An Extension of the Bollinger Scoring System to Analyse the Distribution of Macrovascular Disease of the Lower Limb in Diabetes.

OBJECTIVE: While it is generally considered that patients with diabetes mellitus (DM) have more distal peripheral arterial disease (PAD), there is little information on how individual vessels are affected. The aim of this study was to adapt Bollinger's scoring system for lower limb angiograms (DSAs) to include the distal and planter vessels. The reliability of this extension was tested and was used to compare the distribution of disease in two cohorts of patients with and without DM. METHODS: Patients who had undergone DSA ± angioplasty for PAD at a single centre between September 2010 and April 2014 were identified. Twenty-five patients' images were reviewed by four clinicians and scored using an extended version of the Bollinger score. A total of 153 patients with DM were matched, for age, sex, ethnicity, smoking, and hypertension, with 153 patients without DM. The infrainguinal vessels were divided into 16 arterial segments, including plantar vessels, and scored using the Bollinger score. The score ranges from 0 to 15. Fifteen represents an arterial segment with more than 50% of its length occluded. Interobserver reliability was tested using interclass correlation (ICC) and Cohen's kappa coefficient. RESULTS: The ICC demonstrated good agreement between observers (0.76 [0.72-0.79]) with good internal consistency (Cronbach's alpha 0.93). When the Bollinger scores were categorised, the results were weaker, Cohen's kappa ranged from 0.39 (standard error 0.033) to 0.54 (0.030). Patients with DM had a higher burden of disease in the anterior tibial and posterior tibial arteries with relative sparing of the peroneal artery and no difference in the plantar vessels. CONCLUSION: It has been demonstrated that the Bollinger score can be extended to include the distal vessels. This amended scoring system can be used to compare the burden of distal disease in patients with PAD. How the score relates to clinical presentation and outcomes needs further investigation.

An unusual presentation of acute onset Charcot arthropathy.

Charcot arthropathy is a progressive condition primarily affecting the lower limbs in patients with diabetes mellitus. It is a rare complication of diabetic neuropathy and if left untreated can lead to severe limb destruction necessitating major amputation. Here, we report the case of a 41-year-old female who presented with rapidly progressive Charcot foot over a 10-day period, necessitating open reduction and internal fixation of Lisfranc-type fracture dislocations. Her presentation with a rapidly progressing red, swollen foot with a blister on the plantar aspect prompted initial treatment on the basis of a diabetic foot infection. The report will therefore serve as a useful reminder to maintain a high index of suspicion for Charcot foot, which may present in an atypical manner.

Early and Late Outcomes of Surgery for Neurogenic Thoracic Outlet Syndrome in Adolescents.

BACKGROUND: Neurogenic thoracic outlet syndrome is a condition that is both complex to diagnose and manage successfully. The aim of our study was to present our experience and outcomes of surgical management of thoracic outlet syndrome in adolescents. METHODS: We performed a retrospective analysis of a prospectively held database of consecutive adolescents (age 10-19 years) who underwent surgery for neurogenic thoracic outlet syndrome between 2005 and 2017 at our university hospital. RESULTS: Fourteen patients were identified (19 operations), with a mean age of 16.5 years (SD: 1.9). All patients had symptomatic relief with surgery with low complication rates (1 pneumothorax). Median hospital stay was 2 days (IQR: 1). There were no early recurrences but 5 late ones which occurred 2, 2.5, 3, 4 and 10 years after surgery (20%). None required a second procedure and were managed successfully with physiotherapy. CONCLUSIONS: Surgical intervention for thoracic outlet syndrome in the adolescent population results in excellent outcomes in the short term. However, we found that recurrence of symptoms in this population is common and patients need to be counseled clearly about this prior to surgical intervention. However in our experience these do not require further surgery.

Impact of Frailty on Outcomes in Patients Undergoing Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Frailty is a global state that does not relate directly to comorbidities and is prevalent among patients with vascular disease. The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to independently predict mortality and morbidity after elective open abdominal aortic aneurysm (AAA) repair. METHODS: We retrospectively reviewed our institutional National Vascular Registry (NVR) data to identify all patients who underwent an elective open juxta or infrarenal AAA repair between January 2014 and December 2018. The NVR data set included preoperative risk factors, imaging findings, intraprocedural variables, and postprocedural outcomes. RESULTS: A total of 184 patients were assessed using the CFS before they underwent elective open AAA repair. Among 26 (14%) individuals categorized as vulnerable using the CFS, there was no significant difference in age or preoperative cardiac and respiratory testing compared with nonfrail patients. However, vulnerable patients were significantly more likely to have a longer length of stay (12.2 days vs. 8.8 days, P-value 0.044), suffer from respiratory complications (35% vs. 15%, P-value 0.022) and renal failure (23% vs. 6%, P-value 0.013), or die (23% vs. 2%, P-value 0.0003). The regression analysis identified a vulnerable frailty score to be the only significant predictor of mortality (odds ratio = 36.7, P < 0.001), all other factors were not shown to be independent predictors. CONCLUSIONS: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective open AAA repair and can be used to predict mortality and morbidity after surgery.

Artery Ligation for Infected Femoral Pseudoaneurysms Does Carry a High Risk of Major Amputation.

BACKGROUND: Arterial ligation has been described in the literature as a safe and effective procedure with a relatively low number of patients requiring major amputations. METHODS: We performed a retrospective analysis of a prospectively held database of all patients who underwent arterial ligation for infected femoral pseudoaneurysms due to chronic intravenous drug abuse from January 2012 to March 2018. Information recorded for each patient included age, gender, blood investigations, microbiologic results, diagnostic modality, operative details, outcome of surgery, postoperative complications, and follow-up. RESULTS: There were 25 patients identified, with 2 of them undergoing bilateral ligations. It was more common in men (4:1), and the mean age at presentation was 39.7 years (standard deviation 8.2 y). Nine patients underwent major limb amputation for severe limb ischemia (7 transfemoral amputations and two 53 hip disarticulation). Average hospital stay was 24 days, and there was no mortality. We found a trend with a higher level of arterial ligation, leading to a higher rate of amputation. CONCLUSIONS: Our study is the first to show that there is a trend toward a higher risk of amputation with a higher level of ligation in this cohort of patients, and therefore, we suggest avoidance of external iliac artery ligation even at the most distal part just under the ligament, leaving the circumflex iliac vessel in circuit. Arterial ligation also carries a higher risk of major amputation than previously reported.

Early cannulation grafts for haemodialysis: An updated systematic review.

PURPOSE: Early cannulation grafts are specifically designed for dialysis, whereas standard expanded polytetrafluoroethylene grafts were not. There is developing collective experience and literature available to allow the assessment of outcomes of these early cannulation grafts. The aim of this review was to review the evidence for both short- and long-term outcomes of early cannulation grafts. METHODS: Using standardized searches of electronic databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses, the primary outcomes for this study were primary and secondary patency rates for early cannulation grafts for dialysis at 12 months and beyond. Secondary outcomes were timing of first cannulation, rates of access thrombosis, steal syndrome, pseudo-aneurysm and infection. RESULTS: A total of 19 studies were identified and included. These were divided into different graft types. Flixene™, Avflo™, Acuseal™ and Vectra™ grafts all showed that early cannulation within 72 h is possible. Twelve-month pooled primary and secondary patency rates were 43.3% (95% confidence interval: 31.6-55.4) and 73.4% (95% confidence interval: 63-82.7) for the Flixene graft, 58.2% (95% confidence interval: 48-68.1) and 79.2% (95% confidence interval: 68-88.7) for the Avflo graft, 43.6% (95% confidence interval: 30.7-56.9) and 70.5% (95% confidence interval: 49.7-87.8) for the Acuseal graft and 63.7% (95% confidence interval: 53.4-73.4) and 85.8% (95% confidence interval: 82.9-88.4) for the Vectra graft. Data for outcome beyond 12 months were limited to the more recent studies. CONCLUSION: This review confirms that early cannulation is not detrimental on the early outcome of early cannulation graft patencies. It has also shown that both Vectra and Avflo grafts have adequate long-term patencies. The data do not allow specific graft recommendations, as comparative trials would be required.

The role of compression after endovenous ablation of varicose veins.

OBJECTIVE: The aim of this review was to identify the evidence regarding the optimal duration of compression therapy after endovenous ablation of varicose veins. METHODS: Electronic databases were searched for studies assessing the use of compression after endovenous ablation in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The primary outcomes for this study were pain score and complications. Secondary outcomes were time to full recovery, quality of life score, leg circumference, bruising score, and compliance rates. RESULTS: Following strict inclusion and exclusion criteria, five studies were included in our review, including a total of 734 patients. The short-duration compression therapy ranged from 4 hours to 2 days, whereas the longer duration ranged from 3 to 15 days. A single study showed a better outcome in terms of complications with a short compression therapy. A single study showed a benefit to pain and quality of life with extended compression therapy, whereas the others did not. There was no significant difference in terms of bruising, recovery time, and leg swelling. CONCLUSIONS: Our review showed that there is no evidence for the extended use of compression after endovenous ablation of varicose veins.

Vascular access for home haemodialysis.

INTRODUCTION:: Home haemodialysis has been advocated due to improved quality of life. However, there are very little data on the optimum vascular access for it. METHOD:: A retrospective cohort study was carried on all patients who initiated home haemodialysis between 2011 and 2016 at a large university hospital. Access-related hospital admissions and interventions were used as primary outcome measures. RESULTS:: Our cohort consisted of 74 patients. On initiation of home haemodialysis, 62 individuals were using an arteriovenous fistula as vascular access, while the remaining were on a tunnelled dialysis catheter. Of the 12 patients who started on a tunnelled dialysis catheter, 5 were subsequently converted to either an arteriovenous fistula ( n = 4) or an arteriovenous graft ( n = 1). During the period of home haemodialysis use, four arteriovenous fistula failed or thrombosed with patients continuing on home haemodialysis using an arteriovenous graft ( n = 3) or a tunnelled dialysis catheter ( n = 1). To maintain uninterrupted home haemodialysis, interventional rates were 0.32 per arteriovenous fistula/arteriovenous graft access-year and 0.4 per tunnelled dialysis catheter access-year. Hospital admission rates for patients on home haemodialysis were 0.33 per patient-year. CONCLUSION:: Our study has shown that home haemodialysis can be safely and independently performed at home within a closely managed home haemodialysis programme. The authors also advocate the use of arteriovenous fistulas for this cohort of patients due to both low complication and intervention rates.

Effect of tumescent anesthesia and patient positioning on laser tip junctional distance during endovenous laser ablation.

BACKGROUND: The correct positioning of the laser tip at the saphenofemoral or saphenopopliteal junction during endovenous laser therapy is paramount to ensure a safe and effective procedure. The aim of this study was to demonstrate how patient positioning and tumescence infiltration can affect this safe junctional distance. METHODS: A retrospective review of a prospectively maintained database was carried out for all patients who received endovenous laser treatment for symptomatic varicose veins between February 2008 and February 2014 in one surgeon's practice in a teaching hospital vascular unit. The junctional distance of the laser tip from the saphenofemoral or saphenopopliteal junction was measured two times during the procedure: before tumescence and before laser deployment with the patient in a Trendelenburg position. RESULTS: Junctional distance was found to have increased in 62% cases (490 patients; great saphenous vein [GSV], 348; small saphenous vein [SSV], 142). Of these, 17% (84) required the laser tip to be advanced (GSV, 56; SSV, 28) to maintain a desired junctional distance of 0.75 to 2 cm. In 185 patients (23%), the junctional distance was noted to have been reduced (GSV, 155; SSV, 30), with 58% (GSV, 79; SSV, 28) requiring the laser tip to be withdrawn to the desired junctional distance; 23% of patients (185) had no change in the junctional distance. CONCLUSIONS: This study has demonstrated the effect of tumescence infiltration and Trendelenburg positioning on laser tip placement, and thus a final junctional measurement before activation of the laser is recommended to maintain a safe and optimal junctional distance.

Identification of occult active infection using PET-CT in a combined liver-kidney transplant candidate.

This case describes a patient being considered for combined liver-kidney transplantation for Caroli's disease with a failed renal transplant. A chronic septic focus could not be located with standard imaging techniques, such as ultrasonography and computed tomography. This case report highlights the observation that a retained non-functioning transplant can be the cause of fever of unknown origin and PET-CT can be useful in diagnosing these challenging cases.

Novel use of infrared thermal imaging to predict arteriovenous fistula patency and maturation.

OBJECTIVE: The arteriovenous fistula (AVF) is the preferred method of long-term haemodialysis. However, it has been shown to have a substantial rate of maturation failure. The formation of an AVF creates haemodynamic changes to blood flow in the arm with diversion of blood away from the distal circulation into the low pressure venous system, in turn, leading to thermal changes distally. In this study, we aimed to assess the novel use of infrared thermal imaging as a predictor of arteriovenous maturation. METHODS: A prospective cohort study was conducted on 100 consecutive patients who had AVF formation from December 2015 to June 2016. Infrared thermal imaging was undertaken pre- and post-operatively on the day of surgery to assess thermal changes to the arms and to assess them as predictors of clinical patency and functional maturation. RESULTS: For clinical patency, infrared thermal imaging was found to have a positive predictive value of 88% and a negative predictive value of 86%. For functional maturation, it was found to have a positive predictive value of 84%, a negative predictive value of 95%. In addition, it was shown to have superiority to the commonly used intra-operative predictor of thrill as well as other independent pre-operative patient factors. CONCLUSIONS: Infrared thermal imaging has been found to be a very useful tool in accurately predicting fistula patency and maturation.

Duplex ultrasound surveillance after carotid artery endarterectomy.

OBJECTIVE: After carotid endarterectomy (CEA), patients have been regularly followed up by duplex ultrasound imaging. However, the evidence for long-term follow-up is not clear, especially if the results from an early duplex scan are normal. This study assessed and systematically reviewed the evidence base for long-term surveillance after CEA and a normal early scan. METHODS: Electronic databases were searched for studies assessing duplex surveillance after CEA in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome for this study was the incidence of restenosis after a normal early scan. The secondary outcome was the number of reinterventions after a normal early scan. RESULTS: The review included seven studies that reported 2317 procedures. Of those patients with a normal early scan, 2.8% (95% confidence interval, 0.7%-6%) developed a restenosis, and 0.4% (95% confidence interval, 0%-0.9%) underwent a reintervention for their restenosis during the follow-up period. CONCLUSIONS: This review confirms that routine postoperative duplex ultrasound surveillance after CEA is not necessary if the early duplex scan is normal.