The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization.

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

Clinical validation of a machine-learning-based handheld 3-dimensional infrared wound imaging device in venous leg ulcers.

Chronic venous insufficiency is a chronic disease of the venous system with a prevalence of 25% to 40% in females and 10% to 20% in males. Venous leg ulcers (VLUs) result from venous insufficiency. VLUs have a prevalence of 0.18% to 1% with a 1-year recurrence of 25% to 50%, bearing significant socioeconomic burden. It is therefore important for regular assessment and monitoring of VLUs to prevent worsening. Our study aims to assess the intra- and inter-rater reliability of a machine learning-based handheld 3-dimensional infrared wound imaging device (WoundAide [WA] imaging system, Konica Minolta Inc, Tokyo, Japan) compared with traditional measurements by trained wound nurse. This is a prospective cross-sectional study on 52 patients with VLUs from September 2019 to January 2021 using three WA imaging systems. Baseline patient profile and clinical demographics were collected. Basic wound parameters (length, width and area) were collected for both traditional measurements and measurements taken by the WA imaging systems. Intra- and inter-rater reliability was analysed using intra-class correlation statistics. A total of 222 wound images from 52 patients were assessed. There is excellent intra-rater reliability of the WA imaging system on three different image captures of the same wound (intra-rater reliability ranging 0.978-0.992). In addition, there is excellent inter-rater reliability between the three WA imaging systems for length (0.987), width (0.990) and area (0.995). Good inter-rater reliability for length and width (range 0.875-0.900) and excellent inter-rater reliability (range 0.932-0.950) were obtained between wound nurse measurement and each of the WA imaging system. In conclusion, high intra- and inter-rater reliability was obtained for the WA imaging systems. We also obtained high inter-rater reliability of WA measurements against traditional wound measurement. The WA imaging system is a useful clinical adjunct in the monitoring of VLU wound documentation.

Clinical validation of an artificial intelligence-enabled wound imaging mobile application in diabetic foot ulcers.

There is a lifetime risk of 15% to 25% of development of diabetic foot ulcers (DFUs) in patients with diabetes mellitus. DFUs need to be followed up on and assessed for development of complications and/or resolution, which was traditionally performed using manual measurement. Our study aims to compare the intra- and inter-rater reliability of an artificial intelligence-enabled wound imaging mobile application (CARES4WOUNDS [C4W] system, Tetsuyu, Singapore) with traditional measurement. This is a prospective cross-sectional study on 28 patients with DFUs from June 2020 to January 2021. The main wound parameters assessed were length and width. For traditional manual measurement, area was calculated by overlaying traced wound on graphical paper. Intra- and inter-rater reliability was analysed using intra-class correlation statistics. A value of <0.5, 0.5-0.75, 0.75-0.9, and >0.9 indicates poor, moderate, good, and excellent reliability, respectively. Seventy-five wound episodes from 28 patients were collected and a total of 547 wound images were analysed in this study. The median wound area during the first clinic consultation and all wound episodes was 3.75 cm2 (interquartile range [IQR] 1.40-16.50) and 3.10 cm2 (IQR 0.60-14.84), respectively. There is excellent intra-rater reliability of C4W on three different image captures of the same wound (intra-rater reliability ranging 0.933-0.994). There is also excellent inter-rater reliability between three C4W devices for length (0.947), width (0.923), and area (0.965). Good inter-rater reliability for length, width, and area (range 0.825-0.934) was obtained between wound nurse measurement and each of the C4W devices. In conclusion, we obtained good inter-rater and intra-rater reliability of C4W measurements against traditional wound measurement. The C4W is a useful adjunct in monitoring DFU wound progress.

Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study.

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case-control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow-up (33% vs 76%, P < .001), decrease in 1-year minor amputation rate (14% vs 3%, P = .007), and decrease in 1-year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.

Randomized Controlled Trial Comparing Drug-coated Balloon Angioplasty versus Conventional Balloon Angioplasty for Treating Below-the-Knee Arteries in Critical Limb Ischemia: The SINGA-PACLI Trial.

Background There is a paucity of randomized trials demonstrating superior efficacy of drug-coated balloon angioplasty (DCBA) compared with conventional percutaneous transluminal angioplasty (PTA) for below-the-knee arterial disease in patients with -critical limb ischemia. Purpose To compare DCBA versus PTA for below-the-knee lesions in participants with critical limb ischemia through 12 months. Materials and Methods In this prospective, randomized, two-center, double-blind superiority study, participants with critical limb ischemia with rest pain or tissue loss with atherosclerotic disease in the native below-the-knee arteries were randomly assigned (in a one-to-one ratio) to DCBA or PTA after stratification for diabetes and renal failure between November 2013 and October 2017. The primary efficacy end point was angiographic primary patency at 6 months analyzed on an intention-to-treat basis. Secondary end points through 12 months were composed of major adverse events including death and major amputations, wound healing, limb salvage, clinically driven target-lesion revascularization, and amputation-free survival. Primary and binary secondary end points, analyzed by using generalized-linear model and time-to-event analyses, were estimated with Kaplan-Meier survival curves and hazard ratios (Cox regression). Results Seventy participants (mean age, 61 years ± 10 [standard deviation]; 43 men) in the DCBA group and 68 (mean age, 64 years ± 10; 50 men) in the PTA group were evaluated. The percentage of patients with angiographic primary patency at 6 months was 43% (30 of 70) in the DCBA group and 38% (26 of 68) in the PTA group (P = .48). Through 12 months, the percentage of deaths was similar: 21% in the DCBA group and 16% in the PTA group (P = .43). Amputation-free survival rate assessed with Kaplan-Meier curves differed through 12 months: 59% (41 of 70) in the DCBA group compared with 78% (53 of 68) in the PTA group (P = .01). Conclusion In participants with critical limb ischemia, the drug-coated balloon angioplasty group and the conventional percutaneous transluminal angioplasty group had similar primary patency rates at 6 months after treatment of below-the-knee arteries. Amputation-free survival rates through 12 months were higher in the percutaneous transluminal angioplasty group. © RSNA, 2021 Online supplemental material is available for this article.

Systematic review and meta-analysis of the prevalence of abdominal aortic aneurysm in Asian populations.

OBJECTIVE: The prevalence of abdominal aortic aneurysms (AAAs) is well reported in Western countries and AAA screening programs are well-established. However, although individual studies have reported that the prevalence of AAAs is lower in Asian populations, high-quality data on the prevalence of AAA in Asians are relative lacking. The present study aimed to systematically synthesize the data available in the literature and report the prevalence of AAAs in Asians. METHODS: An electronic search was performed using two major databases (PubMed and EMBASE) with no limitations imposed on the year of publication. The review conformed to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies that reported the prevalence of AAAs in Asians were selected, and the population characteristics, AAA definition, method of screening, target population, and total number of patients screened were recorded. RESULTS: Our search yielded 157 unique articles. After a full-text review, 17 articles were included in the present study. All 17 studies of fair quality. The overall AAA prevalence was 1.30% (95% confidence interval [CI], 1.01%-1.59%) in Asian populations. The prevalence of AAAs was 2.56% (95% CI, 1.81%-3.31%) in Asian populations selected for cardiovascular risk factors and 0.61% (95% CI, 0.37%-0.85%) in Asian populations not selected for cardiovascular risk factors. CONCLUSIONS: The prevalence of AAAs in the general Asian population is low. However, the prevalence in Asian populations selected for cardiovascular risk factors approaches the prevalence of AAAs in Western populations. As such, screening for AAAs in carefully selected Asian male populations with cardiovascular risk factors could potentially yield benefits. Opportunistic screening for AAAs during ultrasound examination of the abdomen or transthoracic echocardiography for other indications could also be considered. However, further studies are needed to evaluate the potential benefits of screening for AAAs in carefully selected Asian populations.

Novel home use of mechanical negative pressure wound therapy in diabetic foot ulcers.

OBJECTIVE: Mechanical negative pressure wound therapy is an ultraportable, light weight and disposable single-use device that has been shown to promote wound healing. This study evaluated home use of a mechanically powered negative pressure wound therapy (NPWT) in diabetic foot wounds. METHODS: Patients underwent revascularisation and/or debridement or amputation before starting mechanical NPWT. Wound outcomes and images of the wounds were recorded at each follow-up visit by the wound nurse. Patients were followed up until wound closure or end of therapy. RESULTS: A total of 12 patients (each with one wound) were included in the study. Of the 12 wounds, 33.3% (n=4) of wounds achieved primary wound closure while the remaining 66.6% (n=8) of wounds demonstrated a mean wound size reduction of 37.5±0.13%. Of the closed wounds, mean time to healing was 4.75±2.50 weeks. There was 100% limb salvage with no further debridement or amputations, and no 30-day unplanned readmissions. Mean length of hospital stay before starting home NPWT was 9.75±6.31 days. Mean number of NPWT changes was 8.33±2.67 sessions, while mean duration of therapy was 4.0±1.54 weeks. Mean cost of home NWPT therapy was US$1904±731 per patient. CONCLUSION: The home use of mechanically powered NPWT in diabetic foot wounds demonstrated excellent wound healing rates and 100% limb salvage, with no complications.

Validating the use of contrast-induced nephropathy prediction models in endovascular aneurysm repairs.

BACKGROUND: Existing risk prediction models for contrast-induced nephropathy (CIN) are based on studies for percutaneous coronary interventions, with none validated for use in vascular procedures. We aim to validate existing CIN prediction models in patients who underwent aortic endovascular aneurysm repair (EVAR). METHODS: A retrospective review of 216 patients who underwent EVAR between January 2008 and December 2015 was undertaken. Incidence of acute kidney injuries at 24, 48, and 72 hours and at follow-up were evaluated. Of 12 CIN prediction models within the literature, 8 were suitable for validation in patients who underwent EVAR and validation was performed with C-statistics. RESULTS: There were 216 EVARs performed within the study period. The mean patients age was 73 years and 162 (75%) were performed in an elective setting. Percentage of preoperative chronic kidney disease stages 1 to 5 were 16%, 42%, 31%, 6%, and 5%, respectively. The mean intraprocedure contrast volume used was 280 mL. Incidence of acute kidney injuries at 24, 48, and 72 hours and at follow-up were 8%, 12%, 11%, and 6%, respectively. Three percent of patients became dialysis dependent. Validation of the eight existing CIN predication models reveal area under curve C-statistics between 0.61 and 0.75 (P = .026 to P < .001). Five of the 8 had good discriminative ability (C-statistics of >0.70) and the CIN prediction models by Mehran and Tziakas had the highest C-statistics at 0.75 (P < .001). CONCLUSIONS: In our study population, 8 of 12 CIN prediction models within the literature were validated for use in patients undergoing EVAR and five are useful in identifying patients at risk for CIN.

Intravascular Ultrasound-Guided Revascularization of Chronic Juxtarenal Aortoiliac Occlusion.

Chronic juxtarenal aortoiliac occlusion (JRO) represents the most severe form of aortoiliac occlusive disease, classified under Trans-Atlantic Inter-Society Consensus (TASC II) as a TASC II D lesion with surgical treatment as the main recommendation. Although endovascular revascularization of other TASC II D lesions are routinely performed, JRO is often considered a contraindication for endovascular treatment due to the extensive nature, extending from the level of the renal arteries down to the iliac arteries. We hereby illustrate an intravascular ultrasound-guided re-entry based technique to facilitate endovascular reconstruction of a JRO. A 58-year-old man with JRO presented with an infected nonhealing forefoot ulcer. A transradial pigtail catheter was positioned at the level of the occlusion as an imaging catheter and landmark for re-entry. Subintimal wiring was performed through bilateral groin accesses to the level of the pigtail catheter. Intravascular-guided re-entry catheter was used to identify the true lumen guide firing of the needle catheter, allowing passage for a guidewire into the true lumen of the suprarenal aorta. The intimal fenestration was dilated using a 4-mm angioplasty balloon which allowed passage of the contralateral guidewire. Kissing stent grafts were deployed bilaterally, extending from the level of the infrarenal aorta down to the level of the distal external iliac arteries in overlapping fashion. Completion angiography showed brisk flow from the aorta through the stented portion into the femoral arteries. The patient underwent forefoot amputation 2 days later with successful wound healing and limb salvage at 6 months.

Managing Endovascular Workload during COVID-19 Outbreak-The Singapore Experience.

At the outset and during the throes of the COVID-19 pandemic, as valuable resources are channeled to combat the pandemic, challenges in timely delivery of non-COVID-19-related health care services such as endovascular service arise. As such, this article looks at a tertiary institution's experience in managing its endovascular workload-referenced to the American College of Surgeons' triage of vascular surgery patient acuity-based case classification.

Effect of Thoracic Endovascular Aortic Repair on Aortic Remodeling in Patients with Type B Aortic Dissection in an Asian Population.

BACKGROUND: Management of uncomplicated type B aortic dissection (TBAD) has traditionally been aggressive medical therapy. Recent studies brought about a paradigm shift with evidence to suggest benefits from early endovascular intervention to a high risk subgroup of acute uncomplicated TBAD patients. AIMS: We aim to review the effects of aortic remodeling in Asian patients with TBAD with and without endovascular intervention, including maximal aortic diameter, true lumen diameter, and false lumen thrombosis. METHODS: This is a single-center retrospective study of a prospective database. Patients who presented to our institution with acute TBAD from January 2008 to December 2015 (n = 44) were evaluated. Eighteen percent (8 patients) presented with complicated TBAD and underwent emergency thoracic endovascular aortic repair (TEVAR) while the remaining 82% (36 patients) were treated with optimal medical therapy (OMT). RESULTS: Six patients under the conservative arm crossed over to elective TEVAR after 6 weeks because of interval radiological progression of disease. There was no significant difference in the baseline demographics of the TEVAR group and the OMT group. At 24 months, mean maximal aortic diameter difference was -7.7 mm and +1.9 mm (P = 0.077), mean true lumen diameter difference was +10.0 mm and +2.6 mm (P = 0.049), and false lumen thrombosis was 100% and 20% (P = 0.012) for TEVAR and OMT, respectively. Kaplan-Meier analysis showed no significant difference in mortality between the 2 groups at 30 days and 2 years. CONCLUSIONS: Within an Asian population with TBAD, TEVAR with OMT has a significant positive effect on aortic remodeling, compared with OMT-only management.

Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage.

Use of negative pressure wound therapy (NPWT) in peripheral artery disease (PAD) and diabetic limb salvage (DLS) improves wound healing by providing moist wound conditions, reducing exudate, controlling wound-bed infection, and stimulating granulation. NPWT duration may take several weeks, and home-based NPWT allows patient to recover in the community while minimising risks of prolonged hospitalisation. The aim of this study is to review the use and outcomes of home NPWT in PAD and DLS. The methodology is the retrospective review of patients who were discharged with home NPWT after in-patient PAD revascularisation and DLS debridement or minor amputations. The results included a total of 118 patients who received home NPWT between January 2017 and December 2017. The mean age was 62.8 years with 66% male and 34% female patients. The study population comprised 25% smokers, 98% patients with diabetics, 35% with ischemic heart disease, and 21% with end-stage renal failure (ESRF). Of which, 56% of patients required revascularisation while 31% of patients underwent foot debridement, 48% underwent toe amputations, and 20% underwent forefoot amputations. All patients received in-patient NPWT for a week before being discharged on home NPWT for 4 weeks. Then, 62% received targeted antibiotics regime while 36% received empirical antibiotics on discharge; 60% of patients achieved wound healing on home NPWT, with 9% requiring split-thickness skin graft; 4% required further surgical debridement, 16% required further minor amputation while 20% required major amputation. 9% required further home NPWT extension, with a mean length of 7.1 ± 4.7 weeks' extension. Overall survival of 1 year was 89%. Risk factors that predict the failure of home NPWT includes subjects with a background of ESRF and wet gangrene on presentation. Home NPWT is a useful adjunct in the management of PAD and DLS foot wounds.

Outcomes of incisional negative pressure wound therapy following brachiobasilic transposition arteriovenous fistula creation: A 1:2 propensity score matched study.

Incisional negative wound pressure therapy (iNPWT) use on closed incisions has been shown to improve wound outcomes, but no studies have evaluated the use of iNPWT following brachiobasilic transposition arteriovenous fistula (BBT-AVF). We aim to investigate the efficacy of iNPWT vs conventional wound therapy in reducing surgical site infections (SSIs) for BBT-AVF incisions. This is a retrospective cohort study of patients who underwent BBT-AVF creation between January 2010 and December 2017. A 1:2 propensity score matching (PSM) was performed to reduce selection bias and address for confounding factors. Study outcomes included SSI and haematoma incidence, 30-day readmission, and 30-day mortality. A total of 154 patients were reviewed in this study: 47 (30.5%) had iNPWT and 107 (69.5%) had conventional wound therapy. The overall median age was 60.5 (interquartile range 54-69). PSM with a 1:2 ratio resulted in a total of 117 patients (39 iNPWT and 78 conventional wound therapy). In the unmatched cohort, SSI incidence was lower in the iNPWT group (n = 1/47 [2.1%] vs n = 14/107 [13.1%], P = .035). However, incidence of SSI was comparable between iNPWT and conventional wound therapy after matching (n = 1/39 [2.6%] vs n = 9/78 [11.5%], P = .102). There was no significant difference in 30-day readmission and 30-day mortality. Within our study population of patients with BBT-AVF incisions, there is a non-statistically significant reduction in SSI incidence for patients who received iNPWT as compared with conventional wound therapy. Further prospective randomised controlled studies should be conducted to validate these findings.

Clinical and economic burden of wound care in the tropics: a 5-year institutional population health review.

The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5-year institutional population health review. Within our data analysis, wounds are broadly classified into neuro-ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound-related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound-related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1-year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years-old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1-year all-cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound-related 30-day re-admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789-17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.

Use of Multilayer Stent and Fenestrated Endograft in a Single Session to Treat Long-Segment Aorta.

A 72-year-old man with suprarenal aneurysm and 2 large penetrating ulcers (PAUs) in the descending aorta was referred for endovascular treatment. To avoid long-segment aortic coverage and the attendant risk of spinal ischemia, combination of 2 different stent technologies was used. A multilayer flow modulator was implanted in the thoracic aorta for the PAU, followed by implantation of a customized 4-vessel fenestrated stent graft for the suprarenal aneurysm. The patient remained well at 2 years with computed tomography evidence of exclusion of the suprarenal aneurysm and involution of the PAU.

Toe Pressure in Predicting Diabetic Foot Ulcer Healing: A Systematic Review and Meta-analysis.

BACKGROUND: Foot ulceration is the most frequently recognized lower extremity complication in diabetic patients. Predicting wound healing is an essential step in the management of diabetic foot ulcers (DFUs), as it is estimated that early detection and appropriate treatments may prevent up to 85% of amputations. Toe systolic blood pressure (TBP) is a quick and portable bedside assessment and is less affected by medial sclerosis of arteries present in the diabetic population compared to other measurements like ankle-brachial index. This systematic review seeks to evaluate the sensitivity and specificity of toe pressure in prediction of DFU wound healing. METHODS: PubMed/MEDLINE and EMBASE databases were systematically searched up to September 20, 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All randomized control, prospective and retrospective trials were considered for inclusion if they reported healing rates of DFUs with respect to different TBP readings. Healing was defined to be intact skin for at least 6 months or at time of death. Quality assessment of articles was performed using the RevMan Quality Assessment. Information on healing rates with respect to different TBP values was extracted. Summary estimates of sensitivity and specificity of TBP in predicting healing of DFU wounds were obtained using a bivariate model. RESULTS: A total of 580 articles were screened. Eight studies (6 prospective and 2 retrospective) inclusive of 909 patients were eligible for inclusion. It was found that a TBP of more than 30 mm Hg is associated with a sensitivity and specificity of 0.86 and 0.58 respectively for healing of DFUs. CONCLUSIONS: A TBP of more than 30 mm Hg is sensitive but not specific in the prediction of healing of DFUs. Due to its portability and quick analysis, TBP may be used as a bedside assessment to complement current clinical parameters to aid in predicting the healing of diabetic foot ulcers.

Common Femoral Artery Caliber Changes after Percutaneous versus Surgical Access in Endovascular Aneurysm Repair in the Asian Population.

BACKGROUND: Western studies showed vascular caliber changes post-endovascular aneurysm repair (EVAR). This study aims to evaluate for postoperative changes of the common femoral artery inner diameter (CFA ID) in the Asian population. METHODS: From January 2011 to June 2016, 202 patients who underwent EVAR were reviewed. CFA IDs were evaluated at 3 fixed levels on computed tomography (CT) aortograms. Preoperative and postoperative measurements were compared. Per-groin analysis was carried out after division into percutaneous access endovascular aneurysm repair (PEVAR) and surgical access endovascular aneurysm repair (SEVAR) groups. Independent sample t-test compared for differences in overall CFA ID changes between PEVAR and SEVAR groups. Paired sample t-test evaluated CFA ID changes in each group. P value < 0.05 was considered significant. RESULTS: One hundred and twenty patients were included, with 200 groins subsequently analyzed. The PEVAR and SEVAR groups have no significant demographic differences, except in sheath size and duration of CT aortogram follow-up. No significant differences in overall CFA ID changes comparing PEVAR and SEVAR groups (-0.12 ± 1.05 mm, -0.10 ± 0.81 mm, P = 0.36). No significant overall CFA ID changes in both PEVAR (7.92 ± 1.23 mm, 7.80 ± 1.38 mm, P = 0.34) and SEVAR groups (7.47 ± 1.44 mm, 7.36 ± 1.64 mm, P = 0.15). CONCLUSIONS: No significant differences in CFA caliber changes comparing PEVAR and SEVAR. No significant CFA caliber changes in either group.

A Review of Arteriovenous Fistulae Creation in Octogenarians.

BACKGROUND: To analyze the outcomes of arteriovenous fistulae (AVFs) creation in octogenarians. METHODS: A retrospective study of 47 AVFs created in patients aged 80 years and above from 2008 to 2014. Patient and AVF characteristics and outcomes were evaluated. Predictors of patency were analyzed with multivariate analysis and Kaplan-Meier patency, and survival analysis was performed. RESULTS: Forty-seven of 1,259 AVFs created were for octogenarians (4%). Mean age was 83 years old (range: 80-91 years), with 27 male (57%) and 35 with tunneled dialysis catheters in situ (75%). There were a total of 15 (32%) radiocephalic AVFs, 30 (64%) brachial-cephalic AVFs, and 2 (4%) brachial-basilic transposition AVFs. At 12 months, assisted primary patency rate was 28% (13 patients) while primary failure rate was 72% (34 patients). Subset analysis showed brachial-cephalic AVFs to have the highest assisted primary patency rate at 33%. Within 24 months, tunneled dialysis catheter-related sepsis rate was 31% (11 patients). Multivariate analysis did not reveal any factor to be statistically significant in predicting AVF patency. Kaplan-Meier survival curve showed a 50% survival rate at 63 months after AVF creation. CONCLUSIONS: In view of high AVF primary failure rate and relatively low tunneled dialysis catheter bacteremia rate, long-term tunneled dialysis catheters as the main form of hemodialysis renal access may be a viable option. However, with 50% of end-stage renal failure patients surviving up to 63 months after AVF creation, the risks and benefits of long-term tunneled dialysis catheters must be balanced against those of AVF creation.

Diabetic Foot Limb Salvage-A Series of 809 Attempts and Predictors for Endovascular Limb Salvage Failure.

BACKGROUND: To review patient characteristics and outcomes of in-patient diabetic foot limb salvage and identify risk factors predicting for endovascular limb salvage failure. METHODS: Retrospective study of limb salvage attempts in 809 patients between August 2013 and July 2015. RESULTS: Sixty-eight percent of our study population were male with mean age at 65 years and 73% presented with Rutherford grade 6 critical limb ischemia, with the remaining 27% Rutherford grade 5. Eighty-one percent had toe pressures of less than 50 mm Hg, 64% had infrainguinal trans-Atlantic inter-society consensus (TASC II) C or D lesions while 78% had infrapopliteal TASC II C or D lesions. Seven hundred seventy-seven patients (96%) underwent endovascular-first approach limb salvage, with 95% requiring infrapopliteal angioplasty, with 84% of them requiring 2-vessel or 3-vessel revascularization. Thirty-two patients (4%) underwent surgical bypass limb salvage, with 63% performed as salvage procedures for failed angioplasties. The mean in-patient stay was 12.3 days within the endovascular group and 31.1 days within the bypass group (P < 0.01). One-year limb salvage was successful in 88% of endovascular group, as compared with 72% in bypass group (P = 0.01). Overall 1-year survival was 93% within the endovascular group and 88% within the bypass group (P = 0.27). The mean in-patient cost was SGD$5,518 within the endovascular group and SGD$15,141 within the bypass group (P < 0.01). Multivariate analysis showed that independent predictors for failure of endovascular limb salvage include end-stage renal failure (ESRF) (odds ratio [OR] 2.04, P = 0.01), toe pressures <50 mm Hg (OR 2.15, P = 0.01), infrainguinal TASC II patterns C or D (OR 1.99, P = 0.03), and indirect angiosome revascularization (OR 2.03, P = 0.02). CONCLUSIONS: Within our study population of Asian ethnicity, most in-patient diabetic foot peripheral arterial disease presented with Rutherford grade 6 disease, with mostly TASC II C or D lesions and required infrapopliteal revascularization. As most patients had multiple comorbidities and were poor surgical candidates, the majority underwent endovascular-first approach revascularization. Independent predictors of endovascular limb salvage failure include ESRF, toe pressures <50 mm Hg, infrainguinal TASC II patterns C or D, and indirect angiosome revascularization.