Case report of an arteriovenous graft for renal dialysis, with multiple complications treated successfully over 5 years.

INTRODUCTION: Arteriovenous grafts (AVG) is a good alternative when native arteriovenous fistula (AVF) is not possible. However, complications are higher and close surveillance is required for successful salvage intervention. PRESENTATION OF CASE: We present the case of a 35 year old man with a history of a successful Brachio-Axillary AVG performed in his right arm in 2012. He had a background of multiple previous failed attempts of a native AVF formation. He presented in 2014 with symptoms consistent with AVF stenosis. He underwent a successful fistuloplasty and 2 stent insertion. In June 2015 he presented again with re-stenosis and successful fistuloplasty was performed with balloon dilatation. In October 2015 he presented with AVF thrombosis. This was treated with fistuloplasty and thrombolysis. He presented again in August 2016 with a recurrent thrombosis in his AVG and this was again treated with a successful fistuloplasty and thrombolysis on two separate occasions. He then presented in September 2016 with re-stenosis. This was treated with fistuloplasty and 2 stent insertion. He underwent a successful renal transplant during this time and presented again with a sinus discharge in February 2019 when the plan was made for subtotal graft excision. CONCLUSION: Incidence of complications is higher when a graft is used over a native AVF. However, close surveillance and prompt intervention can lead to multiple successful salvage procedures thus prolonging the lifespan of the graft. As in our case we were able to prolong the lifespan of the AVG with multiple successful interventions.

Risks for Surgical Site Infection after Infra-inguinal Bypass

Aims To define the burden of wound complications in patients with infra-inguinal bypass surgery. Methods A retrospective review of 50 consecutive patients from January 2012 to July 2017. Data collected included patient demographics, operative details, length of stay (LOS) and postoperative complications. Results The average age was 64 years (range 25-88 years) and 10 had a body mass index (BMI) ≥25 kg/m2. Pre-operative methicillin-resistant Staphylococcus aureus (MRSA) screening was performed in 17 patients (n=4 positive). Surgical antimicrobial prophylaxis (SAP) continued longer than 24 hours in 25. Surgical site infection (SSI) was the most common complication (n=10) and associated with female gender (p= 0.039), high BMI (p=0.017), shorter preoperative (p=0.039) and longer postoperative LOS (p=0.022). Three of 46 patients and four of 38 had graft occlusion at 30 days and one year respectively. Conclusion Pre-operative co-morbidity (e.g., BMI reduction), and MRSA screening optimization and SAP are areas identified for improvement.

Burnout and stress amongst interns in Irish hospitals: contributing factors and potential solutions.

BACKGROUND: The transition from medical school to internship can be daunting for newly qualified doctors. High rates of stress and burnout have been reported, with negative impacts on patient care and physician wellbeing. AIMS: We surveyed interns in our hospital group to evaluate rates of stress and burnout, as well as identify the causative factors and propose potential solutions to these. METHODS: A hundred and one interns working in four different hospitals over a 2-year period were invited to participate in an anonymous survey. The survey collected basic demographic details and surveyed aspects of mental health using the burnout scale, Maslach Burnout Inventory (MBI) and the stress scale and 12-item General Health Questionnaire (GHQ-12). Interns were also asked to rate a variety of workplace factors on a Likert scale based on the degree of stress caused. Finally, they were surveyed on their awareness of support services available to them. RESULTS: Our results showed that 37% of interns met the criteria for psychological distress, high levels of emotional exhaustion, high depersonalisation and a low sense of personal accomplishment were reported in 55.4, 51.5 and 41.6%, respectively. Inadequate preparation for practice, financial worries, poor role definition and sleep deprivation were reported as significant stressors. Most were unaware of available support services and expressed interest in leaving Ireland after internship. CONCLUSIONS: Burnout and stress are significant problems amongst doctors in Irish hospitals. Ensuring better preparation for clinical practice and awareness of support services is vital to tackle this issue.

An Irish Experience in Establishing and Evaluating an Intern Led Teaching Programme.

Near-Peer Teaching is a relatively new and expanding area of medical education. The benefit to medical students has been demonstrated in numerous contexts around the world. Our aim was to establish a structured Intern-Led Teaching (ILT) programme in the context of an Irish Intern Training Network affiliated to an Irish Medical School. We then sought to evaluate the success of this programme. Seventy interns were enrolled in the ILT programme and completed a Train the Trainer course involving teaching methods and skills of effective feedback. Following this, the intern tutors delivered several one-hour teaching sessions in small groups to final year medical students on a weekly basis. At the end of each teaching block, a feedback questionnaire was distributed to participating students to evaluate their experiences of this new teaching modality. Tutorial topics were varied. They included clinical examination, history taking, prescribing, and emergencies. Eighty-one percent of students found the intern-led tutorials to be beneficial compared to tutorials run by more senior doctors. Additionally, students felt that with intern led tutorials they could ask questions they otherwise would not. There was a more comfortable environment, and information taught was considered more relevant. A significant number of students felt less nervous about the final medical examinations after the intern-led tutorials. The establishment of a structured intern-led teaching programme was well received by final year medical students. This project shows that interns are a valuable teaching resource in the medical school and should be included in medical schools' curricula.

How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review.

PURPOSE: Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications. METHODS: We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia. RESULTS: Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive. CONCLUSIONS: We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

Radiofrequency ablation: an assessment of clinical and cost efficacy.

BACKGROUND: Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. AIMS: The aim of this study was to directly compare RFA and open saphenofemoral ligation. METHODS: This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. RESULTS: During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P = <0.001) when compared with open ligation with a success rate of 98 %. No significant inter-group difference was noted for 30-day readmission (p = 0.203). Focused cohort analysis identified an increase in hospital day case activity (74 vs. 90 %, p = 0.002), which contributed to a reduction in procedural cost (€1,024 vs. €971, p = 0.003) over the study period. CONCLUSIONS: Radiofrequency ablation is a viable alternative to open repair offering excellent efficacy. It is however associated with a higher procedural cost than the open surgical option.

The effect of carotid stenting on endarterectomy practice--A single institution experience.

OBJECTIVES: The number of operations performed per surgeon is thought to determine the quality of carotid endarterectomy (CEA) surgery. The advent of carotid artery stenting (CAS) threatens to reduce the volume of CEA. This paper assesses CEA and the effects of the introduction of CAS service on outcomes. DESIGN: Retrospective cohort study. METHODS: Clinical data and results of CEA were reviewed retrospectively for the treatment of carotid stenosis, between January 1988 and December 2010. CEA patients were grouped into those treated before and after the introduction of CAS to our hospital in 2001. RESULTS: 757 patients underwent a CEA between 1988 and 2010. The perioperative stroke rate prior to the introduction of CAS was 4.9%, and 3.3% after stent introduction in 2001. In this latter period, 85.5% had symptomatic stenosis which suggests that the patients were not low risk. The major adverse event rate (inclusive of death and myocardial infarction) post introduction of CAS from 2001 to 2010 was 4.1%. There was no correlation between post-operative stroke/MAE and procedure volume, despite the trend of decreasing CEA numbers over time. CONCLUSION: The introduction of carotid artery stenting has led to a decrease in carotid endarterectomy volume. However, outcomes in our high risk patient population are acceptable. Therefore, CEA remains the procedure of choice for carotid artery revascularization.

Endovascular versus open repair of ruptured abdominal aortic aneurysm.

INTRODUCTION: Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre. METHODS: Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p < 0.05 considered significant. RESULTS: A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3-4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029). CONCLUSIONS: Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

Making the case for cardiovascular screening in Irish males: detection of abdominal aortic aneurysms, and assessment of cardiovascular risk factors.

INTRODUCTION: AAA screening programmes have proven to be beneficial and cost effective worldwide for males greater than 65 years of age, with 4.9% males of 65-75 years of age having an un-diagnosed AAA at screening, resulting in a 42% reduction in the risk of rupture in an English population. This study assessed the incidence of AAA and risk factors for atherosclerosis in Irish males of 55-75 years. METHODS: From April 2006 to December 2007, males between the ages of 55 and 75 years, living within the catchment area of Blanchardstown Hospital were invited for AAA screening using duplex ultrasound and cardiovascular risk factor screening. RESULTS: 1.9% (17/904) of the study population had previously un-diagnosed aneurysms detected, with sizes ranging from 3.0 cm to 5.8 cm (0.6% in 55-65 years old (yo) and 4.2% in 65-75 yo, p<0.01). 33% (302/904) of patients had hyperlipidaemia, while 16% of those with a previous diagnosis of hyperlipidaemia, were inadequately controlled on the test date. 31% of patients had a single elevated blood pressure reading, meriting further investigation for possible hypertension. 3% (28/904) of all patients had a raised glucose levels which had not previously been identified and of those who had a previous history of DM, 46% had abnormal glucose levels. 16% of patients (93/573) were morbidly obese (BMI>30) and 64% (292/573) were overweight. CONCLUSION: The incidence of AAAs in 65-75-year-old men is similar to international figures. This study confirms that screening for hyperlipidaemia, hypercholesterolaemia, obesity and hypertension may be worthwhile in all males over 55 years, while AAA screening should be reserved for 65-75-year-old Irish males.

Carotid artery stenting: to be or not to be?

Carotid endarterectomy (CEA) has been the standard of care for suitable patients with symptomatic or asymptomatic high grade carotid stenosis since the landmark NASCET (North American Symptomatic Carotid Endarterectomy Trial), ECST (European Carotid Surgery Trial) and ACAS (Asymptomatic Carotid Artery Surgery) studies performed in the 1990s and more recently the ACST (Asymptomatic Carotid Surgery Trial). Carotid artery stenting (CAS) in the treatment of both symptomatic and asymptomatic patients with high grade carotid stenosis has recently been investigated as an alternative to CEA. We present a review of the most recent CAS trials and examine some of the controversies that surround them.

Endoscopic thoracic sympathectomy for long QT syndrome.

BACKGROUND: A 54-year-old woman was referred to our service with intractable ventricular arrhythmias secondary to a familial long-QT syndrome. Her first presentation was 4 years previously, when she suffered a cardiac arrest, at this time an (Automatic Implantable Cardioverter Defibrillator) AICD device was inserted and she was commenced on sympathetic blockers. She remained symptomatic with ongoing tachyarrhythmias and the subsequent automatic cardioversion or defibrillation was causing significant amount of distress. RESULTS: She underwent a left transthoracic endoscopic cardiac sympathectomy and made a good postoperative recovery. She remains asymptomatic at four months. CONCLUSION: Though open sympathectomy is an established treatment, there are only isolated reports of thoracoscopic sympathetic cardiac denervation in the literature.

Taurine and vitamin C modify monocyte and endothelial dysfunction in young smokers.

BACKGROUND: Endothelial dysfunction initiated by monocyte-endothelial interactions has previously been observed in many vasculopathies, including chronic cigarette smoking. Taurine, a semiessential amino acid, and vitamin C, a naturally occurring antioxidant, have previously been shown to have endothelial protective effects when exposed to proinflammatory insults. Therefore, we hypothesized that taurine and vitamin C would restore endothelial function in young smokers by modifying monocyte-endothelial interactions. METHODS AND RESULTS: Endothelial-dependent vasodilatation was assessed in vivo using duplex ultrasonography, and monocyte-endothelial interactions were assessed in vitro using endothelial cell culture (human umbilical vein endothelial cells [HUVECs]) with monocyte-conditioned medium (MCM). Endothelial-dependent vasodilatation was significantly impaired in young smokers compared with nonsmokers. Pretreatment of young smokers for 5 days with 2 g/d vitamin C and, more significantly, with 1.5 g/d taurine attenuated this response. MCM taken from smokers impaired the release of nitric oxide and increased the levels of endothelin-1 release from HUVECs. When HUVECs were cultured with MCM from smokers who had been treated with taurine, the levels of nitric oxide and endothelin-1 returned toward control levels. This was attributed to an upregulation in endothelial nitric oxide synthase expression. CONCLUSIONS: These observations suggest that taurine supplementation has a beneficial impact on macrovascular endothelial function, and an investigation of its effect on altered endothelial function in dyslipidemic states is warranted.

Preoperative treatment with recombinant human growth hormone prevents ischemia reperfusion-induced diaphragmatic dysfunction.

BACKGROUND: Respiratory complications continue to be a major cause of morbidity and mortality following major vascular surgery. The recent UK Small Aneurysm Trial cited preoperative respiratory function as the major predictor of outcome following elective aortic surgery. AIM: The aim of this study was to investigate the effect of aortic clamping and revascularization on diaphragmatic muscle function in a small animal model and to evaluate the role of preoperative treatment with recombinant human growth hormone (rhGH) in preventing diaphragmatic muscle dysfunction. METHODS: Male Sprague-Dawley rats (n = 18) were randomized into one of three groups: control (n = 6) underwent laparotomy only; IR (n = 6) had a laparotomy with infrarenal cross-clamping for 30 min followed by lower torso revascularization for 2 h; IR + rhGH (n = 6) were treated with rhGH (Genotropin 0.3 IU/kg/day) for 5 days before laparotomy and aortic cross-clamping for 30 min followed by lower torso revascularization for 2 h. Diaphragmatic muscle contractile function was assessed ex vivo using electrical field stimulation in a tissue bath. RESULTS: Two hours of IR injury resulted in a significant impairment in diaphragmatic twitch (Control, 242.01 + 38.45 g; IR, 108.55 + 7.15 g). This impairment was prevented by pretreatment with rhGH (rhGH, 319.14 + 30.71 g; P < 0.01). Tetanic function was also significantly impaired by ischemia reperfusion injury (control, 605 + 77.63 g; IR, 228.12 + 14.38 g). Again, pretreatment with rhGH prevented this deterioration (IR + rhGH, 704.39 + 45.69 g; P < 0.05) compared with controls. CONCLUSION: The results of this study suggest that preoperative administration of rhGH may have a role in preventing the diaphragmatic dysfunction associated with infrarenal aortic cross-clamping and revascularization.

Oral vitamin C attenuates acute ischaemia-reperfusion injury in skeletal muscle.

Ischaemia-reperfusion injury (IRI) is caused by endothelial and subendothelial damage by neutrophil-derived oxidants. Vitamin C is an antioxidant which attenuates endothelial injury after IRI. Our aim was to evaluate the effect of oral vitamin C in the prevention of IRI in skeletal muscle. We used a model of cross-clamping (3 hours) and reperfusion (1 hour) of the cremaster muscle in rats. Muscle function was assessed electrophysiologically by electrical field stimulation. Infiltration by neutrophils was determined by the activity of tissue myeloperoxidase (MPO) and tissue oedema by the wet-to-dry ratio. Neutrophil respiratory burst activity was measured in control animals and groups pretreated with vitamin C. IRI significantly decreased muscle function and increased muscle neutrophil MPO activity and muscle oedema. Pretreatment with vitamin C preserved muscle function and reduced tissue oedema and neutrophil infiltration. Neutrophil respiratory burst activity was reduced in the group treated with vitamin C compared with the control group. We conclude that pretreatment with oral vitamin C protects against acute muscle IRI, possibly by attenuating neutrophil respiratory burst activity.