Applications of intraoperative Duplex ultrasound in vascular surgery: a systematic review.

OBJECTIVE: This review aims to summarise the contemporary uses of intraoperative completion Duplex ultrasound (IODUS) for the assessment of lower extremity bypass surgery (LEB) and carotid artery endarterectomy (CEA). METHODS: We performed a systematic literature search using the databases of MEDLINE. Eligible studies evaluated the use of IODUS during LEB or CEA. RESULTS: We found 22 eligible studies; 16 considered the use of IODUS in CEA and 6 in LEB. There was considerable heterogeneity between studies in terms of intervention, outcome measures and follow-up. In the assessment of CEA, there is conflicting evidence regarding the benefits of completion imaging. However, analysis from the largest study suggests a modest reduction in adjusted risk of stroke/mortality when using IODUS selectively (RR 0.74, CI 0.63-0.88, p = 0.001). Evidence also suggests that uncorrected residual flow abnormalities detected on IODUS are associated with higher rates of restenosis (range 2.1% to 20%). In the assessment of LEB, we found a paucity of evidence when considering the benefit of IODUS on patency rates or when considering its utility as compared to other imaging modalities. However, the available evidence suggests higher rates of thrombosis or secondary intervention in grafts with uncorrected residual flow abnormalities (up to 36% at 3 months). CONCLUSIONS: IODUS can be used to detect defects in both CEA and LEB procedures. However, there is a need for more robust prospective studies to determine the best scanning strategy, criteria for intervention and the impact on clinical outcomes.

Systematic review of ambulatory selective variceal ablation under local anesthetic technique for the treatment of symptomatic varicose veins.

OBJECTIVE: The ambulatory selective variceal ablation under local anesthesia (ASVAL) technique subscribes to the "ascending" theory of varicose vein etiology, which recommends primary ambulatory phlebectomy as a treatment for tributary varicosities and truncal vein incompetence. This systematic review explores the efficacy and safety of the ASVAL technique for the treatment of symptomatic varicose veins. METHODS: A comprehensive search of the Medline and Embase databases and the Cochrane Register of Controlled Trials in May 2019 revealed 11 original articles that were qualitatively reviewed. The primary outcome was the absence from recurrent varicose veins at 1-year follow-up. Secondary outcomes were resolution of great saphenous vein (GSV) reflux on duplex ultrasound, change in GSV diameter, objective and subjective clinical improvement in chronic venous disease, and patient-reported outcome measures. RESULTS: A total of 2106 limbs underwent intervention in 1734 patients reported in two randomized controlled trials, one case control study, three cohort studies, and five case series. Varicosity recurrence at 1 year ranged from 0.5% to 13.5% in patients. Of 1622 limbs with diagnosed GSV incompetence before intervention, 1114 were competent at 1 year (mean, 68.2% [±12.62%]). All studies measuring GSV diameter reported statistically significant reductions in vein size. CONCLUSIONS: ASVAL may be considered as a minimally invasive treatment for early stages of chronic venous disease in the presence of truncal reflux. The evidence base should be strengthened by prospective randomized controlled trials that follow standardized procedures and report according to recognized measures of quality of life alongside clinical and hemodynamic data.

Various Endoluminal Approaches Available for Treating Pathologies of the Aortic Arch.

Open surgical repair of the aortic arch for degenerative aortic disease in an unfit patient is associated with significant morbidity and mortality. Endoluminal techniques have advanced over the last decade. Contemporary endovascular options including a hybrid approach (supra-aortic debranching and aortic stent graft), inner branched endograft, chimney stents, and scallop or fenestrated endografts are being used frequently as an alternative to open surgical arch repair. Understanding of the available endoluminal technology along with careful planning and effective teamwork is required to minimise complications associated with the endoluminal techniques, particularly neurological ones. Custom made techniques are superior to chimney or parallel technology in terms of their complications and durability. Integration of the protective devices such as embolic protection filters into stent design may reduce the risk of poor neurological sequelae. Long-term data are needed to assess the durability of these devices.

Fate of the tributaries of sapheno femoral junction following endovenous thermal ablation of incompetent axial vein - A review article.

Sapheno femoral junctional tributaries are usually left untreated at the time of endovenous ablation of axial vein. The long-term clinical significance of these untreated tributaries remains elusive and there is very little research done into this area. This article reviews the fate of untreated tributaries at sapheno femoral junction following ablation of incompetent axial vein. A literature search and analysis of evidence reveal that the junctional tributaries are one of the commonest (ranges between 8% and 31%) cause for recurrence following endovenous ablation of the axial veins. Follow up of this subset of patients after their axial vein treatment should be considered to identify neoreflux in side branches at sapheno femoral junction and plan treatment.

A comprehensive characterisation of the metabolic profile of varicose veins; implications in elaborating plausible cellular pathways for disease pathogenesis.

Metabolic phenotypes reflect both the genetic and environmental factors which contribute to the development of varicose veins (VV). This study utilises analytical techniques to provide a comprehensive metabolic picture of VV disease, with the aim of identifying putative cellular pathways of disease pathogenesis. VV (n = 80) and non-VV (n = 35) aqueous and lipid metabolite extracts were analysed using 600 MHz 1H Nuclear Magnetic Resonance spectroscopy and Ultra-Performance Liquid Chromatography Mass Spectrometry. A subset of tissue samples (8 subjects and 8 controls) were analysed for microRNA expression and the data analysed with mirBase (www.mirbase.org). Using Multivariate statistical analysis, Ingenuity pathway analysis software, DIANALAB database and published literature, the association of significant metabolites with relevant cellular pathways were understood. Higher concentrations of glutamate, taurine, myo-inositol, creatine and inosine were present in aqueous extracts and phosphatidylcholine, phosphatidylethanolamine and sphingomyelin in lipid extracts in the VV group compared with non-VV group. Out of 7 differentially expressed miRNAs, spearman correlation testing highlighted correlation of hsa-miR-642a-3p, hsa-miR-4459 and hsa-miR-135a-3p expression with inosine in the vein tissue, while miR-216a-5p, conversely, was correlated with phosphatidylcholine and phosphatidylethanolamine. Pathway analysis revealed an association of phosphatidylcholine and sphingomyelin with inflammation and myo-inositol with cellular proliferation.

Optimization of metabolite extraction of human vein tissue for ultra performance liquid chromatography-mass spectrometry and nuclear magnetic resonance-based untargeted metabolic profiling.

Human vein tissue is an important matrix to examine when investigating vascular diseases with respect to understanding underlying disease mechanisms. Here, we report the development of an extraction protocol for multi-platform metabolic profiling of human vein tissue. For the first stage of the optimization, two different ratios of methanol/water and 5 organic solvents--namely dichloromethane, chloroform, isopropanol, hexane and methyl tert-butyl ether (MTBE) solutions with methanol--were tested for polar and organic compound extraction, respectively. The extraction output was assessed using (1)H Nuclear Magnetic Resonance (NMR) spectroscopy and a panel of Ultra Performance Liquid Chromatography-Mass Spectrometry (UPLC-MS) methodologies. On the basis of the reproducibility of extraction replicates and metabolic coverage, the optimal aqueous (methanol/water) and organic (MTBE/methanol) solvents identified from the first stage were used in a sequential approach for metabolite extraction, altering the order of solvent-mixture addition. The combination of organic metabolite extraction with MTBE/methanol (3 : 1) followed by extraction of polar compounds with methanol/water (1 : 1) was shown to be the best method for extracting metabolites from human vein tissue in terms of reproducibility and number of signals detected and could be used as a single extraction procedure to serve both NMR and UPLC-MS analyses. Molecular classes such as triacylglycerols, phosphatidylcholines, phosphatidylethanolamines, sphingolipids, purines, and pyrimidines were reproducibly extracted. This study enabled an optimal extraction protocol for robust and more comprehensive metabolome coverage for human vein tissue. Many of the physiological and pathological processes affecting the composition of human vein tissue are common to other tissues and hence the extraction method developed in this study can be generically applied.

Untargeted UPLC-MS profiling pipeline to expand tissue metabolome coverage: application to cardiovascular disease.

Metabolic profiling studies aim to achieve broad metabolome coverage in specific biological samples. However, wide metabolome coverage has proven difficult to achieve, mostly because of the diverse physicochemical properties of small molecules, obligating analysts to seek multiplatform and multimethod approaches. Challenges are even greater when it comes to applications to tissue samples, where tissue lysis and metabolite extraction can induce significant systematic variation in composition. We have developed a pipeline for obtaining the aqueous and organic compounds from diseased arterial tissue using two consecutive extractions, followed by a different untargeted UPLC-MS analysis method for each extract. Methods were rationally chosen and optimized to address the different physicochemical properties of each extract: hydrophilic interaction liquid chromatography (HILIC) for the aqueous extract and reversed-phase chromatography for the organic. This pipeline can be generic for tissue analysis as demonstrated by applications to different tissue types. The experimental setup and fast turnaround time of the two methods contributed toward obtaining highly reproducible features with exceptional chromatographic performance (CV % < 0.5%), making this pipeline suitable for metabolic profiling applications. We structurally assigned 226 metabolites from a range of chemical classes (e.g., carnitines, α-amino acids, purines, pyrimidines, phospholipids, sphingolipids, free fatty acids, and glycerolipids) which were mapped to their corresponding pathways, biological functions and known disease mechanisms. The combination of the two untargeted UPLC-MS methods showed high metabolite complementarity. We demonstrate the application of this pipeline to cardiovascular disease, where we show that the analyzed diseased groups (n = 120) of arterial tissue could be distinguished based on their metabolic profiles.

Comparison of disease-specific quality of life tools in patients with chronic venous disease.

OBJECTIVES: This work was presented as a poster in the American Venous Forum 25th Annual Meeting; 28 February 2013; Phoenix, Arizona, USA. Quality of life (QoL) is an important outcome measure in the treatment for chronic venous disease. The Aberdeen Varicose Vein Questionnaire (AVVQ) and the ChronIc Venous Insufficiency quality of life Questionnaire (CIVIQ-14) are two validated disease-specific QoL questionnaires in current use. The aim of this study is to evaluate the relationship between the AVVQ and the CIVIQ-14 to enable better comparison between studies and to compare these disease-specific QoL tools with generic QoL and clinician-driven tools. METHODS: Adults attending our institution for management of their varicose veins completed the AVVQ, CIVIQ-14 and EuroQol-5D (EQ-5D). Clinical data, CEAP classification and the Venous Clinical Severity Score (VCSS) were collected. The relationship between the AVVQ and CIVIQ-14 scores was analysed using Spearman's correlation. The AVVQ and CIVIQ-14 scores were also analysed with a generic QoL tool (EQ-5D) and a clinician-driven tool, the VCSS. RESULTS: One hundred patients, mean age 57.5 (44 males; 56 females), participated in the study. The median AVVQ score was 21.9 (range 0-74) and the median CIVIQ-14 score was 30 (range 0-89). A strong correlation was demonstrated between the AVVQ and CIVIQ-14 scores (r = 0.8; p < 0.0001). Strong correlation was maintained for patients with C1-3 disease (r = 0.7; p < 0.0001) and C4-6 disease (r = 0.8; p < 0.0001). The VCSS correlated strongly with the AVVQ and CIVIQ-14 scores (r = 0.7; p < 0.0001 and r = 0.7; p < 0.0001, respectively). Both the AVVQ and CIVIQ-14 scores correlated well with the EQ-5D score (r = -0.5; p < 0.0001 and r = -0.7; p < 0.0001, respectively). CONCLUSIONS: This study demonstrates that there is good correlation between two widely used varicose vein specific QoL tools (AVVQ and CIVIQ-14) across the whole spectrum of disease severity. Strong correlation exists between these disease-specific QoL tools and generic and clinician-driven tools. Our findings confirm valid comparisons between studies using either disease-specific QoL tool.

A simple and inexpensive method for laparoscopic appendectomy.

Laparoscopic appendectomy (LA) was introduced into clinical practice by Kurt Semm in 1983. Since then, a number of methods for performing LA have emerged in the literature. However, the majority of these modifications require costly equipment. In this short technical chapter, we describe a very simple and inexpensive method of performing this procedure without resorting to any additional expensive paraphernalia.

Outcome of acutely perforated colorectal cancers: experience of a single district general hospital.

INTRODUCTION: Perforation of colorectal cancer (CRC) is rare and is associated with a significantly high mortality and morbidity. The aim of the current study was to evaluate various factors influencing the outcome in these patients. MATERIAL AND METHODS: A retrospective analysis of 42 patients with perforated CRC between 1999 and 2003 was performed. A number of variables including age, sex, site of perforation, presence of faecal peritonitis, grade of surgeon, presence of metastasis, stage of tumour, type of surgery, ASA grade and CR POSSUM score were analysed for their influence on the outcome in these patients using MS Excel, MS Access and Stata. RESULTS: Of the 42 patients 19 were female and 23 were male. The mean age of the patients was 70.5 (range 44-96yr). Thirty patients had perforation at the tumour, 10 proximal to the tumour, and one distal to the primary tumour. The perforation was localised in 25 patients. However, 17 patients had free perforation with frank faecal peritonitis. Twenty-one patients had resection and anastomosis, 18 patients had resection without restoration of bowel continuity and 3 had palliative colostomy. The in-hospital mortality (within 30d) was 40.5% (n=17) with only 15 patients being alive at the end of 2yr with an overall mortality of 64.3% (n=27). The outcome was not altered by variables such as sex, surgeon's grade, surgical procedure, Dukes' staging or the site of perforation (p>0.5). Univariate analysis showed that advanced age (p<0.01), higher ASA grade (p<0.001), higher CR POSSUM score (p<0.001) and degree of peritonitis (p<0.01) were strongly associated with adverse outcomes. However, in stepwise multivariate logistic regression analysis ASA grade (p=0.01) and CR POSSUM score (p=0.01) were the only significant predictors of in-hospital mortality. CONCLUSION: The outcome of perforated colonic cancer continues to be poor. ASA score and CR POSSUM score are good predictors of the short-term outcome.