant source of morbidity and mortality. Authors studied the use of carbon dioxide (CO2) as a non-nephrotoxic contrast agent for EVAR. Data was analyzed retrospectively for 114 consecutive patients who underwent EVAR with CO2 as the contrast agent over 44 months. CO2 was used exclusively in 72 patients and in an additional 42 patients iodinated contrast (IC) was given (mean, 37 mL). Renal and hypogastric artery localization and completion angiography were done with CO2 in all patients. Preoperative National Kidney Foundation glomerular filtration rate (GFR) classification was normal in 16 patients, mildly decreased in 52, moderate to severely decreased in 44, and two patients were on dialysis. All graft deployments were successful with no surgical conversions. CO2 angiography identified 20 endoleaks (two type 1, 16 type 2, and two type 4) and three unintentionally covered arteries. Additional use of IC in 42 patients did not modify the procedure in any case. When compared with a cohort of patients who underwent EVAR using exclusively IC, the operative time was shorter with CO2 (177 vs 194 minutes; P = .01); fluoroscopy time was less (21 vs 28 minutes; P = .002), and volume of IC was lower (37 vs 106 mL; P< .001). Postoperatively, there were two deaths, two instances of renal failure requiring dialysis, and no complications related to CO2 use. Among patients with moderate to severely decreased GFR, those undergoing EVAR with IC had a 12.7% greater decrease in GFR compared with the CO2 EVAR group (P = .004). At 1, 6, and 12-month follow-up, computed tomography angiography showed well-positioned endografts with the expected patent renal and hypogastric arteries in all patients and no difference in endoleak detection compared with the IC EVAR group. CO2-guided EVAR is technically feasible and safe; it may expedite the procedure, and avoids deterioration in renal function in patients with pre-existing renal insufficiency.

Journal of Vascular Surgery 2012;55(6):1570-1575

 

 

Imaging vascular trauma

This systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included. Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.

British Journal of Surgery 2012;0.1002/bjs.7763

 

 

Endovascular suitability and outcome after open surgery for ruptured abdominal aortic aneurysm

CT angiograms of ruptured aortic aneurysms (rAAA) were retrospectively assessed by 2 blinded investigators aiming to determine whether anatomical suitability will impact on outcomes after open repair. This study examined a series of 248 patients of whom 237 underwent open repair. Seventy patients (28·2 per cent) were classified as ‘suitable’ and 100 (40·3 per cent) as ‘unsuitable’ for endovascular repair; 63 (25·4 per cent) were considered ‘borderline suitable’. The postoperative 30-day mortality rate was 15·3 per cent (38 deaths). Multiple logistic regression demonstrated that the odds of perioperative death increased 9-fold for ‘unsuitable’ rAAA and 7-fold for ‘borderline’ rAAA compared with ‘suitable’ rAAA. This selection effect was robust across sensitivity analyses and sustained for at least 5 years of follow-up. Suitability for endovascular repair is an independent strong predictor of survival for ruptured AAA.
British Journal of Surgery 2012 DOI:10.1002/bjs.8780

 

 

Does Contralateral Carotid Stenosis increase the Risk of Stroke in Carotid Endarterectomy?

This retrospective analysis of a CEA database included 2576 patients and aimed to determine the correlation between perioperative stroke complications with the degree of contralateral carotid stenosis (CLA) in patients undergoing CEA.

The overall 30-day stroke and TIA rate was 1.4% and 0.5% respectively. 44.7% of patients were found to have a mild stenosis of the CLA, with a smaller proportion having either a moderate (15.3%), severe (16.6%) stenosis or complete CLA occlusion (8.4%). For patients with mild CLA stenosis, the stroke rate was 1.3%, and this increased to 1.5% and 1.9% for moderate and severe stenosis respectively and 1.8% for occlusion (not significant, Fisher’s exact test, P>0.05). There was a significantly higher risk of TIA following surgery, rising from 0.2% for mild CLA stenosis to 0.9% for patients with severe stenosis (P < 0.05). The authors conclude that the rate of perioperative and 30 day risk of stroke following CEA is not influenced by the degree of contralateral ICA stenosis. However, a slightly higher risk of TIA occurs in patients with severe CLA stenosis compared with mild CLA.

This interesting study was presented orally at the ASGBI International Congress 2012

 


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