Influence of crural vessel run-off on short- and mid-term outcomes following femoro-popliteal bypass grafting.

OBJECTIVES: To determine the influence that the number of patent crural run-off vessels has on short- and mid-term outcomes following femoro-popliteal bypass. METHODS: All patients undergoing index femoro-popliteal bypass grafting between 2013 and 19 at our unit were included. Preoperative imaging was used to stratify patients into cohorts with either one or ≥2 patent run-off vessels. Primary outcomes measures included bypass patency and limb salvage rates at one and 3 years post-operatively. Survival analysis was performed using Kaplan-Meier curves and Logrank test. RESULTS: 147 bypasses performed on 143 patients were included. 24 patients had one-vessel run-off and 123 had ≥2 vessels patent. Patients with one-vessel run-off had a higher proportion of emergency admissions (54% vs 41%) and diabetes (42% vs 31%). 31% of patients underwent diagnostic angiogram imaging in addition to having duplex ultrasound and/or computed tomography angiography. There were no significant differences in primary, primary-assisted or secondary patency rates between the cohorts at 12 or 36 months. Limb salvage rates were significantly higher amongst those with ≥2 vessel run-off at 12 (86% vs 71%, p = 0.03) and 36 (85% vs 71%, p = 0.04) months. For those with occluded grafts, a higher proportion of patients with ≥2 vessel run-off subsequently had an attempt at redo bypass grafting. CONCLUSIONS: Femoro-popliteal bypass is a reasonable treatment option for patients with one-vessel run-off. However, whilst patency rates are comparable, clinicians should be aware of the lower successful limb salvage rates for patients with one patent vessel (especially those presenting with tissue loss).

Significance of preoperative thrombus burden in the prediction of a persistent type II and reintervention after infrarenal endovascular aneurysm repair.

BACKGROUND: Persistent type II endoleak has necessitated prolonged surveillance and is a reason for reintervention after infrarenal endovascular aneurysm repair (EVAR). The aim of this study was to assess the association of thrombus burden (TB) within the aneurysmal sac in the prediction of a persistent type II endoleaks. METHODS: Consecutive patients who underwent infrarenal EVAR from October 2009 to October 2017 in a single vascular network were included. TB was assessed on preoperative computed tomography angiogram and was defined as a percentage of thrombus across the maximal sac diameter in comparison with the luminal diameter measured orthogonally at the same level. Patients were categorized into three groups: low TB (<25%), medium TB (25%-50%), and high TB (>50%). All patients underwent postoperative EVAR surveillance comprising computed tomographic angiography or duplex ultrasound imaging. Type II endoleak observed for more than 1 year was defined as persistent type II endoleak. Odds ratio (OR) and Student's t-test were used to determine significance. RESULTS: Some 275 EVARs were performed in the study period. A total of 45 procedures were excluded because of either iliac-only intervention (n = 9), no preoperative information (n = 7), abandoned (n = 1), or less than 1 year's follow-up data (n = 28). For the 230 procedures included, the median follow-up was 43 (12-102) months. There were no significant differences between the groups for age, gender, and comorbidities nor preoperative sac diameter. There was high interobserver reliability with a kappa value of 0.89 (0.84-0.94) with a total discordance of 7% across the cohorts. Persistent type II endoleak occurred significantly more frequently with reduced TB: 41% of the low TB cohort compared with 4% of the high TB cohort (OR, 15.36 [3.5-67.3]; P = .0003). Reintervention was also significantly more likely to occur in the presence of a persistent type II endoleak compared with its absence; n = 12 of 13 (92%) patients who underwent reintervention had a persistent type II endoleak (OR, 43.4 [5.5-242]; P = .0003). Sac size reduction was significantly greater in medium TB and high TB cohorts when compared with low TB: -25% and -27% vs -15% (P = .0046 and P < .0001). Decreased TB was associated with a significant increase in inferior mesenteric artery (IMA) patency, the mean TB, where the IMA was patent, being 29% compared with 40% where the IMA was occluded P < .0001. When considered together, patients with a low TB and a patent IMA were even more likely to have a persistent type II endoleak when compared with those with a high TB and an occluded IMA (OR, 34.1 [1.99-583]; P = .015). CONCLUSIONS: Low TB is associated with increased rates of persistent type II endoleak, especially in the presence of a patent IMA. High TB is associated with increased sac regression and low reintervention rates. TB can be assessed reliably and could be used for risk stratification in the planning of infrarenal EVAR. Pre-emptive embolization of IMA or lumbar vessels in those with low TB may be beneficial. TB could be a useful tool for designing a post-EVAR surveillance regimen.

Safety and Validity of the Proposed European Society for Vascular Surgery Infrarenal Endovascular Aneurysm Repair Surveillance Protocol: A Single Centre Evaluation.

OBJECTIVE: Long term surveillance after endovascular aneurysm repair (EVAR) is essential to detect late complications, but there is variation in practice. The European Society for Vascular Surgery (ESVS) made a recommendation for a new surveillance protocol; one element involves risk stratifying patients depending on sac size reduction and presence of endoleak at their 30 day computed tomography angiogram into low risk groups (delayed imaging to five years) or higher risk groups (continue with the current protocol). The aim was to test this suggested protocol retrospectively within an EVAR patient cohort. METHODS: Data on EVARs performed from October 2009 to October 2019 were collected. Information gathered from an existing surveillance programme was used to assess the proposed ESVS protocol. All patients who underwent re-intervention were reviewed to see whether adopting the proposed ESVS protocol would have detected these events. RESULTS: In total, 309 procedures were included. Altogether, 219 of these patients had no endoleak (70.9%) and 86 had a type II (27.8%) endoleak. Only four developed a type I or III endoleak. No patient in the low risk cohort (no initial endoleak or sac shrinkage > 1 cm) required secondary intervention. Five year follow up data were available for 103 patients. In the type II endoleak group, there were 28 secondary interventions in 22 patients. No patient experienced a ruptured aneurysm within five years post-operatively. Had the proposed ESVS protocol been followed, all patients requiring a secondary intervention or with increasing sac size would have been detected/captured. Further, adherence to the ESVS guidelines would have resulted in 103 patients with a five year follow up history qualifying for reduced surveillance. A further 120 patients who had reached the three and four year follow up timepoints could have qualified for a reduced surveillance, reducing imaging cost further. CONCLUSION: Adopting the proposed ESVS EVAR surveillance protocol safely identified "low risk" patients who did not go on to require a secondary intervention. These patients could benefit from reduced surveillance scanning.

Mortality After Paclitaxel-Coated Device Use in Patients With Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: To report the risk of all-cause mortality after treatment with paclitaxel-coated devices vs uncoated controls in patients with chronic limb-threatening ischemia (CLTI). MATERIALS AND METHODS: A search of the PubMed, Embase, Cochrane, CINAHL, DARE, and PROSPERO databases was made on 5 November 2019 to identify randomized controlled trials (RCT) using intention-to-treat analysis to compare a paclitaxel-coated device to an uncoated device in PAD patients having clinical follow-up of at least 6 months. Half of the study population had to have CLTI or extractable data on the CLTI subgroup if <50%. The search identified 11 trials having 1450 patients randomized to a paclitaxel-coated device (n=866) or an uncoated control (n=584). There were 1367 (94.3%) patients with CLTI (range 10-429). The single endpoint was all-cause mortality, which was analyzed by pooling the mortality data in a DerSimonian and Laird random effects model. Summary statistics are expressed as relative risk ratios (RR) with a 95% confidence interval (CI). RESULTS: The mean follow-up was 25.6 months (range 6-60); 10 of 11 studies reported a minimum 12-month follow-up. There were 161 (18.6%) deaths among 866 subjects in the paclitaxel device group and 116 deaths among 584 (19.9%) subjects in the non-coated control group (RR 0.93, 95% CI 0.78 to 1.12, p=0.45). CONCLUSION: There was no observed difference in short- to midterm mortality among a pooled patient population of predominately CLTI patients treated with paclitaxel-coated balloons or stents compared with uncoated controls.

The Relationship Between Operative Volume and Peri-operative Mortality After Non-elective Aortic Aneurysm Repair in Australia.

OBJECTIVE: Hospital and surgeon operative caseload is thought to be associated with peri-operative mortality following the non-elective repair of aortic aneurysms; however, whether such an association exists within the Australian healthcare setting is unknown. METHODS: The Australasian Vascular Audit was interrogated to identify patients undergoing non-elective (emergency [EMG] or semi-urgent [URG]) aortic aneurysm repair between 2010 and 2016, as well as their treating surgeon and hospital. Hierarchal logistic regression modelling was used to assess the impact of caseload on outcomes after both endovascular (EVAR) and open surgical repair (OSR). RESULTS: Volume counts were determined from 14 262 patients (4 121 OSR and 10 141 EVAR). After exclusion of elective procedures and duplicates, 1 153 EVAR (570 EMG and 583 URG) and 1 245 OSR (946 EMG and 299 URG) non-elective cases remained for the analysis. Crude mortality was 24.0% following OSR (EMG 29.2%; URG 7.7%) and 7.5% following EVAR (EMG 12.6%; URG 2.4%). Univariable analysis demonstrated an association between OSR mortality and hospital volume (quintile [Q] 1: 25.3%, Q2: 27.8%, Q3: 23.9%, Q4: 27.0%, Q5: 16.2%; p = .030), but not surgeon (Q1: 25.2%, Q2: 27.4%, Q3: 26.0%, Q4: 21.4%, Q5: 19.5%, p = .32). Multivariable analysis confirmed this association (odds ratio (OR) [95% CI]; Q1 vs 5: 1.91 [1.13-3.21], Q2 vs. 5: 2.01[1.24-3.25], Q3 vs. 5: 1.41 [0.86-2.29], Q4 vs. 5: 1.92 [1.17-3.15]; p = .020). The difference was most pronounced in the EMG OSR group [Q1 - 3 vs. 4-5] (OR 1.63 [1.07-2.48]; p = .020). Mortality after EVAR was not associated with either hospital (Q1: 6.3%, Q2: 10%, Q3: 6.8%, Q4: 4.5%, Q5: 10%; p = .14) or surgeon volume (Q1: 9.3%, Q2: 5.7%, Q3: 8.1%, Q4: 7.0%, Q5: 7.3%; p = .67). CONCLUSION: There is an inverse correlation between hospital volume and peri-operative mortality following EMG open repair of aortic aneurysm. These data support restructuring Australian pathways of care to direct suspected ruptured aneurysm to institutions that reach a minimum volume threshold.

Mortality After Paclitaxel-Coated Device Use in Dialysis Access: A Systematic Review and Meta-Analysis.

Purpose: To report the risk of all-cause mortality in patients who underwent dialysis access treatment using paclitaxel-coated devices compared with percutaneous transluminal angioplasty (PTA) with an uncoated balloon. Materials and Methods: A systematic review and meta-analysis of randomized controlled trials were performed to investigate the mortality outcomes associated with paclitaxel-coated devices in the treatment of patients with a failing dialysis access (last search date February 28, 2019). The primary endpoint was all-cause mortality. This analysis included 8 studies comparing paclitaxel-coated balloon (PCB) angioplasty (n=327) and PTA (n=331) in the treatment of failing dialysis access. None investigated paclitaxel-coated stents. Mortality data were pooled using a random effects model. Statistical heterogeneity was evaluated with a chi-square test and the I2 statistic. Summary statistics are expressed as relative risk ratios (RR) with a 95% confidence interval (CI). Results: At the pooled mean follow-up of 13.5 months (median 12, range 6-24) all-cause mortality was similar in the PCB group (13.8%) compared with PTA (11.2%; RR 1.26, 95% CI 0.85 to 1.89, p=0.25; I2=0%). Subgroup analysis, stratified according to length of follow-up, confirmed that there were no statistically significant differences in mortality at short- and midterm follow-up [6-month (8 studies): 5.2% vs 4.8%, RR 1.24, 95% CI 0.62 to 2.47, p=0.55; 12-month (6 studies): 6.3% vs 6.0%, RR 1.06, 95% CI 0.43 to 2.63, p=0.90; and 24-month (3 studies): 19.0% vs 13.5%, RR 1.38, 95% CI 0.90 to 2.12, p=0.14). Conclusion: The analysis found no difference in short- to midterm mortality among patients treated with a drug-coated balloon compared with PTA. With proven benefit and no evidence of harm, the authors recommend ongoing use of PCB for the failing dialysis access.

The Relationship Between Aortic Aneurysm Surgery Volume and Peri-Operative Mortality in Australia.

OBJECTIVES: Operative caseload is thought to be associated with peri-operative mortality following intact aortic aneurysm repair. The aim was to study that association in the Australian setting, which has a unique healthcare provision system and geographical population distribution. METHODS: The Australasian Vascular Audit database was used to capture volume measurements for both individual surgeon and hospital and to separate it into quintiles (1, lowest, to 5, highest) for endovascular (EVAR), open surgical repair (OSR), and subgroups of repair types between 2010 and 2016. Multivariable logistic regression modelling was used to assess the impact of caseload volumes on in hospital mortality after adjustment for confounders. RESULTS: Volume counts were determined from 14,262 aneurysm repair procedures (4121 OSR, 10,106 EVAR). After exclusions, 2181 OSR (161 complex, 2020 standard) and 7547 EVAR (6198 standard, 1135 complex, 214 thoracic (TEVAR)) elective cases were available for volume analysis. Unadjusted mortality after EVAR was unaffected by either surgeon (Quintile 1, 1.0%; Quintile 5, 0.9%; p = .28) or hospital volume (Quintile 1, 0.8%; Quintile 5, 1.3%; p = .47). However, univariable analysis of the TEVAR subgroup revealed a significant correlation with hospital volume (Quintiles 1-2 vs. Quintiles 3-5; p = .02). Univariable analysis for OSR demonstrated a marginal, non-significant value for surgeon (Quintile 1, 4.0%; Quintile 5, 3.6%; p = .06), but not hospital volume (Quintile 1, 4.7%; Quintile 5, 4.0%; p = .67). After adjustment for confounders hospital volume remained a significant predictor of peri-operative TEVAR mortality (Quintile 1-2 vs. 3-5; OR 5.62, 95% CI 1.27-24.83; p = .02) and surgeon volume a predictor following standard OSR (Quintile 1-2 vs. Quintile 3-5; OR 2.15, 95% CI 1.21-3.83; p = .01). CONCLUSIONS: There is an inverse correlation between both surgeon volume of open aortic aneurysm repair, hospital volume of thoracic endovascular aneurysm repair and in hospital mortality. These findings suggest that in Australia TEVAR should be performed by high volume hospitals and OSR by high volume surgeons.

Cost Analysis of Initial Treatment With Endovascular Revascularization, Open Surgery, or Primary Major Amputation in Patients With Peripheral Artery Disease.

PURPOSE: To compare the total initial treatment costs for open surgery, endovascular revascularization, and primary major amputation within a single-payer healthcare system. METHODS: A multicenter, retrospective analysis was undertaken to evaluate 1138 patients with symptomatic peripheral artery disease (PAD) who underwent 1017 endovascular procedures, 86 open surgeries, and 35 major amputations between 2013 and 2016. A cost-mix analysis was performed on individual patient data generated for selected diagnosis-related groups. Mean costs are presented with the 95% confidence interval (CI). RESULTS: There was no intergroup difference in demographics or private health insurance status. However, the amputation group had a higher proportion of emergency procedures (68.6% vs 13.3% vs 27.9%, p<0.001) and critical limb ischemia (88.6% vs 35.9% vs 37.2%, p<0.001) compared with the endovascular therapy and open surgery groups, respectively. The endovascular revascularization group spent less time in hospital and used fewer intensive care unit (ICU) resources compared with the open surgery and major amputation groups (hospital length of stay: 3.4 vs 10.0 vs 20.2 days, p<0.01; ICU: 2.4 vs 22.6 vs 54.6 hours, p<0.01), respectively. While mean prosthetic and device costs were higher in the endovascular group [AUD$2770 vs AUD$1658 (open) and AUD$1219 (amputation), p<0.01], substantial disparities were observed in costs associated with longer operating theater times, length of stay, and ICU utilization, which resulted in significantly higher costs in the open and amputation groups. After adjusting for confounders, the AUD$18,396 (95% CI AUD$16,436 to AUD$20,356) mean cost per admission for the endovascular revascularization group was significantly less (p<0.001) than the open surgery (AUD$31,908, 95% CI AUD$28,285 to AUD$35,530) and major amputation groups (AUD$43,033, 95% CI AUD$37,706 to AUD$48,361). CONCLUSION: Endovascular revascularization procedures for PAD cost the health payer less compared with open surgery and primary amputation. While devices used to deliver contemporary endovascular therapy are more expensive, the reduction in bed days, ICU utilization, and related hospital resources results in a significantly lower mean total cost per admission for the initial treatment.

Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins.

BACKGROUND: Short (or small) saphenous vein (SSV) varices occur as a result of an incompetent sapheno-popliteal junction, where the SSV joins the popliteal vein, resulting in reflux in the SSV; they account for about 15% of varicose veins. Untreated varicose veins may sometimes lead to ulceration of the leg, which is difficult to manage. Traditionally, treatment was restricted to surgery or conservative management. Since the 1990s, however, a number of minimally invasive techniques have been developed; these do not normally require a general anaesthetic, are day-case procedures with a quicker return to normal activities and avoid the risk of wound infection which may occur following surgery. Nerve injury remains a risk with thermal ablation, but in cases where it does occur, the injury tends to be transient. OBJECTIVES: To compare the effectiveness of endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and ultrasound-guided foam sclerotherapy (UGFS) versus conventional surgery in the treatment of SSV varices. SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Specialised Register (last searched 17 March 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2). We searched clinical trials databases for details of ongoing or unpublished studies. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing EVLA, endovenous RFA or UGFS with conventional surgery in the treatment of SSV varices for inclusion. DATA COLLECTION AND ANALYSIS: We independently reviewed, assessed and selected trials that met the inclusion criteria; any disagreements were resolved by discussion. We extracted data and used the Cochrane's tool for assessing risk of bias. When the data permitted, we performed either fixed-effect meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs) or random-effects meta-analyses where there was moderate to significant heterogeneity. MAIN RESULTS: We identified three RCTs, all of which compared EVLA with surgery; one also compared UGFS with surgery. There were no trials comparing RFA with surgery. The EVLA versus surgery comparison included 311 participants: 185 received EVLA and 126 received surgery. In the UGFS comparison, each treatment group contained 21 people. For several outcomes in the EVLA comparison, only a single study provided relevant data; as a result, the current review is limited in its ability to demonstrate meaningful results for some planned outcomes. The quality of evidence according to GRADE was moderate to low for the outcome measures in the EVLA versus surgery comparison, but low for the UGFS versus surgery comparison. Reasons for downgrading in the EVLA versus surgery comparison were risk of bias (for some outcomes, the outcome assessors were not blinded; and in one study the EVLA-surgery allocation of 2:1 did not appear to be prespecified); imprecision (data were only available from a single small study and the CIs were relatively wide); indirectness (one trial reported results at six months rather than one year and was inadequately powered for SSV varices-only analysis). Reasons for downgrading in the UGFS versus surgery comparison were imprecision (only one trial offered UGFS and several participants were missing from the analysis) and a limitation in design (the study was inadequately powered for SSV participants alone).For the EVLA versus surgery comparison, recanalisation or persistence of reflux at six weeks occurred less frequently in the EVLA group than in the surgery group (OR 0.07, 95% CI 0.02 to 0.22; I2 = 51%; 289 participants, 3 studies, moderate-quality evidence). Recurrence of reflux at one year was also less frequent in the EVLA group than in the surgery group (OR 0.24, 95% CI 0.07 to 0.77; I2 = 0%; 119 participants, 2 studies, low-quality evidence). For the outcome clinical evidence of recurrence (i.e. presence of new visible varicose veins) at one year, there was no difference between the two treatment groups (OR 0.54, 95% CI 0.17 to 1.75; 99 participants, 1 study, low-quality evidence). Four participants each in the EVLA and surgery groups required reintervention due to technical failure (99 participants, 1 study, moderate-quality evidence). There was no difference between the two treatment groups for disease-specific quality of life (QoL) (Aberdeen Varicose Veins Questionnaire) either at six weeks (mean difference (MD) 0.15, 95% CI -1.65 to 1.95; I2 = 0%; 265 participants, 2 studies, moderate-quality evidence), or at one year (MD -1.08, 95% CI -3.39 to 1.23; 99 participants, 1 study, low-quality evidence). Main complications reported at six weeks were sural nerve injury, wound infection and deep venous thrombosis (DVT) (one DVT case in each treatment group; EVLA: 1/161, 0.6%; surgery 1/104, 1%; 265 participants, 2 studies, moderate-quality evidence).For the UGFS versus surgery comparison, there were insufficient data to detect clear differences between the two treatment groups for the two outcomes recanalisation or persistence of reflux at six weeks (OR 0.34, 95% CI 0.06 to 2.10; 33 participants, 1 study, low-quality evidence), and recurrence of reflux at one year (OR 1.19, 95% CI 0.29 to 4.92; 31 participants, 1 study, low-quality evidence). No other outcomes could be reported for this comparison because the study data were not stratified according to saphenous vein. AUTHORS' CONCLUSIONS: Moderate- to low-quality evidence exists to suggest that recanalisation or persistence of reflux at six weeks and recurrence of reflux at one year are less frequent when EVLA is performed, compared with conventional surgery. For the UGFS versus conventional surgery comparison, the quality of evidence is assessed to be low; consequently, the effectiveness of UGFS compared with conventional surgery in the treatment of SSV varices is uncertain. Further RCTs for all comparisons are required with longer follow-up (at least five years). In addition, measurement of outcomes such as recurrence of reflux, time taken to return to work, duration of procedure, pain, etc., and choice of time points during follow-up should be standardised such that future trials evaluating newer technologies can be compared efficiently.

Effectiveness of topical corticosteroids in addition to antiviral therapy in the management of recurrent herpes labialis: a systematic review and meta-analysis.

BACKGROUND: Recurrent herpes labialis (RHL) is one of the most common viral infections worldwide. The available treatments have limited efficacy in preventing the recurrence of ulcerative lesions and reducing the duration of illness. The objective of this review was to identify the effectiveness of topical corticosteroids in addition to antiviral therapy in the treatment of RHL infection. METHODS: A systematic review of randomized clinical trials comparing the efficacy of combined therapy (topical corticosteroids with antiviral) with placebo or antiviral alone in the management of RHL was conducted. MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane library, and Google Scholar databases were searched. We used RevMan software to conduct the meta-analysis. A fixed-effects model was used for mild to moderate heterogeneity, whereas a random-effects model was used for significant heterogeneity. Heterogeneity among trials was established using I(2) and chi-square test for heterogeneity. RESULTS: Four studies that fulfilled the selection criteria were included in this review. The total number of participants across included studies was 1,891 (range, 29 to 1,443). The antiviral drugs used were acyclovir, famciclovir, and valacyclovir. Corticosteroids used were 1% hydrocortisone and 0.05% fluocinonide. Pooled results showed that patients receiving combined therapy had a significantly lower recurrence rate of ulcerative lesions compared to those in both the placebo group (OR, 0.50; 95% CI, 0.39-0.66; P < .001) and the antiviral treatment alone group (OR, 0.73, 95% CI, 0.58-0.92; P = .007). The healing time was also significantly shorter in combined therapy in comparison to placebo (P < .001). However, there were no significant differences in healing time between combined therapy and antiviral alone. The adverse reactions in combined therapy were not significantly different than the placebo group (OR, 1.09; 95% C, 0.75-1.59; P = .85). CONCLUSION: Treatment with combined therapy is safe and more effective than placebo or antiviral alone for preventing the recurrence of ulcerative lesions in RHL infection.

Endovascular repair of abdominal aortic aneurysm.

BACKGROUND: An abnormal dilatation of the abdominal aorta is referred to as an abdominal aortic aneurysm (AAA). Due to the risk of rupture, surgical repair is offered electively to individuals with aneurysms greater than 5.5 cm in size. Traditionally, conventional open surgical repair (OSR) was considered the first choice approach. However, over the past two decades endovascular aneurysm repair (EVAR) has gained popularity as a treatment option. This article intends to review the role of EVAR in the management of elective AAA. OBJECTIVES: To assess the effectiveness of EVAR versus conventional OSR in individuals with AAA considered fit for surgery, and EVAR versus best medical care in those considered unfit for surgery. This was determined by the effect on short, intermediate and long-term mortality, endograft related complications, re-intervention rates and major complications. SEARCH METHODS: The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (January 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 12). The TSC also searched trial databases for details of ongoing or unpublished studies. SELECTION CRITERIA: Prospective randomised controlled trials (RCTs) comparing EVAR with OSR in individuals with AAA considered fit for surgery. and comparing EVAR with best medical care in individuals considered unfit for surgery. We excluded studies with inadequate data or using an inadequate randomisation technique. DATA COLLECTION AND ANALYSIS: Three reviewers independently evaluated trials for appropriateness for inclusion and extracted data using pro forma designed by the Cochrane PVD Group. We assessed the quality of trials using The Cochrane Collaboration's 'Risk of bias' tool. We entered collected data in to Review Manager (version 5.2.3) for analysis. Where direct comparisons could be made, we determined odds ratios (OR). We tested studies for heterogeneity and, when present, we used a random-effects model; otherwise we used a fixed-effect model. We tabulated data that could not be collated. MAIN RESULTS: Four high-quality trials comparing EVAR with OSR (n = 2790) and one high-quality trial comparing EVAR with no intervention (n = 404) fulfilled the inclusion criteria. In individuals considered fit for surgery, a pooled analysis, including 1362 individuals randomised to EVAR and 1361 randomised to OSR, found short-term mortality (including 30-day or inhospital mortality, excluding deaths prior to intervention) with EVAR to be significantly lower than with OSR (1.4% versus 4.2%, OR 0.33, 95% confidence interval (CI) 0.20 to 0.55; P < 0.0001). Using intention-to-treat analysis (ITT) there was no significant difference in mortality at intermediate follow-up (up to four years from randomisation), with 221 (15.8%) and 237 (17%) deaths in the EVAR (n = 1393) and OSR (n = 1390) groups, respectively (OR 0.92, 95% CI 0.75 to 1.12; P = 0.40). There was also no significant difference in long-term mortality (beyond four years), with 464 (37.3%) deaths in the EVAR and 470 (37.8%) deaths in the OSR group (OR 0.98, 95% CI 0.83 to 1.15; P = 0.78). Similarly, there was no significant difference in aneurysm-related mortality between groups, either at the intermediate- or long-term follow up.Studies showed that both EVAR and OSR were associated with similar incidences of cardiac deaths (OR 1.14, 95% CI 0.86 to 1.52; P = 0.36) and fatal stroke rate (OR 0.81, 95% CI 0.42 to 1.55; P = 0.52). The long-term reintervention rate was significantly higher in the EVAR group than in the OSR group (OR 1.98, 95% CI 1.12 to 3.51; P = 0.02; I(2) = 85%). Results of the reintervention analysis should be interpreted with caution due to significant heterogeneity. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between the EVAR and OSR groups. However, there was a slightly higher incidence of pulmonary complications in the OSR group compared with the EVAR group (OR 0.36, 95% CI 0.17 to 0.75; P = 0.006).In individuals considered unfit for conventional OSR, the one included trial found no difference between the EVAR and no-intervention groups with regard to all-cause mortality at final follow up, with 21.0 deaths per 100 person-years in the EVAR group and 22.1 deaths per 100 person years in the no-intervention group (adjusted hazard ratio (HR) with EVAR 0.99, 95% CI 0.78 to 1.27; P = 0.97). Aneurysm-related deaths were, however, significantly higher in the no-intervention group than in the EVAR group (adjusted HR 0.53, 95% CI 0.32 to 0.89; P = 0.02). There was no difference in myocardial events (HR 1.07, 95% CI 0.60 to 1.91) between the groups in this study. AUTHORS' CONCLUSIONS: In individuals considered fit for conventional surgery, EVAR was associated with lower short-term mortality than OSR. However, this benefit from EVAR did not persist at the intermediate- and long-term follow ups. Individuals undergoing EVAR had a higher reintervention rate than those undergoing OSR. Most of the reinterventions undertaken following EVAR, however, were catheter-based interventions associated with low mortality. Operative complications, health-related quality of life and sexual dysfunction were generally comparable between EVAR and OSR. However, there was a slightly higher incidence of pulmonary complications in the OSR group than in the EVAR group.In individuals considered unfit for open surgery, the results of a single trial found no overall short- or long-term benefits of EVAR over no intervention with regard to all-cause mortality, but individuals may differ and individual preferences should always be taken into account.

Observational Study on the Risk of Surgical Site Infection in Patients Undergoing Common Femoral Endarterectomy in Conjunction With an Endovascular Procedure Compared With Common Femoral Endarterectomy Alone.

Objective: A hybrid approach is being employed increasingly in the management of peripheral arterial disease. This study aimed to assess the surgical site infection (SSI) incidence of hybrid revascularisation (HR) compared with common femoral endarterectomy (CFEA) alone. Methods: This was a retrospective review of consecutive patients who underwent CFEA or HR alongside CFEA between 2017 and 2021 including one year of follow up. The primary outcome was SSI incidence. Secondary outcomes included length of surgery, duration of admission, further revascularisation surgery, limb salvage, and death. Differences in outcomes were assessed with the Student's unpaired t test, chi square test, and Fisher's exact test. Results: A total of 157 groin incisions from 155 patients were included: 78 had CFEA procedures and 79 had HR procedures. No statistical difference was found between groups for age, sex, and indication for surgery. Surgical site infection occurred in five of the CFEA patients (6%) compared with seven of the HR patients (9%) (p = 0.77). The HR procedures took significantly longer, with an average of 299 minutes compared with 220 minutes for CFEA (p < 0.001). No statistically significant difference was identified for length of admission: median stay five days for CFEA vs. four days for HR (p = 0.44). Major amputation was performed within one year in five of the CFEA procedures (6%) and five of the HR procedures (6%) (p = 1.0). Further revascularisation surgery was attempted in two patients in the HR group and six patients in the CFEA group (p =. 17). No statistically significant difference was found in the one year mortality rate: eight CFEA (10%) and seven HR (9%) (p = 0.77). Conclusion: Patients who underwent HR alongside CFEA did not have a statistically significantly increased incidence of SSI, despite increased surgical time. Using HR techniques enabled patients to have multilevel disease treated in one stage without an increased incidence of SSI.

Beta blockers for peripheral arterial disease.

BACKGROUND: Beta (ß) blockers are indicated for use in coronary artery disease (CAD). However, optimal therapy for people with CAD accompanied by intermittent claudication has been controversial because of the presumed peripheral haemodynamic consequences of beta blockers, leading to worsening symptoms of intermittent claudication. This is an update of a review first published in 2008. OBJECTIVES: To quantify the potential harmful effects of beta blockers on maximum walking distance, claudication distance, calf blood flow, calf vascular resistance and skin temperature when used in patients with peripheral arterial disease (PAD). SEARCH METHODS: For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2013, Issue 2). SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the role of both selective (ß1) and non-selective (ß1 and ß2) beta blockers compared with placebo. We excluded trials that compared different types of beta blockers. DATA COLLECTION AND ANALYSIS: Primary outcome measures were claudication distance in metres, time to claudication in minutes and maximum walking distance in metres and minutes (as assessed by treadmill).Secondary outcome measures included calf blood flow (mL/100 mL/min), calf vascular resistance and skin temperature (ºC). MAIN RESULTS: We included six RCTs that fulfilled the above criteria, with a total of 119 participants. The beta blockers studied were atenolol, propranolol, pindolol and metoprolol. All trials were of poor quality with the drugs administered over a short time (10 days to two months). None of the primary outcomes were reported by more than one study. Similarly, secondary outcome measures, with the exception of vascular resistance (as reported by three studies), were reported, each by only one study. Pooling of such results was deemed inappropriate. None of the trials showed a statistically significant worsening effect of beta blockers on time to claudication, claudication distance and maximal walking distance as measured on a treadmill, nor on calf blood flow, calf vascular resistance and skin temperature, when compared with placebo. No reports described adverse events associated with the beta blockers studied. AUTHORS' CONCLUSIONS: Currently, no evidence suggests that beta blockers adversely affect walking distance, calf blood flow, calf vascular resistance and skin temperature in people with intermittent claudication. However, because of the lack of large published trials, beta blockers should be used with caution, if clinically indicated.

A 2-year Comparative Analysis of Outcomes and Endovascular Interventions in Radio-Cephalic vs. Brachio-Cephalic Fistulae.

BACKGROUND: Arterio-venous fistulae are often compromised by complications, notably thrombosis. We assess the 2 year follow-up data of a cohort of patients from a single vascular centre in the UK who underwent BCF or RCF creation with the objective of assessing the outcome differences and intervention rates between fistula types. MATERIALS AND METHODS: We retrospectively assessed a cohort of 195 patients who underwent creation of arterio-venous fistula (100 BCF, 95 RCF) between January 2016 and December 2018, following them up for 2 years assessing the outcomes and interventions on their AVFs. The outcomes assessed were primary and cumulative patency at 6 weeks, 6, 12 and 24 months. Multinomial logistic regression to account for confounding variables age, gender, procedure, side, anticoagulant, vessel size and co-morbidities was performed. A Kaplan-Meier analysis of time to endovascular intervention was also performed comparing RCF and BCF. RESULTS: Cumulative patency rates for BCF vs RCF were 91% vs. 89% at 6 weeks (X2 (3, N = 194) = 4.70, P = .19), 83% vs. 76% at 6 months (X2 (3, N = 188) = 7.72, P = .05), 78% vs. 69% at 12 months (X2 (4, N = 175) = 5.37, P = .25) and 68% vs. 65% at 24 months (X2 (4, N = 161) = 5.24, P = .24). Endovascular intervention rate becomes divergent at 5 months, with the steepest difference between 6 and 12 months. Comparative endovascular intervention rates between BCF and RCF were 20% vs. 31% at 6 months, 41% vs. 40% at 12 months and 40% vs. 49% at 24 months. CONCLUSION: RCF seem to have significantly lower patency at 6 months and have higher endovascular intervention rates compared to BCF. A focussed surveillance protocol could prove effective in improving outcomes for RCF.

Bilateral Acute Lower Limb Ischemia Secondary to COVID-19.

COVID-19 has to date affected over 5 million people worldwide and caused in excess of 300000 deaths. One of the principal finding is that of a thrombotic tendency within the lungs leading to high mortality. There have been increasing number of reports of peripheral arterial thrombosis as well. Most cases of arterial thrombosis is noted in patient in intensive care setting. Here-in we report a case of acute bilateral lower limb arterial thrombosis in a patient recovering at home with mild COVID-19 symptoms, highlighting that patients with milder symptoms may also suffer from prothrombotic state resulting in acute arterial occlusions. Arterial thrombosis should be suspected in these patients despite the absence of predisposing factors.

Posterior Cerebral Circulation Stroke Secondary to Foetal Origin of Posterior Communicating Artery: An Indication for Carotid Endarterectomy.

INTRODUCTION: Posterior cerebral circulation strokes are most commonly caused by posterior vasculature in situ thrombosis, cardiac emboli, or arterial dissection. However, the foetal origin of the posterior communicating artery is an anatomical variant of the cerebral circulation that results in communication between the internal carotid and posterior cerebral circulation. Therefore, rarely this can result in posterior cerebral territory infarction from internal carotid artery thrombo-embolism. This is the report of a case in which a patient suffered posterior circulation stroke secondary to this anatomical variation of the circle of Willis. REPORT: A 71 year old male patient was admitted to the stroke team with seizures, headache, and confusion. Examination revealed a left sided homonymous hemianopia. Diffusion weighted magnetic resonance imaging (MRI) of the brain 36 hours into his admission revealed an acute right posterior circulation infarct with extensive haemorrhagic transformation. Duplex ultrasound three days later revealed a heavily calcified right internal carotid artery mixed echogenicity plaque with 80%-90% stenosis. Subsequent computed tomography angiography showed a large right foetal variant posterior communicating artery. Following improvement in functional status, the patient underwent uneventful carotid endarterectomy to reduce risk of future stroke. DISCUSSION: In patients presenting with posterior circulation infarction, clinicians should consider embolism from an atheromatous internal carotid artery via the variant foetal origin of posterior communicating artery. If detected, consideration should be given to undertaking carotid endarterectomy to reduce future stroke risk if no other source is detected.

Vessel diameter and close surveillance helps predict early patency in native arteriovenous fistulas.

INTRODUCTION: Arteriovenous fistulas are the preferred method of vascular access for haemodialysis. Data suggests patency rates can be low and may be related to vessel diameters prior to creation. We use specific size criteria for fistula selection. We aimed to establish patency rates in relation to vessel size and whether other factors affect fistula patency. METHODS: Consecutive patients undergoing radiocephalic (RCF) or brachiocephalic (BCF) creation between 2016 and 2018 were analysed. Preoperative arterial and venous diameters were collected. Six-week and six-month primary and secondary patency rates were analysed to establish any impact of vessel size on patency and re-intervention rates between groups. A univariate analysis was performed. RESULTS: Ninety four RCFs and 101 BCFs were created. Median artery and vein size for RCF were 2.7 and 3.0 mm respectively. For BCF, they were 4.6 and 4.3 mm respectively. At 6-weeks, overall satisfactory patency for RCF and BCF combined was 91.8%. 89.7% demonstrated primary patency; 2.1% secondary patency. At 6-months, overall patency was 78.7%; 58.5% demonstrated primary patency, 20.2% secondary patency. A univariate analysis, for both groups, revealed vein size was a significant predictor of overall satisfactory patency at 6-weeks, with larger veins more likely to remain patent (p = 0.025 RCF, p = 0.007 BCF). However, artery size was not predictive (p = 0.1 RCF, p = 0.5 BCF). At 6-months, neither artery nor vein diameter were predictive in either group. When comparing size of vessel based on fistula type, vessels used to create RCFs were smaller than those for BCFs (p < 0.001). RCFs were more likely to receive endovascular intervention or occlude when compared to BCFs (p = 0.014). DISCUSSION: Excellent patency and maturation rates can be achieved using fairly strict vessel size criteria. Vein size might be the more important predictor of early success. RCFs can be challenging due to smaller vessels, but maturation rates can be optimised by close surveillance and aggressive re-intervention.

Dynamic Banding (DYBAND) Technique for Symptomatic High-Flow Fistulae.

INTRODUCTION: High flow rates may develop in arteriovenous fistula (AVF), resulting in clinical syndromes of steal, aneurysmal fistula, or high-output cardiac failure. Various techniques with varying success have been advocated to treat this difficult problem. We present a hemodynamically validated novel banding technique. METHODS: We designed a computational fluid dynamic (CFD) model of the native high-flow AVF and tested various juxta-anastomotic venous diameters to determine the effect on AVF blood flow and pressure. We translated this principle in our banding technique, wherein adjustable banding was performed in conjunction with ultrasound-guided brachial artery flow measurement to determine the optimal band diameter. Polyurethane patch was used to fashion the adjustable band. Patient demographics, AVF flow parameters pre- and postintervention, operative intervention, and ultrasound follow-up data were collected prospectively. RESULTS: Our CFD testing demonstrated that the band diameter needed to achieve optimal distal blood pressure and preserve AVF flow depending on blood pressure, end capillary pressure, venous pressure, and vascular diameters. Five patients subsequently underwent dynamic banding of symptomatic high-flow AVF. Mean brachial artery blood flow rates pre- and postbanding were 2964 mL/min (confidence interval [CI]: 1487-4440 mL/min) and 1099 mL/min (CI: 571.7-1627 mL/min), respectively (P = .01). All patients had symptomatic improvement, and at a mean follow-up of 1 year, this benefit was sustained with no AVF thrombosis or loss. CONCLUSION: Adjustable dynamic band using ultrasound-guided brachial artery flow shows promising results in producing accurate AVF blood flow reduction with sustained efficacy in the short term for patients with symptomatic high-flow AVF.