The utilisation of vascular limb salvage services in the assessment and management of chronic limb-threatening ischaemia and diabetic foot ulceration: A systematic review.

Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.

Cardiovascular Risk Reduction is Important for Improving Patient and Graft Survival After Ligation and Bypass Surgery for Popliteal Artery Aneurysm.

OBJECTIVES: To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival. MATERIALS AND METHODS: A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively. RESULTS: Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively. CONCLUSION: This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.

Role of Simulation in Endovascular Aneurysm Repair (EVAR) Training: A Preliminary Study.

BACKGROUND: Endovascular aneurysm repair (EVAR) requires a high-level of technical-competency to avoid device-related complications. Virtual reality simulation-based training (SBT) may offer an alternative method of psychomotor skill acquisition; however, its role in EVAR training is undefined. This study aimed to: a) benchmark competency levels using EVAR SBT, and b) investigate the impact of supervised SBT on trainee performance. METHODS: EVAR procedure-related metrics were benchmarked by six experienced consultants using a Simbionix Angiomentor EVAR simulator. Sixteen vascular surgical trainees performing a comparable EVAR before and after structured SBT (>4 teaching sessions) were assessed utilising a modified Likert-scale score. These were benchmarked for comparison against the standard set by the consultant body. RESULTS: Median procedural-time for consultants was 43.5 min (IQR 7.5). A significant improvement in trainee procedural-time following SBT was observed (median procedural time 77 min [IQR 20.75] vs. 56 min [IQR: 7.00], p < .0001). The mean (SD) trainee Likert score pre- and post-SBT improved (16.6 [SD 1.455] vs. 28.63 [SD 2.986], p < .0001). Fewer endoleaks were observed (p = .0063) and trainees chose an appropriately sized device more often after SBT. CONCLUSION: This study suggests that EVAR-SBT should be considered as an adjunct to standard psychomotor skill teaching techniques for EVAR within the vascular surgery training curricula.

Procedural risk following carotid endarterectomy in the hyperacute period after onset of symptoms.

OBJECTIVES: There have been concerns that performing carotid endarterectomy (CEA) in the hyperacute period after onset of a transient ischaemic attack (TIA) or stroke may be associated with a significant increase in the procedural risk that could offset any long-term benefit to the patient. The aim of this audit was to determine the 30-day risk of stroke/death after CEA in symptomatic patients, stratified for delay from the most recent neurological event, mode of presentation, and age. METHODS: Retrospective audit in 475 recently symptomatic patients between October 1, 2008, and April 24, 2013. RESULTS: Forty-one patients (9%) underwent surgery <48 hours of their most recent event, with a 30-day death/stroke rate of 2.4% (1/41). The procedural risk was 1.8% in 167 patients who underwent surgery within 3-7 days (3/167), falling to 0.8% in 133 patients who underwent surgery between 8 and 14 days (1/133) and 0.8% in 134 patients whose surgery took place after >14 days had elapsed (1/134). Overall, 208 (44%) underwent surgery within 7 days of their most recent neurological event (30-day risk = 1.9%), while 341 (72%) underwent CEA within 14 days (30 day risk = 1.5%). 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). CONCLUSIONS: 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.

Clinical fellowships in surgical training: analysis of a national pan-specialty workforce survey.

BACKGROUND: Fellowship posts are increasingly common and offer targeted opportunities for training and personal development. Despite international demand, there is little objective information quantifying this effect or the motivations behind undertaking such a post. The present study investigated surgical trainees' fellowship aims and intentions. METHODS: An electronic, 38-item, self-administered questionnaire survey was distributed in the United Kingdom via national and regional surgical mailing lists and websites via the Association of Surgeons in Training, Royal Surgical Colleges, and Specialty Associations. RESULTS: In all, 1,581 fully completed surveys were received, and 1,365 were included in the analysis. These represented trainees in core or higher training programs or research from all specialties and training regions: 66 % were male; the mean age was 32 years; 77.6 % intended to or had already completed a fellowship. Plastic surgery (95.2 %) and cardiothoracic (88.6 %) trainees were most likely to undertake a fellowship, with pediatrics (51.2 %), and urology (54.3 %) the least likely. Fellowship uptake increased with seniority (p < 0.01) and was positively correlated (p = 0.016, r = 0.767) with increasing belief that fellowships are necessary to the attainment of clinical competence, agreed by 73.1 %. Fellowship aims were ranked in descending order of importance as attaining competence, increasing confidence, and attaining subspecialist skills. CONCLUSIONS: Over three-quarters of trainees have or will undertake a clinical fellowship, varying with gender, specialty, and seniority. Competence, confidence, and subspecialty skills development are the main aims. The findings will influence workforce planning, and perceptions that current training does not deliver sufficient levels of competence and confidence merit further investigation.

Dexamethasone-induced cytokine changes associated with diminished disease severity in horses infected with Anaplasma phagocytophilum.

Anaplasma phagocytophilum is the zoonotic cause of granulocytic anaplasmosis. We hypothesized that immune response, specifically gamma interferon (IFN-γ), plays a role in disease severity. To test this, horses were infected and IFNG expression was pharmacologically downregulated using corticosteroids. Eight horses were infected with A. phagocytophilum; 4 received dexamethasone on days 4 to 8 of infection. Clinical signs, hematologic parameters, and transcription of cytokine/chemokine genes were compared among treated and untreated horses. Infection was quantitated by msp2 real-time PCR and microscopy. As anticipated, there was significantly greater leukopenia, thrombocytopenia, and anemia in infected versus uninfected horses. The A. phagocytophilum load was higher for dexamethasone-treated horses. Dexamethasone reduced IFNG transcription by day 12 and IL-8 and IL-18 by days 7 to 9 and increased IL-4 on day 7. The ratio of IL-10 to IFNG was increased by dexamethasone on day 9. There were no hematologic differences between the infected horses. Dexamethasone suppression of proinflammatory response resulted in delayed infection-induced limb edema and decreased icterus, anorexia, and reluctance to move between days 6 and 9 and lower fever on day 7. These results underscore the utility of the equine model of granulocytic anaplasmosis and suggest that Th1 proinflammatory response plays a role in worsening disease severity and that disease severity can be decreased by modulating proinflammatory response. A role for Th1 response and macrophage activation in hematologic derangements elicited by A. phagocytophilum is not supported by these data and remains unproven.

Below-the-ankle angioplasty is a feasible and effective intervention for critical leg ischaemia.

AIM: Occlusion or severe stenosis of pedal and plantar arteries limits surgical options for critical limb ischaemia (CLI). Below-the-ankle (BTA) angioplasty is potentially useful as an adjunct to proximal angioplasty. In this study, the feasibility and outcome of this procedure were explored, as they have not been evaluated previously. METHODS: Patients' demographics, indications, procedures and outcomes were recorded. Outcomes were determined by technical success, primary patency, limb salvage and amputation-free survival (AFS) rates. RESULTS: Between 2004 and 2008, 42 cases of BTA angioplasty were performed for 39 patients. Forty cases (95.2%) had CLI. Technical success was achieved in 88% of cases. At 6, 12 and 24 months, AFS was 70.7%, 60.9% and 57.1%, limb salvage was 84.9%, 81.9% and 81.9% and patient survival was 83.3%, 73.8% and 67.3, respectively. Seven major amputations (16.6%) were performed, four of which had failed angioplasty. Two patients required re-intervention. Univariate analysis showed insulin-dependent diabetics, occlusive lesions, failure of angioplasty and state of the run off to be the predictors of limb loss. CONCLUSIONS: BTA angioplasty for pedal and plantar arterial occlusive disease is technically feasible. It has good medium-term clinical outcome and limb salvage in a group of patients with poor surgical options.

Review of direct anatomical open surgical management of atherosclerotic aorto-iliac occlusive disease.

BACKGROUND: Aortofemoral bypass(AFB), iliofemoral bypass(IFB), and aortoiliac endarterectomy(AIE) are the three most common techniques for anatomical open surgical revascularisation for patients with aorto-iliac occlusive disease(AIOD), but the optimal method of reconstruction is unknown. AIMS: To review and compare mortality, morbidity and short- and long-term patency rates for AFB, IFB and AIE in patients with AIOD reported in the English language literature METHODS: A MEDLINE(1970-2007) and Cochrane Library search for articles relating to AFB, IFB, AIE and AIOD was undertaken. Studies were included if: a) patency rates based on life-tables were available, and b) patient/study characteristics were reported. RESULTS: 29 studies(5738 patients) for AFB, 11 studies(778 patients) for IFB and 11 studies(1490 patients) for AIE were included. Operative mortality was 4.1% for AFB, 2.7% for IFB and 2.7% for AIE (p<0.0001). Systemic morbidity was 16.0% for AFB, 18.9% for IFB and 12.5% for AIE (p<0.05). Overall 5-year primary patency rates were 86.3%, 85.3% and 88.3% for AFB, IFB and AIE, respectively (p=NS). CONCLUSION: Aorto-iliac endarterectomy was associated with significantly lower peri-operative morbidity and mortality rates compared with bypass grafting. All three techniques were equally effective in terms of long-term patency.

Local versus general anaesthesia for varicose veins surgery: a prospective non-randomized controlled trial.

OBJECTIVE: To compare the acceptability and outcome of primary varicose vein (VV) surgery (saphenofemoral or saphenopopliteal ligation/excision) under local anaesthesia (LA) with that of general anaesthesia (GA). METHODS: A non-randomized controlled trial of consecutive patients treated between April 2004 and March 2006 was performed. After complete informed consent individual patients were asked to select their preferred form of anaesthesia (LA or GA). Preoperative disease status and co-morbidities were recorded. Outcomes were assessed perioperatively and at six weeks and six months postoperatively using patient scoring systems including the Aberdeen varicose veins severity score (AVVSS). RESULTS: Seventy-two (LA 46[62%] and GA 26[38%]) patients participated; median (range) age was 48 (21-74) years versus 36 (21-59) years (P = 0.0164), respectively. All procedures were performed as day cases. Median postoperative pain scores for LA and GA did not differ at 12 hours (4 versus 4; P = 0.48) and four days (5 versus 6; P = 0.44). Median improvement in the AVVSS at six weeks and six months for LA and GA cohorts were 5.7 versus 6.1 (P = 0.875) and 6.5 versus 8.3 (P = 0.131), respectively. Overall patient satisfaction did not show any intergroup difference at six weeks. CONCLUSIONS: Surgical treatment of VV under LA can be performed safely with comparable results to GA in self-selected patients.

The impact of hormone replacement therapy on the pathophysiology of peripheral arterial disease.

BACKGROUND: Hormone replacement therapy (HRT) is recommended to post-menopausal women to control menopausal symptoms and prevent osteoporosis. The management of women with peripheral arterial disease (PAD) and who are taking HRT is controversial. AIM: To summarise what is known about HRT and its effect on the natural progression of PAD and its subsequent treatment. METHODS: A MEDLINE (1966-2004) and Cochrane library search for articles relating to HRT and PAD was undertaken. RESULTS: The potential benefits of unopposed estrogen therapy on atherosclerotic progression and limb microcirculation are outweighed by the increased risk of endometrial dysplasia and thrombotic complications. Only one major study (Rotterdam) specifically assessed the impact of HRT on the clinical course of PAD. The findings suggested a decreased risk of PAD among healthy post-menopausal women taking HRT which contrasts with the sub-group analyses of other major studies (HERS/HERS II). HRT appears to reduce the primary success rates of both endovascular and open surgical revascularisation in patients with PAD. CONCLUSIONS: Further studies are required to investigate the effects of HRT on the progression of PAD and its management.

Long-term results of surgical repair of popliteal artery aneurysm.

OBJECTIVE: To determine the long-term outcome of surgical repair of popliteal artery aneurysms (PAA). METHODS: A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1988 and 2006 was performed. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan-Meier methods. RESULTS: 48 patients underwent repair of 63 PAAs (ligation and bypass=45, interposition grafting=18). The 5-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 75%, 95%, 98% and 81%, respectively. The 10-year primary graft patency rates were significantly lower for emergency cases (59%) compared with elective cases (66%) (p=0.0023). Thirteen patients (16 PAAs) required a total of 20 late re-interventions. Duplex ultrasound was available in 33 of 45 PAAs treated by ligation and bypass. Five (15%) PAAs demonstrated perfusion of the aneurysm sac at median (range) follow up of 75 (1-246) months after primary repair and two of these required emergency re-operation. CONCLUSIONS: These data demonstrate that surgical PAA repair is associated with excellent long-term durability and provide an important benchmark with which to compare results of endovascular PAA repair. Patients treated using the ligation and bypass technique should be enrolled in an aneurysm sac surveillance program.

Nonocclusive intestinal ischemia: improved outcome with early diagnosis and therapy.

Nonocclusive intestinal infarction (NOII) is described as bowel necrosis at celiotomy or autopsy without evidence of thromboembolism, vasculitis, or mechanical obstruction. The mortality for this entity is as high as 90 per cent in some series. From January 1990 to January 1995, we identified 15 patients who met the criteria for NOII identified at celiotomy or autopsy. We collected data on demographics, comorbidities, presenting signs and symptoms, laboratory workup, time to definitive therapy, and outcome. Our goal was to improve our ability to identify and treat this devastating surgical problem. There was a 4.5:1 female to male ratio, and patients had an average age of 73 +/- 10 years. Significant comorbidities included coronary artery disease (87%) and atrial fibrillation (73%). Eleven patients were diagnosed at celiotomy and four at autopsy. Overall mortality was 67 per cent. The most common presenting symptoms were abdominal pain (93%) and distention (80%) and mental status changes (60%). Peritonitis was less common, present in only 40 per cent of the patients. Leukocytosis, bandemia, increased creatinine, metabolic acidosis, and hypoxemia were common among all patients. There was a significant difference in time to definitive therapy in survivors versus nonsurvivors (1.2 +/- 0.89 vs 4.8 +/- 2.0 days; P < 0.02, t test). These data suggest that NOII is a lethal surgical problem. A history of coronary artery disease and atrial fibrillation was common among all patients. Various nonspecific presenting signs, symptoms, and laboratory values are suggestive of this diagnosis. A high index of suspicion in select patients and early intervention may lead to improved outcome.