Adipose-derived stem cells in patients with venous ulcers: Systematic review.

OBJECTIVES: Few studies have reported on the safety and durability of adipose-derived stem cells (ADSCs) to support healing in patients with venous leg ulcers (VLU). To establish if there is any evidence to support ADSC use in VLU patients, a systematic review was conducted. METHODS: A systematic review was conducted following the PRISMA guidelines. PubMed and Embase databases were searched for relevant papers. References from retrieved papers were reviewed to identify any extra eligible studies. RESULTS: After duplicate removal, 950 papers were screened for eligibility of which 932 were excluded based on title and abstract. Four papers were included in the final analysis (one randomised study and three non-randomised studies). 66 patients in total received ADSCs for VLU treatment. The only randomised paper reported 6-month healing rates of 75% with ADSCs compared to 50% in controls. 100% healing was achieved in one study. The remaining 2 studies reported 25% and 58% healing; however, they included patients with relatively large VLUs. Pain scores decreased after ADSCs application where reported. No serious procedure related complications were reported. CONCLUSION: ADSCs may enhance ulcer healing in patients with chronic VLU and appears safe based on initial reports. Large, randomised trials are needed to definitively establish the technique's role in VLU patients.

Systematic review of the relationship between Hollenhorst plaques and cerebrovascular events.

BACKGROUND: Few studies have evaluated the association between asymptomatic cholesterol emboli on fundoscopy (known as Hollenhorst plaque) and the subsequent risk of stroke or death.1. AIM: To evaluate the association between the presence of asymptomatic cholesterol retinal emboli and the risk of cerebrovascular events, with assessment of the need for carotid intervention. METHODS: PubMed, Embase, and Cochrane Library databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines. RESULTS: Initial search revealed 43 in Medline and 46 in Embase databases. Twenty-four potentially eligible studies were included after duplicate and non-related studies were excluded based on title and abstract. Three more studies were identified from reference lists. Seventeen studies were included in the final analysis. Asymptomatic cholesterol emboli were present in 1343 patients. Approximately 17.8% (n = 181) had history of either cerebro-vascular Accident (CVA) or transient ischaemic attacks (TIAs) at presentation (more than 6 months). Nine studies mentioned the incidence of cerebrovascular events during follow-up. Of 780 patients, 93 evolved to stroke, TIAs, or death from a major carotid event during the follow-up period (6-86 m), an incidence of about 12%. Death due to stroke was documented in 3 studies (n = 12). CONCLUSION: The presence of asymptomatic retinal emboli indicates a risk of a cerebrovascular event when compared to patients with no plaques seen on fundoscopy. The evidence suggests that these patients warrant referral for medical optimization of cardiovascular risk factors. Currently, there is no recommendation to support carotid endarterectomy in patients with Hollenhorst plaques, or retinal emboli, and further studies are needed to assess this.

Significance of Distal Runoff Score as a Key Influencer on Clinical Outcomes after Endovascular Interventions for Superficial Femoral Artery Disease.

BACKGROUND: Endovascular therapy (EVT) is being adopted by many surgeons as a suitable first choice in the treatment of most femoropopliteal disease when clinically indicated. However, there are multiple factors affecting the outcome of EVT including the anatomy of lesions and distal runoff status. The evidence of runoff effect on the outcome of superficial femoral artery (SFA) interventions is still scarce and not well studied in the current literature. The aim of this study was to investigate the effect of runoff score on the outcomes of SFA endovascular interventions. METHODS: Retrospective analysis was carried out on prospectively collected data on patients who underwent SFA endovascular intervention for critical limb ischemia (CLI) in a single tertiary center. Patients with Rutherford categories 4, 5, and 6 who did not have any previous vascular interventions were included in the study. The modified SVS runoff score was used after calculating scores from popliteal and all tibial vessels. Runoff was stratified into good (score <5), compromised (score 5-10), and poor (score >10). Amputation-free survival, patency rates, and overall survival were compared between all groups at 5 years. RESULTS: Between 2011 and 2018, 254 procedures were performed in 220 patients. Technical success was >92%; 66 patients required SFA stents, and 55 had concomitant tibial angioplasty. There was no significant difference between good, compromised, or poor runoff groups regarding complication rates, with 3.5% overall perioperative mortality (5 cases in the compromised group and 4 in the poor runoff group). A runoff score of <5 was associated with significantly marked clinical improvement (P < 0.001). Patency rates were significantly worse in the compromised and poor runoff groups, with 5-year cumulative primary patency rates of 80%, 50%, and 22% in the good, compromised, and poor runoff groups, respectively (P < 0.001). Amputation-free survival worsened as the runoff got poorer with 98%, 91%, and 78% in the good, compromised, and poor runoff groups, respectively, at 5 years (P < 0.001). SFA stenting and concomitant tibial angioplasty led to slight improvement in patency rates in the poor runoff group. CONCLUSIONS: Poor runoff with a score of >10 was associated with significantly reduced amputation-free survival and patency rates at 5 years in patients undergoing SFA endovascular intervention for CLI. Patients with a runoff score of <5 showed marked clinical improvement postoperatively when compared with patients with a runoff score of ≥5.

Clinical outcomes from profundoplasty performed as a sole procedure for revascularization in critically ischaemic limbs.

OBJECTIVES: The aim of this study is to investigate the durability and clinical efficacy of profundoplasty as a sole procedure in patients presenting with critical limb ischaemia associated with profunda femoral artery disease and superficial femoral artery occlusion. METHODS: Retrospective analysis of outcomes from all patients who underwent surgical profundoplasty in a single tertiary referral centre was performed. Patients who presented with either rest pain or tissue loss and had combined profunda femoral artery disease and superficial femoral artery occlusion were included in the study. Outcomes were compared between the rest pain and the tissue loss groups. RESULTS: Between 2009 and 2019, 51 procedures were performed in 49 patients; 27 (53%) procedures were performed for rest pain and 24 (47%) for tissue loss. Technical success was 100% in both groups. Procedure success was significantly better in the rest pain group owing to lower procedure-related complications (p = 0.037). Incidence of major adverse cardiovascular events was higher in the tissue loss group with five reported cases compared to only one in the rest pain group (p = .05); 85.2% of patients with rest pain experienced clinical improvement compared to only 33.3% in the tissue loss group (p < .001). Higher rates of re-intervention were recorded in the tissue loss group, but this was not statistically significant. Amputation-free survival at 3, 6 and 12 months was 96%, 96% and 92% in the rest pain group, respectively, compared to 77%, 67% and 54% in the tissue loss group (p = .004). At one-year, freedom from major adverse limb events was lower in patients with tissue loss at 43% compared to 81% in patients with rest pain (p = .009). CONCLUSIONS: Profundoplasty performed as a sole procedure for revascularisation of the critically ischaemic limb is a viable straightforward option. However, our results suggest that it may be more effective in the treatment of rest pain rather than in the setting of tissue loss when a combined superficial femoral artery angioplasty or distal bypass may be required.

Common femoral artery endarterectomy in the age of endovascular therapy.

OBJECTIVES: Common femoral artery endarterectomy (CFE) is the standard treatment for common femoral artery occlusive disease. We aim to assess the medium term outcomes of CFE with or without further concomitant procedures. DESIGN: A retrospective observational study. METHODS: All patients who underwent either isolated CFE (ICFE), CFE with angioplasty for occlusive arterial disease (CFEA) or concomitant CFE with endovascular aortic aneurysm repair (CFEE) were included. Patient demographics follow up, clinical improvement, types of CFE closure, patency rates, and survival-free amputation were noted. RESULTS: From 2002 to 2015, 1512 patients were referred with a diagnosis of critical limb ischemia. Of those, 1134 required revascularization. Sixty-one patients underwent 66 CFE. Ten limbs underwent an ICFE, 35 had CFEA, and 21 underwent CFEE. Demographics were comparable in all groups. Twenty-seven were closed primarily, while 39 required patch closure (12 venous, 8 Dacron, 19 biological). Technical success was 100% in ICFEs, 94% in CFEA, and 100% for CFEE ( p = 0.274). Immediate clinical success was 100% in both CFE and CFEE, but was 85.7% in CFEA ( p = 0.035). Immediate hemodynamic success was similar in all three groups ( p = 0.73). Sustained hemodynamic success was 30% in ICFE, 54.3% in CFEA, and 23.8% in CFEE ( p = 0.056). At two years, the primary patency was 90% in ICFE, 74.3% in CFEA, and 100% in CFEE ( p = 0.049). Primary-assisted patency was 90% in ICFE, 82.9% in CFEA, and 100% in CFEE ( p = 0.17). Secondary patency was 90% in ICFE, 94.3% in CFEA, and 100% in CFEE ( p = 0.409). Re-intervention was required in 26.9% of primary closures, versus 12.8% with patch closures ( p = 0.279). Amputation-free survival was 100% in ICFE, 80% in CFEA, and 100% in CFEE ( p = 0.056). CONCLUSION: CFE is a reliable and dependable procedure, even in the absence of good distal runoff.

Varicose veins as a risk factor for venous thromboembolism in arthroplasty patients: Meta-analysis.

OBJECTIVE: A meta-analysis to determine if patients with varicose veins are at an increased risk of venous thromboembolism (VTE) when undergoing major lower limb arthroplasty. METHODS: Medline, Embase, and Cochrane Library databases were searched using appropriate terms for studies that reported post-operative VTE in patients who had lower limb arthroplasty with any history of varicose veins. Methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist. RESULTS: A total of 129 studies were identified with 11 observational studies being eligible for inclusion. This consisted of 265,194 patients who underwent lower limb arthroplasty, 2188 of which had pre-existing varicose veins. Overall, VTE occurred in 1845 patients, and 122 cases had varicose veins present at time of arthroplasty. Meta-analysis indicates that patients undergoing lower limb arthroplasty with varicose veins are at increased risk of having a VTE, OR 2.37, 95% CI 1.54-3.63, (p < 0.001). One study evaluated if previous varicose veins surgery influenced the risk of VTE in arthroplasty patients, OR 0.96 (95% CI 0.7-1.28), p = 0.429. CONCLUSIONS: Varicose veins and lower limb arthroplasty are known independent risk factors for VTE. There is a paucity of data regarding the risk of VTE in patients undergoing lower limb arthroplasty who have co-existing varicose veins. This meta-analysis shows that patients with varicose veins are at an increased risk of VTE when undergoing major lower limb arthroplasty. Further studies are required in order to determine if such patients should undergo varicose vein surgery before undertaking major lower limb joint replacement.

Role of Adipose Derived Stem Cells in Patients with Diabetic Foot Ulcers: Systematic Review and Meta-Analysis of Randomised Controlled Trials.

Few studies to date have investigated the role of adipose derived stem cells (ADSCs) in patients with diabetic foot ulcers (DFU). We aimed to conduct a systematic search of the literature to explore the available evidence behind ADSCs application in patients with DFU to establish if it has any added benefit regarding healing rate and healing time in this cohort of patients. The PubMed and Embase databases were searched for eligible studies. Only randomised controlled trials which investigated the impact of ADSCs alone on the healing of DFU were considered eligible and were included for the review. Reported healing rates, time to healing and procedure related complications were collected and analysed. The initial search resulted in 160 papers. Following duplicate removal, 131 papers were screened for eligibility. Only four trials met the study criteria and were included for the final review and analysis. 97 out of 189 patients who were included in the four studies received ADSCs for treatment of DFU whereas the remaining 92 patients received standard measures (control). The median participant age was 62, predominantly male (72.5%). Complete healing was achieved in 83.5% (n = 81) of patients in the ADSC group compared to 52% (n = 48) for patients in the control group at 12 months (OR = 4.8, 95%CI = 2.25 to 10.24, P < 0.0001). Mean healing time in the ADSC group ranged from 31 to 85 days whereas mean healing time in the control group ranged from 42 to 85 days (Pooled weighted mean difference = -10.832856, 95%CI = -22.44 to 0.77, P = 0.0673). No significant procedure related complications were reported in either group. The use of ADSCs in patients with DFU appears to demonstrate improved healing rates. The procedure of ADSC harvest and administration appears to be safe based on the initial reports. Large, randomised trials are needed to establish its role in patients with diabetic foot wounds.

Bilateral external carotid artery stenting in symptomatic patient with complete occlusion of both internal carotid arteries.

Completely occluded ICA should not always turn a symptomatic patient down for surgical intervention especially if medical treatment fails. Where bilateral ECA intervention is required, endovascular approach should be considered if feasible.

Outcomes of Unibody Bifurcated Endograft and Aortobifemoral Bypass for Aortoiliac Occlusive Disease.

PURPOSE: We compared the outcomes between the total endovascular approach using a unibody bifurcated aortoiliac endograft and the gold standard aortobifemoral bypass (ABF) surgery for the management of extensive aortoiliac occlusive disease (AIOD). MATERIALS AND METHODS: This retrospective observational study compared the outcomes of endovascular technique with unibody bifurcated endograft (UBE) using the Endologix AFX unibody stent-graft and a standard surgical approach (ABF) in the management of AIOD based on patient records in Western Vascular Institute, Galway University Hospital, National University of Ireland. Procedural details and outcomes were documented to compare both groups. RESULTS: From January 2002 to December 2018, 67 patients underwent AIOD (20 UBE and 47 ABF). Both the ABF and UBE groups showed 100% immediate clinical and technical successes without 30-day mortality. There were no statistical differences in the overall survival and sustained clinical improvement between the bypass and the UBE groups; however, statistically significant differences were observed in 3-year freedom from re-intervention and amputation-free survival. Furthermore, the mean length of the intensive care unit (ICU) stay was significantly lower in the UBE group than that in the ABF group (0.75 days vs. 3.1 days, P=0.001). CONCLUSION: Total endovascular reconstruction of AIOD is an alternative to invasive bypass procedures, with a shorter ICU stay.

A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery.

OBJECTIVE: To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair. METHODS: The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012-2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n=500) and in situ repair in group 2 (n=500). The primary outcome measure was the surgery duration. RESULTS: Surgery duration was significantly longer in group 1 than group 2 (49.9±2.3 minutes vs 39.9±1.8 minutes; P<0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P=0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P<0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0±2.7 hours vs 14.0±1.9 hours; P<0.001). CONCLUSION: In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement. ClinicalTrials.gov:NCT01723605.