Outcomes of carotid endarterectomy: Insights from a single-center retrospective cohort study.

OBJECTIVES: To analyze the outcomes of carotid endarterectomy in individuals with carotid artery stenosis in the context of a tertiary care center. METHODS: We carried out a retrospective cohort investigation between 2015-2022. Patient data includes demographics, risk factors, preoperative medications, and operative details. The primary outcomes were 30-day postoperative stroke and mortality rates, while the secondary outcome of the study was to assess the morbidity of the procedure. RESULTS: The mean age of the 54 patients was 66.9±9.88 years, and 57.4% were men. The 30-day stroke rate was 3.7%, and the mortality rate was 1.9%. Most patients did not develop postoperative complications; however, surgical site hematoma was the most common complication encountered (12.9%). Long-term follow-up showed disease regression in 68.5% of patients, with a minority of patients developing ipsilateral restenosis. Admission to an intensive care monitoring unit was the only independent predictor of postoperative complications. CONCLUSION: This study provided insights into the outcomes of carotid endarterectomy in patients with carotid artery stenosis, emphasizing the importance of careful patient selection and postoperative monitoring. Perioperative risks, including stroke and mortality, were within acceptable limits. Further research incorporating structured and non-structured data for predictive analyses, should explore refining patient profiling and optimizing treatment approaches for different carotid artery stenosis clinical and morphological presentations.

Management and Outcomes of Traumatic Liver Injury: A Retrospective Analysis from a Tertiary Care Center Experience.

BACKGROUND: although liver injuries are one of the most critical complications of abdominal trauma, choosing when to operate on these injuries is challenging for surgeons worldwide. METHODS: We conducted a retrospective analysis of liver injury cases at our institution from 2016 to 2022 to describe the operative and nonoperative management (NOM) outcomes in patients with traumatic liver injuries. Baseline patient characteristics, liver injury details, treatments, and outcomes were analyzed. RESULTS: Data from 45 patients (male, 77.8%) were analyzed. The mean age was 29.3 years. Blunt trauma was the most common injury mechanism (86.7%), whereas penetrating injuries were 8.9% of cases. Conservative management was associated with 18.9% of complications. The overall complication rate was 26.7%; delirium and sepsis were the most common (13.3%), followed by acute renal failure (4.4%), pneumonia, biliary leaks, and meningitis/seizures. CONCLUSIONS: Notwithstanding its limitations, this retrospective analysis demonstrated that NOM can serve as a safe and effective strategy for hemodynamically stable patients with liver trauma, irrespective of the patient's injury grade. Nevertheless, careful patient selection and monitoring are crucial. Further investigations are necessary to thoroughly evaluate the management of traumatic liver injuries, particularly in the context of multiorgan injuries.

Percutaneous versus Cutdown Access for Endovascular Aortic Repair.

BACKGROUND: This study aimed to compare the outcomes of the percutaneous femoral access and open surgical cutdown access approaches in patients undergoing thoracic/abdominal endovascular aortic repair. METHODS: We retrospectively reviewed the medical records of 59 patients who underwent a thoracic/abdominal endovascular aortic repair at a single tertiary care hospital between 2015 and 2022. Based on their femoral access type, the patients were categorized into the "percutaneous" or "cutdown" groups. Using a computerized sheet, relevant patient data (including demographic information and patient risk factors) were collected. The operative duration, complication rates, mortality rates, intensive care unit admission and stay durations, and total hospital stay were compared between the two groups. The primary outcomes were differences in the postoperative morbidity and mortality associated with the two approaches. RESULTS: The cutdown and percutaneous groups comprised 24 (41%) and 35 (59%) patients, respectively. The two groups displayed comparable demographic and clinical characteristics (p > 0.05). However, the vascular anatomy differed with the common femoral artery diameter being larger in the percutaneous group compared to the cutdown group (9.63 ± 1.81 mm vs. 8.49 ± 1.54 mm, p = 0.028). The ratio of the sheath diameter to the common femoral artery diameter was significantly lower in the percutaneous group than in the cutdown group (0.73 ± 0.16 vs. 0.85 ± 0.20, p = 0.027). A ratio of ≥0.74 was associated with a higher risk of complications (odds ratio, 12.0; 95% confidence interval, 1.4-102.2; p = 0.023) and mortality (odds ratio, 5.79; 95% confidence interval, 1.13-29.6; p = 0.035). Additionally, the operative duration was significantly shorter in the percutaneous group than in the cutdown group (141.43 ± 97.05 min vs. 218.46 ± 126.31 min, p = 0.001). Compared to the cutdown group, the percutaneous group experienced a shorter total hospital stay (21.54 ± 21.49 days vs. 11.60 ± 12.09 days, p = 0.022) and lower intensive care unit-admission rates (66.7% vs. 40%, p = 0.044). CONCLUSION: The percutaneous approach is a viable and more time-efficient alternative to the traditional cutdown method for delivering vascular endografts. It is associated with a significantly shorter operative duration and briefer hospital stays. Additionally, the ratio of the sheath diameter to the common femoral artery diameter can help surgeons preoperatively predict and anticipate the risks of complications and mortality. Future in-depth research is necessary to better understand the association between this ratio and postoperative outcomes and complications.

Synchronous carotid endarterectomy and coronary artery bypass graft: Four case reports.

BACKGROUND: One of the major perioperative complications for coronary artery bypass graft (CABG) is stroke. The risk of perioperative stroke after CABG is approximately 2%. Carotid stenosis (CS) is considered an independent predictor of perioperative stroke risk in CABG patients. The optimal management of such patients has been a source of controversy. One of the possible surgical options is synchronous carotid endarterectomy (CEA) and CABG. Here, we have presented 4 cases of successful synchronous CEA and CABG. CASE SUMMARY: Our center's experience with 4 cases of significant carotid artery stenosis, which were successfully managed with combined CEA and CABG, are detailed. The first case was a female who presented for CABG after a ST-elevation myocardial infarction. She had right internal carotid artery (ICA) occlusion and 90% left ICA stenosis. The second case was a male who was electively admitted for CABG. It was discovered that he had left ICA occlusion and 90% right ICA stenosis. The third case was a male with a history of stroke, two months prior to admission. He presented with non-ST-elevation myocardial infarction. Preoperatively, it was discovered that he had > 90% right ICA stenosis. The final case was a male who was electively admitted for CABG. It was discovered that he had bilateral > 90% ICA stenosis. We have also reviewed the current evidence and guidelines for managing CS in patients undergoing CABG. CONCLUSION: Our case series demonstrated that synchronous CEA and CABG was safe. A multicenter study with additional patients is needed. It is necessary for clinicians to screen for CS in high-risk patients with features.

Carotid body tumor encounters over a two-decade period in an academic hospital.

Carotid body tumors (CBTs) are rare and mostly benign. Research outcomes usually arise from single-center data. We conducted this study to present the characteristics and outcomes of patients who underwent surgical resection of CBT at our hospital over the past 20 years. In this retrospective review, the records of CBTs in our hospital were reviewed between 1998 and 2021. All patients who underwent CBT resection were included. The follow-up period was 12 months. A total of 44 CBTs were treated in our hospital. The male-to-female ratio was 1:2.4. Only 4.5% of patients had Shamblin I tumors. Patients with Shamblin II and III tumors were 56.8% and 38.6%, respectively. Duplex scan was used to diagnose CBT in all of the patients. The majority of our patients (97.7%) did not receive any preoperative embolization despite an average tumor size of 4.9 cm. Cranial nerve injuries were observed in 29.5% of cases. Meanwhile, stroke was reported in only two cases (4.5%). No deaths were encountered. Surgery is the definitive treatment for CBT. Size and local extension appear to be the main reasons for adverse events rather than surgical techniques. Our results are consistent with those of previously published studies. Good outcomes are expected in high-volume centers with appropriate preoperative imaging.

A True Thrombosed External Jugular Vein Aneurysm Presenting as a Cervical Mass: A Case Report and Literature Review.

External jugular venous aneurysms are a rare clinical occurrence. Clinical symptoms such as painless neck swelling that worsens with the Valsalva maneuver, coughing, or straining may point to the diagnosis. Doppler ultrasonography is frequently used to confirm the diagnosis. We report a case of a 43-year-old woman who presented with a one-year history of painless right supraclavicular swelling. She noticed the swelling increases in size with the Valsalva maneuver. Neck ultrasound with color Doppler revealed a vascular structure containing turbulent blood flow; it measured 2.9 x 1.2 cm and appeared partially thrombosed. During further evaluation at our hospital, the patient underwent a computed tomography scan of the neck with intravenous contrast, which revealed a right supraclavicular mass measuring 2.3 x 3.5 cm and likely representing an external jugular vein saccular aneurysm. The patient underwent surgical excision. Histopathological examination of the external jugular vein aneurysm revealed vascular tissue with blood clots, hemosiderin-laden macrophages, and attached benign fibroadipose tissue. The postoperative recovery was uneventful, and the patient was discharged home with regular follow-up in the last one year in our outpatient clinic. Venous aneurysms are an uncommon clinical phenomenon. Saccular venous aneurysms, which mostly affect adults and involve the external jugular venous and internal jugular vein, have degenerative histology and are more prone to thrombosis. Asymptomatic and uncomplicated jugular venous aneurysms should be treated conservatively with regular follow-up. Enlarging, disfiguring, symptomatic, and complicated jugular venous aneurysms, on the other hand, almost always necessitate surgical exclusion and bypass. In comparison to arterial aneurysms, true venous aneurysms are relatively uncommon. For saccular jugular venous aneurysms, surgical excision is the gold standard and is indicated to reduce the risk of aneurysmal rupture and pulmonary embolism.

Vascular thoracic outlet syndrome: Registry of 30-years of patient's outcomes at King Saud University Medical City, Riyadh, Saudi Arabia.

OBJECTIVES: To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS). METHODS: This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months). RESULTS: A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases. CONCLUSION: Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

A Patient-Tailored Approach to Management of Acute Limb Ischemia in Patients with COVID-19: A Case Series.

BACKGROUND Coronavirus disease 2019 (COVID-19) has a tremendous impact on the respiratory tract. In severe COVID-19 infections, patients may experience shock and multiple organ failure. We described 4 cases of severe arterial thrombosis induced by COVID-19 with and without other stressors and their responses to treatment measures. CASE REPORT In Case 1, a 61-year-old man was hospitalized for COVID-19 pneumonia 2 weeks prior to the presentation of acute upper-limb ischemia after intravenous forearm line insertion. He was classified as IIB and thus underwent emergency thrombectomy followed by 3 months of enoxaparin. Case 2 was a 41-year-old female patient with granulomatosis who was admitted to the Intensive Care Unit due to COVID-19 pneumonia and developed acute upper-limb ischemia. A medical approach using therapeutic heparin was used. Case 3 was a 65-year-old man who was admitted due to COVID-19-related pneumonia and was otherwise medically and surgically free. We assessed and managed a new onset of the lower-limb IIB acute limb ischemia (ALI). Case 4 was a patient with the first COVID-19 presentation of ALI, which was managed accordingly. CONCLUSIONS The development of a thrombotic event in patients with COVID-19 was previously reported. Moreover, different management options and outcomes have been reported in the literature. Therefore, careful planning is needed for procedures such as cannulation or central line insertion to prevent such events. In addition, short-term anticoagulation therapy might be of clinical benefit when planning a procedure or if the patient exhibits minor arterial complications.

Are primary care physicians aware of peripheral artery disease risk reduction and management in the Saudi healthcare transformation era? A health cluster observational study.

INTRODUCTION: Patients with peripheral artery disease (PAD) are often underdiagnosed and undertreated. This study aimed to assess the knowledge of the recommended target levels of blood pressure, low-density lipoprotein cholesterol, glycosylated hemoglobin A1C, and knowledge and attitude about PAD risk reduction therapies among physicians working in primary care settings in Saudi Arabia. METHODS: This observational cross-sectional study included family medicine consultants, residents, and general practitioners working in a health cluster in the capital city of Saudi Arabia using a self-administered questionnaire. RESULTS: Of the 129 physicians who completed the survey, 55% had completed PAD-related continuing medical education hours within the past 2 years. Despite this, the knowledge score of the recommended target levels was high in only 13.2% of the participants. Antiplatelet therapy was prescribed by 68.2% of the participants. CONCLUSION: Here we identified the knowledge and action gaps among primary care providers in Saudi Arabia. Physicians had an excellent attitude about screening for and counseling about risk factors. However, they showed less interference in reducing these risk factors. We recommend addressing these knowledge gaps early in medical school and residency programs.

Axillary artery aneurysm associated with Arteriovenous malformations of the upper extremity: A case report.

INTRODUCTION AND IMPORTANCE: Axillary artery aneurysms are an uncommon upper extremity pathology. While trauma is the most common cause, degenerative aneurysms may occur in high-flow vascular conditions, such as upper extremity arteriovenous fistulas. Arteriovenous malformations (AVMs) are a rare cause. CASE PRESENTATION AND DISCUSSION: We herein describe a 41-year-old male with multiple congenital high-flow AVMs in the left upper extremity who presented with an asymptomatic axillary artery aneurysm. The aneurysm was successfully treated with open resection and revascularization using a reversed basilic vein interposition graft. CONCLUSION: Clinicians should be aware of the possibility of an axillary artery aneurysm in patients with upper extremity AVMs.

Endothermal heat-induced thrombosis after endovenous laser ablation: A single-center experience.

Lower limb varicose veins are a common vascular disorder producing pain and disability when truncal vein reflux is present. Endovenous laser ablation (EVLA) of the great saphenous vein (GSV) is a safe and effective method for treating this condition. An unintended complication of this procedure is endothermal heat-induced thrombosis (EHIT) of common femoral vein. A retrospective outcomes analysis of patients who underwent EVLA of the GSV at King Khalid University Hospital from June 2006 to November 2018 was conducted to identify the risks factors and incidence of EHIT. Patients were assessed by clinical examination and duplex ultrasound imaging after the EVLA, and patient demographic characteristics and procedural factors predictive of EHIT were determined. Following EVLA, 11,070 duplex ultrasound examinations were performed for 1,230 limbs, and EHIT was detected in 65 (5.3%) limbs in 60 (6.8%) patients. Essentially all EHIT cases were detected in the first week (n = 63; 96.9%) and clot regression occurred over a period of 1-4 weeks. There were no significant differences in patient demographic characteristics or procedural factors between the EHIT and non-EHIT groups, except for the percentage of women (86% v 73%; P = .02), maximum GSV diameter (6.7 ± 2.7 mm v 6.0 ± 2.1 mm; P = .04), and percentage of patients with a competent saphenofemoral junction (41% v 37%; P < .001). EVLA is a safe treatment for great saphenous vein reflux, but EHIT can occur and was associated with female sex, large maximum GSV diameter, and competent saphenofemoral junction. Venous duplex imaging after EVLA is recommended because EHIT is asymptomatic in most patients.

Ultrasound-guided thrombin injection versus ultrasound-guided compression repair in the treatment of post-catheterization femoral artery pseudoaneurysm: King Saud University Medical Center Experience.

BACKGROUND: This study aims to evaluate the effectiveness of ultrasound-guided thrombin injection versus ultrasound-guided compression repair in the management of iatrogenic femoral artery pseudoaneurysms. METHODS: Between June 2006 and December 2015, a total of 29 consecutive patients (15 males, 14 females; mean age 54 years; range 26 to 81 years) with a femoral pseudoaneurysm treated by ultrasound-guided thrombin injection were retrospectively analyzed. These patients were compared with a historical group of 36 patients (21 males, 15 females; mean age 44 years; range 32 to 65 years) who underwent ultrasound-guided compression repair between February 1999 and May 2006. Medical records and vascular laboratory findings of all patients were reviewed. Successful treatment was defined as complete cessation of flow into the false lumen with preservation of flow in the femoral artery. RESULTS: The ultrasound-guided thrombin injection showed a success rate of 100%, whereas ultrasound-guided compression repair had a success rate of 80.5%, which was possibly affected by anticoagulant therapy, hypertension, and an aneurysm size of >6 cm. However, none of these factors did not affect the success of thrombin injections. CONCLUSION: Ultrasound-guided thrombin injection is a highly successful, easy to perform, accepted, and well-tolerated method by patients. It is more effective compared to compression therapy in patients with hypertension, large aneurysms, and who are on anticoagulant therapy.

Ultrasound-guided thrombin injections for arterial pseudoaneurysms: a 14-year study conducted at King Khalid University Hospital Vascular Lab.

BACKGROUND: Arterial pseudoaneurysms are a well-known complication resulting from procedures requiring arterial wall puncture. Previously, surgical repair was the definitive treatment option for arterial pseudoaneurysms despite being relatively invasive and time-consuming. Ultrasound-guided thrombin injection (UGTI) has become the standard of care since its initial description back in 1997. We aimed to evaluate the safety and efficacy of UGTI for the treatment of arterial pseudoaneurysms at the King Khalid University Hospital Vascular Lab. METHODS: A retrospective analysis of prospectively maintained data was conducted on all patients diagnosed with arterial pseudoaneurysms by Doppler ultrasound between 2006 and 2019. Patients with large arterial pseudoaneurysms (>1.5 cm) qualified for thrombin injections. Individuals with a known hypersensitive to thrombin were excluded. All included patients were treated with UGTI until resolution and were followed at postoperative days 7 and 30. RESULTS: In all, 35 patients qualified for thrombin injections. The mean age of the included patient population was 56.5 (range, 24-81) years. The majority of them were hypertensive (N.=26, 74.3%), and a quarter of them were on anticoagulant treatment (N.=9, 25%). The mean thrombin injection dose was 1000 U (range, 500-1500 U). In 34 of 35 (97.1%) patients, a thrombin injection resulted in complete thrombosis of the pseudoaneurysm lumen within a few seconds. There were no complications or recurrence of pseudoaneurysm after UGTI during the follow-up period. CONCLUSIONS: Throughout the study period of 14 years, we did not encounter any procedural complications or arterial pseudoaneurysm recurrence. This is attributed to a safe procedural technique and proper patient selection. UGTI for arterial pseudoaneurysms is a safe, successful, and convenient treatment for both patients and surgeons.

Vascular anomalies - diagnosis and therapy.

OBJECTIVE: Vascular anomalies were once thought to be impossible to properly diagnose and treat. Hence, we aimed to evaluate the different diagnostic and therapeutic modalities in the management of vascular anomalies. METHODS: We carried out a retrospective review of our experience to evaluate different diagnostic and therapeutic modalities in the management of 25 patients with vascular anomalies over a 2-year-period at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia and follow-up period ranging from 2 months to 2 years. RESULTS: Vascular anomalies were more common in male patients (N=19). Age range was 7 to 46 years. Vascular anomalies were categorized as hemangioma (N=2) or malformation (N=23). The vascular malformation were further subdivided into slow flow (N=5) and fast flow (N=18). Duplex (N=12) and radiographic studies; angiography (N=21), venography (N=7), computerized tomography (N=10) and magnetic resonnance angiography (N=8) were used to confirm diagnosis. The treatment of hemangiomas were surgical resection (N=1) and conservative treatment (N=1). Embolization was the main modality of treatment in vascular malformation (N=16), with surgical resection in 4 patients, sclerotherapy in one and conservative in the other 2. All cases had successful outcome with no complications. CONCLUSION: Control of large vascular malformations with acceptable results can be achieved nowadays. Intra-arterial embolization is the mainstay of treatment and long term follow-up with serial physical examination, duplex and arteriography is required.