Effectiveness of a native vein arteriovenous fistula tracking system.

OBJECTIVE: This study aims to evaluate the effectiveness of a tracking program on the functional maturation rate of arteriovenous fistula (AVF). METHODS: Two major clinical outcomes (commencement of cannulation and functional maturation) of created AVFs were compared between two cohorts. (i) Cohort 1: historical cohort; (ii) Cohort 2: AVFs created after implementation of the tracking project. Multivariable Cox regression models were used to assess the association between cohort allocation and the two major clinical outcomes. RESULTS: Data of 114 and 141 patients were analyzed respectively from Cohorts 1 (historical data) and 2 (with AVF tracking). After adjustment of covariates in the multivariable analysis, the AVFs created in Cohort 2 were more likely to be cannulated earlier (adjusted HR: 2.82; 95% CI: 1.97-4.05; p < 0.001), compared to those in Cohort 1. Similarly, the AVFs of Cohort 2 patients had significantly higher probability of functional maturation (adjusted HR: 1.81; 95% CI: 1.31-2.48; p < 0.001) than fistulas in Cohort 1. Cannulation was commenced for half of the AVFs by 4.1 months post-creation in the historical cohort (Cohort 1), whereas in the post-tracking cohort, 50% of the AVFs were cannulated by 2.3 months after creation (p < 0.001). It took 5.5 and 4.3 months for 50% of the AVFs created in Cohort 1 and Cohort 2 patients to achieve catheter-free functional maturation, respectively (p = 0.06). CONCLUSION: An AVF tracking program with maturation target for the access surgeons, together with a standardized tracking, feedback, and clinical strategy adjustment system is able to improve the AVF functional maturation rate.

A systematic review and meta-analysis of total endovascular versus hybrid repair for the treatment of thoracoabdominal aortic aneurysms.

OBJECTIVE: Although open repair has been the traditional mainstay therapy for thoracoabdominal aortic aneurysms (TAAAs), it remains a surgical challenge. Recently, hybrid repair (HR) and total endovascular repair (TEVR) have emerged as viable alternatives in treating TAAAs. Thus, we aimed to compare the primary outcomes of in-hospital/30-day mortality, as well as secondary outcomes of postoperative complications including spinal cord ischemia, bowel ischemia, long-term dialysis, myocardial infarction and lower limb ischemia for HR vs TEVR for the treatment of TAAAs. We postulated that TEVR was associated with lower in-hospital and 30-day mortality and postoperative complication rates as compared with HR. METHODS: Four scientific databases were searched from inception to November 18, 2021. Meta-analyses were performed for the primary and secondary outcomes. This study was conducted in adherence to the PRISMA guidelines. RESULTS: The search yielded 3312 articles. After a two-stage selection process, five articles were included for final analysis. The in-hospital/30-day mortality rate for TEVR was significantly lower compared with HR (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.20-0.36; P < .00001). TEVR was also associated with reduced bowel ischemia (OR, 0.22; 95% CI, 0.14 -0.35; P < .00001) and long-term dialysis (OR, 0.22; 95% CI, 0.16-0.29; P < .00001). There was, however, no difference in the incidence of spinal cord ischemia (OR, 1.26; 95% CI, 0.74-2.14; P = .39), stroke (OR, 0.65; 95% CI, 0.10-4.20; P = .65), myocardial infarction (OR, 0.60; 95% CI, 0.17-2.05; P = .41), and lower limb ischemia (OR, 0.67; 95% CI, 0.29-1.55; P = .35). Most study outcomes had low heterogeneity. Findings were also robust to sensitivity analysis. CONCLUSIONS: Compared with the HR, TEVR of TAAAs were associated with lower in-hospital and 30-day mortality, bowel ischemia, and long-term dialysis.

A systematic review and meta-analysis of sirolimus-eluting stents for treatment of below-the-knee arterial disease.

OBJECTIVE: We performed a systematic review and meta-analysis to analyze the efficacy and safety of sirolimus-eluting stents (SESs) in the treatment of below-the-knee (BTK) arterial disease. METHODS: An electronic literature search was conducted from inception to July 24, 2021. Retrospective, prospective, and randomized studies that had used SESs to treat BTK arterial disease and had reported the primary patency, technical success, target lesion revascularization, and/or mortality were included. Meta-analyses of the proportions were conducted to derive pooled summary statistics of the outcomes. Where Kaplan-Meier curves were provided for primary patency, a meta-analysis of the individual patient data was conducted via a graphic reconstruction tool to estimate primary patency at various follow-up points. For studies comparing SESs and bare metal stents (BMSs), a two-stage meta-analysis was performed to compare the 6-month primary patency of SESs vs BMSs. RESULTS: Ten studies across 13 publications, including 995 patients, were retrieved for analysis. In the meta-analysis of proportions, across six studies (n = 339 patients), the pooled 6-month primary patency was 87.3% (95% confidence interval [CI], 81.6%-92.1%). Across seven studies (n = 283 patients), the pooled 6-month mortality was 5.4% (95% CI, 1.4%-11.2%). An individual patient data analysis of three studies (n = 282 patients) yielded a primary patency rate of 95.2% (95% CI, 92.7%-97.8%), 82.8% (95% CI, 78.3%-87.6%), 79.8% (95% CI, 75.0%-85.0%), and 79.8% (95% CI, 75.0%-85.0%) at 6, 12, 18, and 24 months, respectively. The 12-month target lesion revascularization rate across four studies (n = 324 patients) was 9.6% (95% CI, 6.4%-13.4%). In the two-stage meta-analysis of 6-month primary patency across three studies (n = 168 patients), the use of SESs was significantly favored over BMSs (risk ratio, 1.28; 95% CI, 1.12-1.46; P < .001). CONCLUSIONS: The overall evidence suggests that the use of SESs appears to be safe and offers favorable outcomes for BTK arterial disease compared with BMSs.

The Effect of Obesity on Outcomes After Arteriovenous Fistulae Creation: A Systematic Review.

BACKGROUND: Establishing reliable vascular access is critical for hemodialysis in end-stage renal disease (ESRD). In recent years, the global health burden of ESRD has grown, matched by a rise in prevalence of obesity. Currently, more and more arteriovenous fistulae (AVFs) are being created for obese patients with ESRD. This is a growing concern as creating arteriovenous (AV) access in obese ESRD patients can be more challenging and may be associated with poorer outcomes. METHODS: We performed a literature search with multiple electronic databases. We included studies that compared outcomes after autogenous upper extremity AVF creation between obese and nonobese patients. The relevant outcomes were postoperative complications, outcomes related to maturation, outcomes related to patency, and outcomes related to reintervention. RESULTS: We included 13 studies with a total of 305,037 patients. We found a significant association between obesity and poorer early and late AVF maturation. Obesity was also strongly associated with lower primary patency rates and a higher need for reintervention. CONCLUSIONS: This systematic review found that higher body mass index and obesity are associated with poorer AVF maturation outcomes, poorer primary patency, and higher reintervention rates.

Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: A systematic review and meta-analysis.

OBJECTIVES: To perform a systematic review and meta-analysis of the techniques and outcomes associated with percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) using the Manta vascular closure device. BACKGROUND: Peripheral VA-ECMO can be used to treat critically ill patients with conditions such as refractory cardiogenic shock. After percutaneous implantation of VA-ECMO, VA-ECMO can also be decannulated completely percutaneously by using a vascular closure device. The Manta vascular closure device is a dedicated device used in the closure of large-bore arteriotomies by sandwiching the arteriotomy with an intra-arterial toggle and an extraluminal collagen plug. METHODS: We performed a thorough literature search using various electronic databases. We included studies that reported outcomes after peripheral femorofemoral VA-ECMO decannulation with the Manta vascular closure device. We performed a meta-analysis of proportions on outcome measures, including technical success, bleeding complications, vascular complications, wound complications, major amputation, and procedural-related deaths. RESULTS: We included seven studies with a total of 116 patients. The overall technical success of percutaneous decannulation of VA-ECMO with the Manta vascular closure device was 93.7%. The overall incidence of bleeding, vascular and wound complications was 1.7%, 13.8%, and 3.4%, respectively. No patient required lower limb amputation or died due to VA-ECMO decannulation. CONCLUSION: Percutaneous decannulation with the Manta vascular closure device is an effective and safe procedure that should be considered in suitable patients on VA-ECMO.

Multi-Modality Imaging of Atheromatous Plaques in Peripheral Arterial Disease: Integrating Molecular and Imaging Markers.

Peripheral artery disease (PAD) is a common and debilitating condition characterized by the narrowing of the limb arteries, primarily due to atherosclerosis. Non-invasive multi-modality imaging approaches using computed tomography (CT), magnetic resonance imaging (MRI), and nuclear imaging have emerged as valuable tools for assessing PAD atheromatous plaques and vessel walls. This review provides an overview of these different imaging techniques, their advantages, limitations, and recent advancements. In addition, this review highlights the importance of molecular markers, including those related to inflammation, endothelial dysfunction, and oxidative stress, in PAD pathophysiology. The potential of integrating molecular and imaging markers for an improved understanding of PAD is also discussed. Despite the promise of this integrative approach, there remain several challenges, including technical limitations in imaging modalities and the need for novel molecular marker discovery and validation. Addressing these challenges and embracing future directions in the field will be essential for maximizing the potential of molecular and imaging markers for improving PAD patient outcomes.

Biomimetic Vasculatures by 3D-Printed Porous Molds.

Despite recent advances in biofabrication, recapitulating complex architectures of cell-laden vascular constructs remains challenging. To date, biofabricated vascular models have not yet realized four fundamental attributes of native vasculatures simultaneously: freestanding, branching, multilayered, and perfusable. In this work, a microfluidics-enabled molding technique combined with coaxial bioprinting to fabricate anatomically relevant, cell-laden vascular models consisting of hydrogels is developed. By using 3D porous molds of poly(ethylene glycol) diacrylate as casting templates that gradually release calcium ions as a crosslinking agent, freestanding, and perfusable vascular constructs of complex geometries are fabricated. The bioinks can be tailored to improve the compatibility with specific vascular cells and to tune the mechanical modulus mimicking native blood vessels. Crucially, the integration of relevant vascular cells (such as smooth muscle cells and endothelial cells) in a multilayer and biomimetic configuration is highlighted. It is also demonstrated that the fabricated freestanding vessels are amenable for testing percutaneous coronary interventions (i.e., drug-eluting balloons and stents) under physiological mechanical states such as stretching and bending. Overall, a versatile fabrication technique with multifaceted possibilities of generating biomimetic vascular models that can benefit future research in mechanistic understanding of cardiovascular diseases and the development of therapeutic interventions is introduced.

Lobar versus Sublobar Resection in the Elderly for Early Lung Cancer: A Meta-Analysis.

OBJECTIVES: We performed a systematic review and meta-analysis of outcomes of lobectomy versus sublobar resection in elderly patients (≥65) with stage 1 nonsmall cell lung carcinoma (NSCLC). METHODS: We searched for relevant articles using a set of inclusion and exclusion criteria. Meta-analytic techniques were applied. RESULTS: Twelve studies (n = 5834) were chosen. Our results indicate that in the elderly, lobectomy for stage 1 NSCLC confers a survival advantage over sublobar resection. Lobectomy patients had a lower risk of death within 5 years and lower odds of local cancer recurrence. Our results show that lobectomy had a better 5-year cancer-specific survival and 5-year disease-free survival that trended toward significance. The sublobar resection group showed better 30-day operative mortality that trended toward significance. Subgroup analysis of stage 1A cancer demonstrated no difference in 5-year overall survival rates. However, for stage 1B tumors 5-year overall survival favored lobectomy. CONCLUSION: Lobectomy for stage 1 NSCLC in elderly patients is superior to sublobar resection in terms of survival and cancer recurrence and should be afforded where possible. For stage 1A tumors, sublobar resection is noninferior and may be considered. Further randomized controlled trials in this topic is required.

A scoping review of vascular surgery education in the medical school curriculum.

OBJECTIVE: Despite the high burden of vascular disease that is assessed, investigated, and managed by generalists, no specific medical school curriculum is in use for vascular surgery (VS). In the present scoping review, we aimed to map the available evidence on the provision of VS education in the medical school curriculum worldwide. METHODS: The present review was conducted in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analysis) extension for scoping reviews. The inclusion criterion was reported research studies on VS education in the medical curriculum. RESULTS: A total of 20 studies were included. Three main themes were identified. VS was perceived as an essential part of the general medical student curriculum by VS applicants. Exposure to VS varied considerably, and students generally expressed a need for an increase in VS coverage. The most important positive determinants when choosing VS as a career were having a VS mentor, the technical aspects of VS, and participation in a VS rotation. Frequently cited deterrents were the long training time and demanding lifestyle potentially compromising family life. CONCLUSIONS: The present scoping review has provided a starting point to better understand the provision of VS education in medical schools across the world. Our review has demonstrated the variability in VS exposure at medical school and described students' sentiments toward VS. We have highlighted the need to determine whether the current curricula are adequate from the perspective of multiple stakeholders (eg, vascular surgeons, educators, general practitioners, a variety of specialists) with a crucial role in the treatment of patients with vascular conditions.

A systematic review of brachial artery ligation as a safe and feasible option in the management of arteriovenous dialysis access infection.

OBJECTIVE: Creation of good long-term arteriovenous access is essential in patients requiring hemodialysis for end-stage renal failure. However, arteriovenous grafts or fistulae can be complicated by infection that may require emergency surgery. For infections that involve the brachial artery anastomosis, or if total graft explantation is indicated, brachial artery repair or reconstruction is often required. An alternative management strategy would be brachial artery ligation (BAL). We performed a systematic review to evaluate the outcomes of BAL that has been performed for infected arteriovenous grafts or fistulae. METHODS: A thorough literature search was conducted using various electronic databases. We included articles that reported outcomes of BAL performed for infected arteriovenous grafts or fistulae. The primary outcome was the incidence of upper limb ischemia after BAL. Secondary outcomes were the need for urgent revascularization, need for upper limb amputation, and incidence of postoperative neurological deficit after BAL. RESULTS: A total of five studies with a total of 125 patients were included in our systematic review. BAL was performed for infected arteriovenous grafts or fistulae for all studies. Follow-up period ranged from 1 to 27 months. The incidence of upper limb ischemia after BAL was low. Only a single study reported three patients who developed upper limb ischemia. Two patients required urgent revascularization, and one patient required forearm amputation after proximal ligation. All studies reported clearance of infection with no recurrence. CONCLUSIONS: Distal BAL may be performed safely for patients with infected arteriovenous fistulae or grafts with low risk of upper limb ischemia, postoperative neurological deficit, and recurrent infection.

Vascular e-Learning During the COVID-19 Pandemic: The EL-COVID Survey.

BACKGROUND: The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning. METHODS: An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020. RESULTS: Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2-4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%). CONCLUSIONS: During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.

Experience from a Singapore tertiary hospital with restructuring of a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic.

Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on January 23, 2020. For 2 weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed because of these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function while reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compare it with preceding months. We discuss our operating room and personal protective equipment protocols in managing a COVID-19 patient and share how we continue surgical training amid the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses.

Laparoscopic versus open appendectomy in pediatric patients with complicated appendicitis: a meta-analysis.

BACKGROUND: Acute appendicitis is a common condition in the pediatric population. In patients with uncomplicated appendicitis, laparoscopic appendectomy (LA) is preferred as compared to open appendectomy (OA). However, in patients with complicated appendicitis (CA), as defined as suppurative, gangrenous or perforated appendicitis, or appendicitis with periappendicular abscess formation, the decision to perform OA or LA remains unclear. METHODS: The PRISMA guidelines were adhered to. An electronic database search from 1997 to 2017 was performed using the Cochrane, Medline, PubMed, Scopus, Ovid, Embase, and Web of Knowledge databases. Data analysis, including subgroup analysis of randomized-control trials, was performed using RevMan 5.3. Assessment of methodological and statistical heterogeneity, as well as publication bias of the included studies, was performed. RESULTS: Six randomized-control trials (296 LA versus 373 OA) and 33 case-control trials (3106 LA versus 4149 OA) were analyzed. Compared to OA, LA has a shorter length of stay (WMD = - 0.96, 95% CI - 1.47 to - 0.45) and a lower rate of surgical site infection (OR 0.37, 95% CI 0.25-0.54), although the rates of intraabdominal abscess formation were similar (OR 1.01, 95% CI 0.71-1.43). LA was also shown to have lower readmission rates, lower incidences of postoperative ileus or intestinal obstruction, lower incidence of reoperation, as well as a shorter time taken to oral intake. Operative time for OA was shorter than LA (WMD = 12.44, 95% CI 2.00-22.87). CONCLUSION: While studies in the past have associated LA with higher rates of intraabdominal abscess in patients with CA, our meta-analysis has shown that they were similar. Considering this, together with other improved postoperative outcomes, LA should be the procedure of choice in pediatric patients presenting with CA.