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.

Aortic graft explants - A single institution analysis of incidence and outcomes.

OBJECTIVES: Explantation of both endovascular endovascular aneurysm repair and open aortic grafts is a procedure associated with high peri-operative risk, and the current study sought to determine the outcomes and trends over time in these patients. METHODS: This study examined data from all patients undergoing explant of an aortic graft (both open and endovascular) between January 2004 and December 2020 at a single centre. Variables analysed included comorbidities, duration to and indication for explantation, type of revascularization, in-hospital complications and mortality, duration of hospital and ICU stay, and out-patient mortality. RESULTS: Of 688 open and 1352 EVARs performed, 46 patients underwent 48 explants. Five were open grafts and 43 were endografts, equating to an explant rate of 0.73% of open and 3.18% EVARs. Average time to explant was 70 months, with patients presenting electively having a significantly longer duration to representation than those presenting emergently (51 vs 44 months, p=0.003). Indication for explant was endoleak in 70%, infection in 23%, and occlusion in 6%. Of the endoleaks, 61% of were Type 1, 22% Type II, 11% Type IV, and 6% Type V. On representation, 17 patients (35%) were symptomatic. Overall mortality rate was 8.3%, with a trend for higher mortality in emergent than elective presentations (11.8 vs 6.5%, p=0.55). There was no change in explant rate over time. CONCLUSIONS: Elective aortic graft explantation is associated with low mortality, despite its complexity and patient comorbidities. Patients presenting with symptoms suffered higher mortality and a longer post-operative course, suggesting that aortic graft explantation should be considered sooner rather than later, rather than persisting with repeated endovascular management.

The failing endograft-A systematic review of aortic graft explants and associated outcomes.

OBJECTIVE: The prominent use of endovascular stent grafts in the management of abdominal aortic aneurysms is associated with increased descriptions of late complications such as graft infection and endoleaks, which can confer significant morbidity and mortality. Failed endovascular management of late complications often requires open conversion and graft explantation. This systematic review sought to highlight the peri- and post-operative course of patients undergoing aortic graft explants to inform readers of the associated morbidity and mortality of patients undergoing this procedure. METHODS: The review was conducted in accordance with PRISMA guidelines. A search of the PubMed, Google Scholar and Ovid MEDLINE databases from January 1995 to April 2021 was performed with a combination of MeSH terms pertaining to endovascular aneurysm repair and open conversion. Articles were screened and included based on pre-determined selection criteria. RESULTS: A total of 818 studies were identified, with 41 meeting inclusion criteria. These studies examined a total of 1324 patients, 84.3% of whom were male with a mean age of 74 years at explantation. Mean time to graft explantation was 36 months, with a mean aneurysm size of 66 mm. The majority of aortic explants were performed for persistent endoleaks (68%), and 10% for infection. There was high morbidity with the procedure, with high rates of post-operative complications (mean, 37%) and 30-day mortality (11%). The most common complications included renal (15%), respiratory (12%) and cardiac (9%). Most explanted grafts were first-generation endografts. Morbidity and mortality rates were reduced in patients undergoing elective explants compared to emergent procedures (3.3% compared to 43.4%). CONCLUSION: Aortic graft explant remains a highly co-morbid procedure, with high rates of peri- and post-operative complications and mortality. The number of explant procedures reported over the past 25 years has increased, reflecting the prominent use of EVAR in the management of AAAs. Whilst remaining a highly co-morbid procedure, patients undergoing elective explants had markedly reduced rates of mortality and morbidity compared to emergent explants. Thus, clinical focus should be on identifying patients who require graft explantation early to perform these procedures in an elective setting.

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.

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.

"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.

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.

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.

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.

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.

Proton Pump Inhibitors and Cardiovascular Events: A Systematic Review.

BACKGROUND: Proton pump inhibitors (PPIs) are a commonly prescribed medication that recent data has linked to an increased risk of cardiovascular morbidity and all cause morbidity. The current study sought to perform a systematic review to investigate the link between PPIs and morbidity and mortality METHODS: A systematic review was carried out as per the PRISMA guidelines, with information databases including Pubmed, Medline, and the Cochrane Review Database. English-language studies of all types published from January 1990 to October 2016 were considered. Dichotomous analysis generating odds ratios was performed using RevMan Version 5.3. RESULTS: Thirty-seven studies were considered, of which five directly compared the effect of PPI use on mortality and/or cardiovascular morbidity (including 22,427 patients in mortality datasets, and 354,446 patients in morbidity datasets). For patients taking PPIs, all cause mortality (OR 1.68 [95% CI 1.53-1.84], p<0.001) and rate of major cardiovascular events (OR 1.54 [95% CI 1.11-2.13], p=0.01) were significantly higher. CONCLUSIONS: The current systematic review demonstrates that, in patients using PPIs, there was a significant increase in morbidity due to cardiovascular disease. Careful consideration should be given to the prescription of PPIs while clinical equipoise remains. Further research in the area is required.

Threatened limb from stingray injury.

We present the case of a 43-year-old female who suffered a stingray injury to her left ankle. The sting caused occlusion of the dorsalis pedis artery, causing dry gangrene of the medial forefoot. A below knee amputation was recommended but she was transferred for a second opinion. A Prostaglandin E1 infusion was commenced, resulting in alleviation of pain and improvement in perfusion. Amputation of great and second toes was performed, with the head of the first metatarsal preserved and covered via a cross-over skin flap raised from the contralateral leg. Achilles tendon lengthening was then performed to return the foot to a functional position. This case serves to highlight the utility of prostaglandin infusion, and the requirement for a multidisciplinary approach to critical limb ischemia in order to avoid major amputation.

Novel Use of an Iliac Branch Device in the Treatment of an Abdominal Aortic Aneurysm.

Iliac branch devices (IBDs) are commonly used to treat iliac artery aneurysms and maintain patency of the internal iliac artery or its branches. This case report illustrates another possible application for an IBD. We present the case of a 77-year-old male who underwent repair of his infrarenal aneurysm with an IBD as a bifurcated aortic stent-graft in a small diameter aorta to maintain bilateral common iliac artery patency.

Open versus Endovascular Repair of Arch and Descending Thoracic Aneurysms: A Retrospective Comparison.

BACKGROUND: Thoracic aortic aneurysms (TAAs) contribute significant mortality if left untreated, but surgical repair has historically carried substantial risks. METHODS: We sought to observe trends and outcomes of open and endovascular thoracic endovascular aneurysm repair thoracic aortic repairs, so conducted a retrospective review of all patients who presented for management of TAAs from 2003 to 2013 at 2 hospitals in Sydney, Australia. RESULTS: A total of 179 patients presented with TAAs over the study period, including 5 ruptures. Fifty-two were treated nonoperatively, with 127 surgically repaired. Operative duration was significantly shorter in endovascular than open repair of arch (193 ± 108 vs. 396 ± 98 min, P = 0.0001) and descending aneurysms (242 ± 116 vs. 422.5 ± 161 min, P = 0.003). There were no differences in mortality or complication rates (including paraplegia), duration of hospital or intensive care unit stay, or transfusion requirements between endovascular and open TAA repairs. CONCLUSIONS: Apart from reduced surgical duration, this study revealed no benefits of endovascular over open TAA repair. Overall morbidity and mortality were low, even in elderly patients.

Venous thromboembolism secondary to penile prosthesis.

We report the case of a 65-year-old male who presented with an extensive iliofemoral venous thrombosis, which computed tomography demonstrated was secondary to compression of the right common and external iliac veins by a 5-cm diameter penile prosthesis reservoir. A similar occurrence has only been reported a handful of times previously, and only in urological journals, never in vascular literature. It is a potentially serious complication of penile prosthesis surgery, the risk of which can be minimized by ready awareness of this postoperative event.

MRI "row of dots sign" in gossypiboma: an enlarging mass 8 months after sarcoma resection.

The retention of foreign bodies after surgery is rare, but carries significant morbidity and mortality as well as financial and legal implications. Such retained items cause a foreign-body reaction, which in the case of cotton-based materials are called gossypibomas. We present the case of an 84-year-old woman with a pseudotumor secondary to a retained dressing gauze roll, presenting 5 months after resection of a gluteal sarcoma, which had raised concerns of local recurrence. We also outline the imaging modalities that may assist in diagnosis of a retained foreign body, and suggest the MRI "row of dots" sign as a useful radiological feature associated with gossypiboma. Awareness of the imaging appearances of retained foreign bodies allows the inclusion of this possibility in differential diagnosis of a mass in patients with a surgical history.

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.

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.