Vascular service provision during the COVID-19 pandemic worsened major amputation rates in socially deprived diabetic populations.

Introduction: The Coronavirus Disease - 2019 (COVID-19) pandemic significantly impacted healthcare service provision and put diabetic patients at increased risk of adverse health outcomes. We aimed to assess the impact of the COVID-19 pandemic on the incidence and demographic shift of major lower-limb amputation in diabetic patients. Methods: We performed a retrospective analysis of diabetic patient records undergoing major lower-limb amputation between 01/03/2019 and 01/03/2021 at the Royal Sussex County Hospital, the regional arterial hub for Sussex. Primary outcomes were amputation incidence rates and patient demographics compared between the prepandemic and pandemic cohorts. Results: The incidence rate ratio of major lower-limb amputations shows a drop in amputations during the pandemic compared to pre-pandemic (IRR 0.82; 95% CI 0.57-1.18). Data suggests a shift in the social deprivation background of patients receiving amputations to disproportionately affect those in the more deprived 50% of the population (p=0.038). Younger patients received more amputations during the pandemic compared to prepandemic levels (p=0.001). Conclusion: Results suggest that during the COVID-19 pandemic there was a paradoxical reduction in amputations compared to prepandemic levels. However, changes to the demographic makeup of patient's receiving amputations are alarming as younger, and more deprived patients have been disproportionately affected by the pandemic.

Through and Through Wire Technique for Stabilization of EVAR Main Body during Contralateral Limb Deployment.

Contralateral gate cannulation is one of the key steps of endovascular aortic aneurysm repair (EVAR), and multiple different techniques and tips have been described to ensure accurate and swift performance of this step. In some cases, a crossover approach, entailing an up-and-over wire access from the ipsilateral limb into the contralateral gate followed by snaring the wire to the contralateral groin and proceeding with contralateral limb deployment is needed. The risks with this technique include the necessity of completely deploying the stent-graft main body, ipsilateral limb, and release of its trigger wires which essentially render the graft untethered, and cause concerns about the graft migrating upwards or "buckling" during advancement of the contralateral limb in challenging anatomy. To overcome this issue, we describe a modification of this technique which involves retaining the through and through wire used for crossover cannulation as a stabilizing mechanism for the stent-graft and advancing a second "buddy wire" into the contralateral gate for deployment of the contralateral limb.

Jotec E-Ventus BX Stent Graft Deployment in the FEVAR and Iliac Branch Device: Single Centre Experience.

Objectives: To evaluate the outcomes of the E-ventus BX balloon-expandable stent graft system (Jotec, Hechingen, Germany) implanted as bridging stent grafts during fenestrated endovascular aortic repair (FEVAR) and the iliac branch device (IBD) of complex aneurysms. Methods: This was a single centre retrospective analysis prospective study including all consecutive patients treated by FEVAR and the IBD performed with E-ventus BX stent grafts as bridging stents. Demographics of patients, the diameter and length of the bridging stent grafts, technical success, reinterventions, occlusions, post-operative events, and imaging (computed tomography [CT] scan and ultrasound) were prospectively collected in an electronic database. Follow-ups were performed with clinical assessment and a CT angiogram scan at four weeks after discharge followed by a duplex ultrasound every six months for two years and then a yearly duplex scan afterwards. Results: Between June 2015 and October 2017, 40 consecutive patients (three females) were treated with custom made fenestrated endografts and the iliac branch device for complex aneurysms, using the E-Ventus BX stent graft. All 82 E-Ventus BX stent grafts were successfully delivered and deployed. There was no in-hospital mortality. The early bridging stents patency rate was 97.6% (80 out of 82). The two-target vessel post-operative occlusion was secondary to kink of the renal stents and failure for re-lining of the renal artery. Of the two patients, only one needed permanent dialysis. On the late follow-up (after 30 days), two other patients demonstrated a renal stent occlusion, with one treated successfully with re-lining of the stent and the other patient treated conservatively. Neither of them needed permanent dialysis. A follow-up was maintained for 36 patients until April 2018 with a median follow-up of 18 months. All bridging stents E-Ventus BX stent grafts remained patent (78 out of 82, 95.1%). Conclusion: E-Ventus BX stent grafts used as bridging stents during FEVAR and the IBD are associated with favourable outcomes at the mid-term follow-up. Long-term follow-up is required to confirm these promising results.

Same features, different diagnosis: A case of ilio-iliac arteriovenous fistula presenting as decompensated heart failure.

In case of high output cardiac failure, an arteriovenous fistula should be considered.

Management of concomitant cancer and abdominal aortic aneurysm.

Background. The coexistence of neoplasm and abdominal aortic aneurysm (AAA) presents a real management challenge. This paper reviews the literature on the prevalence, diagnosis, and management dilemmas of concurrent visceral malignancy and abdominal aortic aneurysm. Method. The MEDLINE and HIGHWIRE databases (1966-present) were searched. Papers detailing relevant data were assessed for quality and validity. All case series, review articles, and references of such articles were searched for additional relevant papers. Results. Current challenges in decision making, the effect of major body-cavity surgery on an untreated aneurysm, the effects of major vascular surgery on the treatment of malignancy, the use of EVAR (endovascular aortic aneurysm repair) as a fairly low-risk procedure and its role in the management of malignancy, and the effect of other challenging issues such as the use of adjuvant therapy, and patients informed decision-making were reviewed and discussed. Conclusion. In synchronous malignancy and abdominal aortic aneurysm, the most life-threatening lesion should be addressed first. Endovascular aneurysm repair where possible, followed by malignancy resection, is becoming the preferred initial treatment choice in most centres.