Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation.

BACKGROUND: Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes. METHODS: The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail. RESULTS: Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity. CONCLUSION: Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

External aortic wrap for repair of type 1 endoleak.

INTRODUCTION: Type 1 endoleak is a rare complication after endovascular abdominal aortic aneurysm repair (EVAR) with a reported frequency up to 2.88%. It is a major risk factor for aneurysmal enlargement and rupture. PRESENTATION OF CASE: We present a case of a 68 year old gentleman who was found to have a proximal type 1 endoleak with loss of graft wall apposition on routine surveillance imaging post-EVAR. An initial attempt at endovascular repair was unsuccessful. Given the patient's multiple medical co-morbidities, which precluded the possibility of conventional graft explantation and open repair, we performed a novel surgical technique which did not require aortic cross-clamping. A double-layered Dacron wrap was secured around the infra-renal aorta with Prolene sutures, effectively hoisting the posterior bulge to allow wall to graft apposition and excluding the endoleak. Post-operative CT angiogram showed resolution of the endoleak and a stable sac size. DISCUSSION: Several anatomical factors need to be considered when this technique is proposed including aortic neck angulation, position of lumbar arteries and peri-aortic venous anatomy. While an external wrap technique has been investigated sporadically for vascular aneurysms, to our knowledge there is only one similar case in the literature. CONCLUSION: Provided certain anatomical features are present, an external aortic wrap is a useful and successful option to manage type 1 endoleak in high-risk patients who are unsuitable for aortic clamping.

Thromboembolic stroke associated with thoracic outlet syndrome.

Thoracic outlet syndrome occurs due to compression of the neurovascular structures as they exit the thorax. Subclavian arterial compression is usually due to a cervical rib, and is rarely associated with thromboembolic stroke. The mechanism of cerebral embolisation associated with the thoracic outlet syndrome is poorly understood, but may be due to retrograde propagation of thrombus or transient retrograde flow within the subclavian artery exacerbated by arm abduction. We report an illustrative patient and review the clinical features, imaging findings and management of stroke associated with thoracic outlet syndrome.

Tension hemothorax following endovascular thoracic aortic transection repair: case report.

Thoracic aortic transection (TAT) is the second commonest cause of death from blunt trauma surpassed only by head injury and is associated with a mortality of 80% to 90%. The injury site is typically anteromedial at the aortic isthmus where differential shear forces act during rapid deceleration. The authors report a lateral aortic laceration managed by endovascular repair that required open thoracotomy for tension hemothorax resulting from an endoleak.

Thyroid cancer in the renal transplant population: epidemiological study.

BACKGROUND: The epidemiology of thyroid neoplasms in the renal transplant population has not been widely published. The present study compares the behaviour of thyroid cancer in the transplant cohort with that of the general population. It also documents the transplantation outcomes of patients with thyroid and non-thyroid cancers. METHODS: All recipients of renal grafts are registered with the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Data were obtained from this institution and analysed using Microsoft Excel and Stata statistical software. Risk ratio, attributable risk, Mann-Whitney test, and the Kaplan-Meier survival probability were calculated. RESULTS: Between 1963 and 31 March 2002, 23 (0.22%) patients were diagnosed with thyroid cancer from a cohort of 10,689 renal transplant recipients. The median age in the renal-transplant thyroid cancer group was 48.2 years (range: 23-67 years), and there were 11 (48%) male patients, compared to 26% of thyroid cancer patients in the general population (P = 0.02). The median time to thyroid cancer diagnosis after transplantation was 68 months (range: 3-253 months) compared to 102 months (range: 3-363 months; P = 0.004) in non-thyroid cancers. Ten patients (43%) were found to have lymphatic metastasis, eight of whom presented at the time of primary diagnosis. The risk ratio (RR) was 5.2 (95% confidence interval: 2.0-16.6), with an attributable risk of 17.4 cases per 10,000. There were two cancer-related deaths resulting in a survival probability of 89% at 5, 10 and 15 years. CONCLUSIONS: There is a higher incidence of thyroid cancer and an altered sex distribution in the renal transplant population. A significant proportion presents with lymphatic metastasis requiring lymph node dissection and radioactive iodine treatment.

Randomized trial on the treatment of oedematous acute otitis externa using ear wicks or ribbon gauze: clinical outcome and cost.

Acute otitis externa is a common condition that can be extremely painful. When there is considerable canal oedema, packing is necessary to facilitate the passage of medication. The experience at the Royal Victoria Eye and Ear Hospital is that ear wicks generally require removal in two to three days by medical staff and can be labour intensive as they often involve serial removals following re-insertions. Alternatively, medicated ribbon gauze is cheap and can be removed by the patient at home. Ear wick and mediated ribbon gauze were investigated by a prospective randomized trial involving 94 patients. Fewer out-patient visits were required for the ribbon gauze group (two vs. three, p<0.0001) with considerably less material and labour costs than the wick group. Similar resolution rates were achieved (70 per cent vs. 64 per cent, p = 0.58). Following development of guidelines, the proportion of otitis externa patient reviews in the accident and emergency department declined from 49 per cent to 36 per cent. Compared with the ear wick, medicated ribbon gauze is a cost-effective method of treating oedematous acute otitis externa.