Indications for and outcomes of major lower limb amputations at a tertiary-referral centre in Australia.

OBJECTIVES: Major amputations are classically associated with significant morbidity and mortality. With the increasing prevalence of risk factors for amputation, namely, diabetes and peripheral arterial disease, we sought to identify the major indications for lower limb amputation in an Australian cohort. A secondary aim was to assess the outcomes, namely, mortality, of amputees over the previous decade. METHODS: This study assessed all patients undergoing major lower limb amputations between 2012 and 2020. Variables analysed included comorbidities, indication for amputation, in-hospital complications and mortality, duration of hospital stay, and out-patient mortality. RESULTS: 317 amputations were performed on 269 patients. 55% of amputations were below knee, 45% above knee, with one through-knee amputation. Indications included ischaemia (55.2%), infection (30.6%), malignancy (6.9%), trauma (4.4%), and chronic pain or instability (2.5%). In-patient mortality rate was 7.6%, with mortality rates of 21.5% at one year, and 70.1% at 10 years. Post-operative complications occurred in 43% of amputations. Rural, regional, and remote (RRR) patients did not suffer disproportionately from major amputations, however, were more likely to require amputations for ischaemia. Patients undergoing amputation for infective causes demonstrated lower mid-term mortality rates compared to those undergoing amputations for ischaemia (56.1 vs 60.4% at 5 years, p = 0.007). CONCLUSION: Major amputations continue to be associated with significant morbidity and mortality, both in the short and long term. Patients undergoing amputations for ischaemic causes demonstrate poorer outcomes than their infective counterparts, with outcomes being even worse in RRR populations. Prevention of amputations via intense management of comorbidities would benefit both patients and the healthcare system.

Medium Term Outcomes of Deep Venous Stenting in the Management of Venous Thoracic Outlet Syndrome.

OBJECTIVE: Venous thoracic outlet syndrome (vTOS) is a relatively rare condition associated with significant morbidity. Its management continues to evolve, with increasing use of endovascular adjuncts, such as percutaneous thrombectomy and angioplasty, in addition to first rib resection. The utility of stenting residual venous stenotic lesions is poorly defined within the literature. This study sought to review the medium term patency rates of upper limb deep venous stenting in the management of vTOS. METHODS: A single centre, retrospective review of patients managed for vTOS with first rib resection followed by upper limb deep venous stenting between January 2012 and February 2021 was conducted. Post-procedural ultrasounds were reviewed to determine stent patency. RESULTS: Twenty-six patients were included, with 33 stents placed. The median duration of follow up was 50 months. On venous duplex ultrasound at three years post-operatively, primary patency rates were 66%, primary assisted patency rates were 88%, secondary patency rates were 91%, and total occlusion rates were 9%. After stent placement, 80% of patients remained asymptomatic with regard to compression symptoms. CONCLUSION: Upper limb deep venous stenting is an effective adjunct to surgical decompression in the management of vTOS. Stent medium term patency rates are promising; however, further studies with longer follow up and larger cohorts with multicentre results are required to confirm these early findings.

Hybrid Repair of a Persistent Sciatic Artery Aneurysm.

Persistent sciatic arteries are rare congenital abnormalities, with an incidence between .01-.6%. Whilst most patients with the pathology are asymptomatic during their younger years, up to 48% of patients will suffer aneurysmal degeneration of the persistent sciatic artery and present with claudication or lower limb ischaemia (from distal embolisation of mural thrombus). Due to the rare nature of persistent sciatic artery aneurysms, optimal management of the pathology is yet to be determined. Both endovascular and open techniques have been described in the management of this pathology, however hybrid management approaches are reported infrequently. The authors present a case of a persistent sciatic artery aneurysm successfully treated in a 69-year-old male utilising a hybrid approach with a femoropopliteal bypass (below knee), Amplatzer plug occlusion of the aneurysm and subsequent resection of the aneurysm.

Patient and Geographical Disparities in Functional Outcomes After Major Lower Limb Amputation in Australia.

BACKGROUND: Major lower limb amputations are associated with considerable disability, low quality of life, and poor rates of returning to work, all of which are often attributed to the poor level of functional mobility that amputees experience postoperatively. This study aimed to quantify ambulatory outcomes after major lower limb amputation and identify potential prognostic factors for patients most likely to achieve ambulation and prosthesis use, with the hypothesis that variation in outcomes correlates to age, level of amputation, and place of residence at the time of amputation. METHODS: This retrospective cohort study identified functional outcomes for patients who had lower limb amputations between 2012 and 2020. Patients were identified from the 10th revision of the International Classification of Diseases Australian Modification (ICD-10-AM)-coded state-wide government-maintained hospital administrative data by procedure codes for lower limb amputation. The primary outcomes were ambulation at the time of discharge from acute hospital stay, discharge destination, and prosthesis use. Variables for adjustment included patient age, comorbidity, level of amputation, and place of residence. RESULTS: Three-hundred and seventeen amputations were performed in 269 patients. Most procedures were transtibial amputations (56.4%) and for ischemic/infective indications (84%). Thirty-seven percent of patients were ambulating independently at the time of discharge and 55.9% demonstrated independent mobility with prosthesis at follow-up. Ambulation at the time of discharge predicted patients who were more likely to return home rather than residential or hospital care (odds ratio [OR] 1.8 95%; confidence interval [CI] 1.0-3.2). Patients with transtibial amputation were more likely to achieve prosthesis use than transfemoral (OR 4.4, 95% CI 2.1-9.5), after adjusting for age, comorbidity, and geographical factors. Mobility and prosthesis use was lowest in patients who were older, had transfemoral amputations, and resided in regional or rural areas. CONCLUSIONS: The significant outcome disparities identified in this cohort study highlight the need for targeted quality interventions aimed at improving functional outcomes for patients undergoing major amputation for peripheral artery disease.

Thoracic endovascular repair of chronic type B aortic dissection: a systematic review.

BACKGROUND: At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD. METHODS: Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data. RESULTS: Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively. CONCLUSIONS: The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.

Has EVAR changed the outcomes of ruptured abdominal aortic aneurysms? A decades worth of experience in an Australian Teaching Hospital.

BACKGROUND: Ruptured abdominal aortic aneurysms (rAAA) are associated with significant mortality, and equipoise remains as to whether patients managed with endovascular stent grafts (rEVAR) demonstrate better outcomes when compared to traditional open repair (OR). This study sought to examine the outcomes of patients presenting with rAAA to our institution and assess the perioperative outcomes and outpatient mortality of patients over the past decade. METHODS: A retrospective analysis was conducted. Patients treated for rAAA between 2010 and 2019 were identified from a search of the hospital database for ACHI and ICD-10 codes for repair of AAA. Demographic, operative and post-operative variables were collected from electronic medical records of identified patients. RESULTS: Eighty patients were identified, 51 of whom presented with a rAAA. The majority of repairs were rEVARs (59%). Median age was 76 years. Median length of admission to ICU was 3 days, and median length of hospital admission was 10 days. Overall in-patient mortality was 26%, with rates of 39% at 3 years and 47% at 5 years. No significant difference in outpatient mortality was found in patients undergoing rEVAR compared to OR, with rates of 61% at 5 years compared to 65% at 5 years, respectively (p = 0.8). CONCLUSION: Perioperative outcomes of our cohort of patients undergoing endovascular repair compared to open repair for ruptured and symptomatic AAAs are comparable over the past decade. Given equipoise remains between repair methods, further observational studies are required to quantify benefits of OR and endovascular repairs for ruptured and symptomatic AAAs.

Use of Suture-Mediated Closure Devices for Closure of Punctures in Prosthetic Patches or Grafts is Associated With High Rates of Technical Success and Low Complication Rates.

OBJECTIVES: Despite the increasing use of endovascular techniques in the management of peripheral vascular disease, there is little data on the safety of percutaneous closure devices in punctures of synthetic vascular material. Our paper sought to address this paucity in the literature by reviewing the incidence of complications occurring in patients in whom the ProGlide device was utilised to achieve haemostasis post-percutaneous puncture of vascular patches and graft materials. METHODS: A retrospective review of patient records was conducted at a tertiary referral centre. Patients who had undergone percutaneous punctures of prosthetic bypass grafts or patch angioplasties between January 2011 and December 2020 were identified from a prospectively collected database. Medical records and post-procedural imaging were reviewed to assess the occurrence of post-procedural complications such as pseudoaneurysms, puncture site stenosis and further interventions for access complications. RESULTS: A total of 73 punctures of prosthetic material were performed in 42 patients, of which 39 utilised ProGlides. Median age of included patients was 72 years. There was male predominance in the cohort (69.8%), and most punctures (87.3%) were through polyurethane patches. Device success rate was 95%, and no patients required open repair. There was a low incidence of complications, with no patients developing pseudoaneurysms, arteriovenous fistulas, ischaemic limbs or > 50% stenosis when either manual pressure or the ProGlide device was used to achieve haemostasis. Furthermore, there were no returns to theatre or further interventions performed for access site complications. CONCLUSION: The use of the ProGlide closure device has a low incidence of complications and its safety appears to be equivalent to manual compression when used to achieve haemostasis in percutaneous punctures of synthetic vascular material in select patients. To our knowledge, this is the only article to date to assess the safety of the ProGlide in this setting.

A novel case of a pseudoaneurysm due to thermal injury from a cement hip spacer.

Vascular injuries sustained during total hip replacements are associated with life- and limb-threatening complications. In the present report, we have described a novel vascular injury of an external iliac artery pseudoaneurysm repaired with an interposition vein graft. The vascular injury had been caused by heat from the curing process of a nearby cement hip spacer. During the curing process of bone cement, in vivo temperatures of ≤70°C can be reached, with such temperatures creating the potential for vascular injury. This case highlights the importance of limiting the exposure of surrounding neurovascular structures to bone cement to reduce the risk of thermal injury.

Utility of Culturing Marginal Bone in Patients Undergoing Lower Limb Amputation for Infection.

Guidelines suggest culturing clinically uninfected bone at the margin after surgical resection for osteomyelitis, but little published evidence supports this procedure. To investigate whether culturing marginal bone after completing resection of infected bone affected antibiotic use or further surgical intervention, we collected data on sequential patients undergoing amputation for a foot infection at our tertiary care hospital between January 2014 and May 2015. We recorded patient age, sex, presence of diabetes mellitus, level of amputation, whether marginal bone was sent for culture, microbiology of any marginal bone specimens, type and duration of antibiotic therapy, and any further surgical resection. Among 132 patients, the mean age was 71.9 years, 103 (78.0%) were male, and 79 (59.8%) had diabetes. Treating surgeons sent marginal bone in 58 (43.9%) of these patients, 50 (86.2%) of which were culture positive. Patients with a positive bone culture were significantly more likely to undergo further surgical intervention (20.0% vs 6.1%, p = .047). For patients with diabetes, compared with those without, surgeons did not send marginal bone for culture more often (46% vs 42%, p = .72), nor did they undertake further surgical interventions more frequently (13.4% vs 10.1%, p = .89). Our results suggest that the clinicians used the marginal bone culture findings to make clinical decisions but do not clarify if there is a benefit to performing this procedure. Although patients whose proximal bone specimens were culture positive were more likely to undergo a surgical intervention, the reasons for, and benefit of, this additional surgery were unclear.

Incidence, Management, and Outcomes of Aortic Graft Infection.

BACKGROUND: Infection complicates 1% of aortic grafts, and although uncommon, the associated morbidity and mortality are significant. We sought to determine risk factors for aortic graft infection (AGI), the long-term outcomes in patients managed both nonoperatively and via explantation. METHODS: This observational study reviewed sequential aortic grafts (thoracic or abdominal) inserted via open or endovascular means between 2000 and 2017. We used Cox proportional hazards regression analyses to compare risk factors between groups who did and did not acquire an AGI and recorded method of management, morbidity, mortality, and duration to adverse event. RESULTS: There were 883 aortic repairs, 49% were endovascular. 17.2% were for ruptured aneurysms, 1.1% for symptomatic aneurysms, 1.4% for type B dissections, and 0.5% for occlusive disease. Twelve patients presented with AGI, of which ten had their index procedure performed at our institution (AGI incidence of 1.1%). There was no difference in rates of AGI between open and endovascular repairs (0.9 vs. 1.4%, P = 0.24). AGI was significantly associated with emergency aortic repair (HR 3.63, 95% CI 1.13-11.57, P = 0.03), septic process requiring in-patient management during follow-up (HR 5.44, 95% CI 1.21-24.26, P = 0.02), and suprarenal clamping during open repair (HR 5.21, 95% CI 1.00-26.99, P = 0.05). Four patients were managed with explantation and revascularization (3 extra-anatomical bypasses) and remained well at a median follow-up of 46 months. Of the 8 patients managed nonoperatively, 4 died at an average of 13.5 days after representation, and the other 4 remained well on oral antibiotics at a median follow-up of 26.5 months. No patient suffered limb loss, and there was no change in the rate of infection over the period. CONCLUSIONS: Incidence of AGI remains low but is associated with significant mortality. Patients with aortic grafts in situ require aggressive treatment of septic foci to prevent graft infection.

"Aortoiliac-Mesenteric Steal Syndrome" Treated with Inferior Mesenteric to Common Iliac Artery Transposition.

We report the case of a 54-year-old female who presented with chronic mesenteric ischemia symptoms which could also be provoked on walking 50-100 m. Computed tomography angiography demonstrated ostial occlusion of all 3 mesenteric vessels, with extensive collateralization reconstituting the inferior mesenteric artery from the iliac arteries. As such, her abdominal pain was secondary to preferential flow to the lower limbs stealing from mesenteric vasculature. Endovascular management was trialed, but failed after short-term improvement, so the patient underwent successful transposition of inferior mesenteric to left common iliac artery. Mesenteric ischemia presenting with pain on walking secondary to preferential flow to the lower limbs has not been previously reported, and vascular and general surgeons should be aware of this unusual differential for abdominal pain.

Factors Predicting Noncompliance with Follow-up after Endovascular Aneurysm Repair.

BACKGROUND: Although the potential for complications after endovascular aneurysm repair (EVAR) mandates lifetime follow-up, noncompliance with follow-up has been shown to be as high as 57%. We sought to investigate the incidence of noncompliance with follow-up in our patient population and to identify risk factors associated with this to allow implementation of targeted strategies to prevent loss to follow-up. METHODS: We carried out a review of consecutive patients undergoing EVAR at 2 Sydney hospitals between 1995 and 2015. Patients noncompliant with standard follow-up were compared with a control group of compliant patients. Data collected included baseline clinical characteristics, perioperative complications, and postoperative complications, as well as distance from treating centers. RESULTS: During the study period, 1,482 patients underwent EVAR, of which 338 patients (22.8%) were not compliant with follow-up. Patients noncompliant with follow-up were significantly more likely to be younger, have hypertension, and be current smokers. Patients who did not attend follow-up were also significantly more likely to be from a non-English-speaking background (28.4 vs. 17.9%; P = 0.01) and live closer to the treating institution (109 ± 151.5 vs. 150 ± 208.34 km; P = 0.01). CONCLUSIONS: Follow-up after EVAR remains suboptimal. The present study serves to demonstrate that several factors, especially current smoking and a non-English-speaking background, are associated with poor compliance with follow-up after EVAR in our patient population and represent a potential area of intervention to improve compliance.

Sizing Considerations for GORE Excluder in Angulated Aortic Aneurysm Necks.

BACKGROUND: Device selection for endovascular treatment of abdominal aortic aneurysms (AAAs) with necks >60° is challenging. We sought to identify whether such anatomy necessitated graft oversizing during (endovascular aneurysm repair [EVAR]), and whether this increased the risk of type 1A endoleaks. METHODS: Prospective analysis of patients undergoing implantation of a C3 Gore Excluder, with aortic anatomy defined as outside Instructions for Use (IFU) due to proximal neck angulation >60° was performed. RESULTS: Of the 1,394 patients enrolled, 127 patients (9.2%) were included, with median follow-up of 236 days. Mean neck angle was 78.0 ± 13.2%, neck length 2.88 ± 1.31, and mean graft oversize 23.5 ± 9.6%. There were 7 type 1A endoleaks (5.5% males, 5.6% females). Neither neck length, angle, nor degree of oversizing were predictors of type IA endoleak. CONCLUSIONS: In conclusion, when selecting endografts for patients with proximal neck angulation over 60°, endovascular interventionalists are not adhering to IFU. However, this was not associated with increased risk of type 1A endoleaks.