2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases.

The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.

Sedoanalgesia with intravenous midazolam and fentanyl for angioplasty of dysfunctional arteriovenous access: A retrospective single-center analysis.

BACKGROUND: Endovascular therapy, such as percutaneous transluminal angioplasty (PTA), stenting, or embolization, is a well-established form of treatment to prolong the lifespan of arteriovenous access. These procedures, especially PTA, can be accompanied with severe pain. We reviewed and analyzed the efficacy, safety, and outcome of sedoanalgesia using intravenous midazolam and fentanyl, for pain relief during these procedures. METHODS: Two hundred and two consecutive patients with dysfunctional dialysis access that had undergone endovascular procedure in our institute between July and November 2017 were included in this study. The dialysis access profile, procedure complication, and 10-point Visual Analog Scale (VAS) were collected. One-year clinical follow-up record was also collected to evaluate arteriovenous access patency and long-term complications. RESULTS: Among the 202 patients, the mean age was (mean ± SD) 67.0 ± 12.08 years. Dialysis access profile of these patients were 119 (58.9%) native arteriovenous fistula and 162 (74.2%) forearm access. The number of lesions treated were 1.63 ± 0.802.Immediate complications included 11 (5.44%) nausea/vomiting, 24 (11.88%) desaturation (SpO2 < 90%, resolved after pillow removal or jaw trust), 16 (7.9%) hypotension (SBP < 90 mmHg, resolved without inotropic agents). There was a low average pain score (1.16 ± 1.594) during the procedure with 136 (67.3%) no pain (VAS 0-1) and 56 (27.7%) mild pain (VAS 2-4). Higher VAS score correlated with overweight patients, longer PTA time and pain after procedure. Six-month primary patency rate was 49.17% and primary assisted patency rate was 93.04%. CONCLUSIONS: Sedoanalgesia with intravenous midazolam and fentanyl is an easy, safe, and effective method for surgeons.

Evaluating the effectiveness of using negative pressure wound therapy in the preservation of the infected prosthetic aortic graft.

BACKGROUND: Infected deep sternal infection due to an associated infection of the prosthetic aortic graft is a devastating condition. Standard management requires the removal of the graft and substituting it with a new one. Often, removal of the prosthetic graft is close to impossible. Negative pressure wound therapy is currently the treatment of choice for patients with deep sternal infection. However, its use in deep sternal infection with exposed infected prosthetic aortic graft has not been well described. METHODS: Eight patients were included in this study. All had type A aortic dissection of the ascending aorta and/or aortic arch. RESULTS: There were 7 men and 1 woman. The median age was 53 years old (range 33-81 years old). The median number of days from the initial aortic operation to the diagnosis of infection was 20 days (range 14-52). The median length of stay in the intensive care unit was 17 days (range 6-338 days). The median time interval from the initial debridement to reconstruction was 20 days (range 6-43 days). The median number of times negative pressure wound therapy was changed was 4 (range 2-9). The most common flap used for reconstruction was the pectoralis major musculocutaneous flap in 7 patients, a free antero-lateral thigh flap in 1 patient, and pedicled omental flap in combination with pectoralis major musculocutaneous flap in 1 patient. One patient had persistent recurrent infection of the graft despite negative pressure wound therapy and flap reconstruction. The median length of follow-up was 38.5 months (range 4-120 months). CONCLUSION: This small study suggests that negative pressure wound therapy could be used successfully for the management of deep sternal infection due to infected prosthetic aortic grafts. In most cases, it eliminated the need to replace the infected prosthetic aortic graft in high-risk patients.

Editor's Choice - Diabetic Limb Salvage With Endovascular Revascularisation and Free Tissue Transfer: Long-Term Follow up.

OBJECTIVE: Combining vascular bypass surgery with free flap coverage is one of the treatment methods for complex soft tissue defects in the ischaemic lower limb. Endovascular revascularisation has become the first line treatment for limb ischaemia in many centres. Surgeons now perform free tissue transfer after angioplasty. The early and long-term limb salvage rate in diabetic patients who had undergone infrapopliteal endovascular revascularisation and free flap reconstruction are assessed. METHODS: This was retrospective study of all consecutive diabetic patients who had undergone endovascular revascularisation with free flap reconstruction for lower limb salvage between 2008 and 2014. They were followed up for at least 2 years or to death (mean follow up 39 ± 17 months). Cox regression analysis was used to analyse variables influencing outcome. RESULTS: There were 55 patients who had undergone 60 procedures. Five patients had undergone the procedure to the contralateral leg. All tissue lesions were Wagner-Meggit classification Grades 3 or 4. Thirty-six patients had TASC C lesions and 24 patients with TASC D lesions. Combined below knee triple vessel disease was seen in 30% of the cases, 28% involved both the anterior and posterior tibial artery, 7% and 2% involved the anterior tibial or the posterior tibial and the peroneal arteries. The free flap success rate was 95%. The peri-operative mortality was 1.7%. Twenty-one cases required surgical re-intervention. Mean length of hospital admission was 32 ± 9 days. One and five year amputation free survival rates were 94% and 68%, patient survival rates were 95% and 67%, limb salvage rates were 93% and 91% and respectively. CONCLUSIONS: The results show that excellent early and late limb salvage can be achieved with free tissue transfer based on endovascular revascularisation of infrapopliteal arteries. This can be a further treatment option in diabetic patients with complex soft tissue defects.

A comparison between combined open bypass revascularization and free tissue transfer versus endovascular revascularization and free tissue transfer for lower limb preservation.

BACKGROUND: Extensive defects of the lower limb as a result of diabetes and peripheral vascular disease require multidisciplinary treatment. Numerous studies with regards combining vascular bypass surgery and free tissue reconstruction of the lower limb had been published. However the trend has evolved toward a combination of endovascular revascularization and free flap reconstruction. The aim of this study was to compare the safety and efficacy of this combination of treatment to the traditional combination of bypass surgery and free tissue reconstruction. METHODS: All patients who had undergone vascular bypass surgery and free tissue reconstruction of the lower limb as well as those who had undergone endovascular angioplasty with free tissue transfer for lower limb preservation, over a 10-year period was included in this study. RESULTS: A total of 46 patients that underwent limb preservation were included in this study, 22 patients underwent open bypass revascularization and free flap transfer and 24 patients underwent endovascular revascularization and free tissue transfer. There were no differences between the two methods with regards to age, sex, defect size, TransAtlantic InterSociety Consensus level, Wagner classification, length of hospitalization, limb preservation rate, total flap necrosis rate, and partial flap necrosis rate. More importantly, there was no significant difference in the limb preservation rate (P = 0.14). CONCLUSION: In this study we found that the safety and the success rate of lower limb preservation using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer.

Endovascular revascularization and free tissue transfer for lower limb salvage.

Combined bypass surgery with free flap reconstruction is an established method for lower limb salvage. But the success of the combination of endovascular revascularization together with free tissue transfer has so far not been well established. A retrospective review of all patients who had undergone endovascular revascularization and reconstructed with free tissue transfer for lower limb salvage at Tzu Chi Dalin General Hospital between 2008 and 2012 was performed. A total of 26 legs underwent limb salvage in 24 patients. There were 10 male and 14 female patients. Their average age was 71.4 years. The average time interval between endovascular intervention and free tissue transfer was 8 days. There was 100% flap survival but partial flap necrosis was seen in three patients. A high rate of wound infection was seen in eight patients, all requiring further debridement. The total limb salvage rate at 1-year follow-up was 96% and 92% at the 2-year follow-up. In conclusion, the success rate of lower limb salvage using a combination of endovascular revascularization and free tissue reconstruction is comparable to using a combination of bypass surgery and free tissue transfer. It is associated with a high flap success rate and a high limb salvage rate. It provides physicians with a further treatment option in the management of ischemic lower limbs with extended tissue loss.

Hepatic interferon receptor mRNA expression: clinical relevance and its relationship with effectiveness of interferon plus ribavirin therapy in patients with genotype 1b hepatitis C virus infection.

BACKGROUND/AIMS: Hepatic expression of interferon (IFN) receptor mRNA has been shown to correlate with the effectiveness of IFN monotherapy in patients with chronic hepatitis C virus (HCV) infection. We investigated the expression of hepatic IFN receptor alpha/beta (IFNAR2c) mRNA and its association with the effectiveness of IFN plus ribavirin (RBV) therapy and with the clinical features in patients with HCV genotype 1b (HCV-1b) infection. METHODS: A total of 42 naive patients who had chronic HCV-1b infection were treated with IFN alpha-2b 3 MU or 5 MU three times weekly plus RBV for 24 weeks. Hepatic IFNAR2c mRNA was quantified by real-time RT-PCR. RESULTS: There was no significant difference in the mean expression level of IFNAR2c mRNA between patients with sustained virological response (SVR) and non-SVR (0.069 +/-0.042 versus 0.053 +/-0.033, P=0.182). Multiple linear regression analysis showed that lower fibrosis scores (P=0.006) and younger age (P=0.03) were associated with hepatic IFNAR2c mRNA expression with r2=0.34. CONCLUSIONS: Hepatic IFNAR2c mRNA expression may not be useful for predicting the response to IFN plus RBV therapy in patients with HCV-1b infection, but appeared to correlate inversely with the fibrosis stage and age.