Spontaneous bilateral superficial femoral artery pseudoaneurysms and a unilateral posterior tibial artery aneurysm in an immunocompromised patient.

Key Clinical Message: The presence of multiple pseudoaneurysms in a patient should prompt investigations for the underlying etiologies including autoimmune and immunosuppressive disease processes. Treatment options include open repair and endovascular stenting. Abstract: Pseudoaneurysms (also known as false aneurysms) are atypical dilatations or outpouchings from a vessel which are not always contained by the three layers of a normal vessel wall, namely the intima, media, and adventitia. These are distinct from a true aneurysm which has a wall comprising all three layers. The underlying etiology for both true aneurysms and pseudoaneurysm can vary. We present the rare case of bilateral superficial femoral artery pseudoaneurysms, of unknown etiology and a concurrent posterior tibial artery saccular aneurysm in a patient with Human Immunodeficiency Virus (HIV) infection and multiple comorbidities. This was managed using a combination of endovascular covered stent grafts and open surgical repair technique. The patient is doing well on follow-up a year later with no post-operative infections. A literature review of the existing reports of superficial femoral artery pseudoaneurysms and posterior tibial artery aneurysms and their management is also reported.

Ruptured subclavian artery pseudoaneurysm following a shoulder massage on a background of clavicle non-union.

We present an unusual case of ruptured subclavian artery pseudoaneurysm following hydrotherapy and shoulder massage session on a background of clavicle non-union.Following a clavicle fracture 16 years ago, which was managed conservatively, a woman in her 30s presents over a decade later with a ruptured subclavian artery pseudoaneurysm.The original midshaft clavicle fracture was sustained 16 years ago. Conservative management was agreed, and she was discharged. Six years ago, she developed a small subclavian artery pseudoaneurysm which was kept under surveillance for 12 months with no active intervention required.Over the following years, she continued to have intermittent shoulder girdle discomfort and neuropathic symptoms. On this presentation, after a sports massage, she presented with rapid-onset supraclavicular and axillary swelling. This was diagnosed as a ruptured subclavian artery pseudoaneurysm and was treated with emergency radiological-guided stenting and subsequent internal fixation of the clavicle non-union.The patient then attended regular orthopaedic and vascular follow-up to ensure her clavicle fracture unites and the graft remains patent.We discuss the case presentation and management of this unusual injury.

Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS: This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION: The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER: NCT03886675.

Comparing the Benefit of Duplex Ultrasound Surveillance Following Both Infrainguinal Bypass Surgery and Stenting for Femoro-Popliteal Disease.

OBJECTIVE: Duplex ultrasound surveillance (DUS) is commonly used following infrainguinal vein bypass. The role of DUS following endovascular revascularisation is as yet unclear. This study focuses on the role of DUS in a contemporary group of patients undergoing infrainguinal bypass or stent insertion. METHODS: All patients undergoing either an infrainguinal vein graft bypass or stent insertion into the femoro-popliteal segment (November 2014 - January 2017) were identified. Patients were followed up for 2 years. Data on entry into DUS, pre-operative characteristics, adjunctive pharmacotherapy and reintervention were collated. The primary outcomes were major lower limb amputation and mortality at 2 years post revascularisation. RESULTS: One hundred and thirty-five patients underwent infrainguinal vein bypass and 100 patients underwent stent insertion. 107 patients in the bypass cohort and 58 patients in the stent cohort entered DUS. For the bypass cohort, entering DUS was associated with a lower mortality rate (P = .003) but was not associated with an improvement in amputation rates. The odds ratio of major amputation or mortality was greater in the no surveillance group (4.58, 95% CI: 1.855 - 11.364). In the stent cohort, DUS was not associated with a significant improvement in either major amputation or death (odds ratio 2.13 (95% CI 0.903 - 5.051; P = .081). CONCLUSION: DUS was associated with improved survival rates in patients undergoing lower limb bypass but had no benefit in those patients undergoing stent insertion. The role of DUS following stent insertion in the femoropopliteal segment needs to be better defined.

Endovascular aneurysm repair in a centenarian: case report and systematic literature review.

The prevalence of abdominal aortic aneurysms (AAA) in the nonagenarian and centenarian populations is set to increase. Endovascular aneurysm repair (EVAR) has been shown to be achievable with excellent outcomes in carefully selected nonagenarians. However, experience with centenarians is limited. We report the case of a 100-year-old who presented with a tender 8-cm AAA and successfully underwent EVAR. This report describes the second case of AAA repair in a centenarian in the literature and the first reported EVAR in this demographic. The patient survived for 2 years after the procedure, was free of EVAR or aneurysm-related complications. Furthermore, we present a systematic review of the existing literature and insights pertaining to outcomes in nonagenarians undergoing EVAR.

Diabetes in day case general and vascular surgery: A multicentre regional audit.

BACKGROUND: People with Diabetes Mellitus (DM) are at increased risk of postoperative complications if their HbA1C readings are not well controlled. In the UK, there are clear national guidelines requiring all people with DM to have HbA1C blood testing within 6months before undergoing surgery and that these readings should be below 69 mmol/mol if this is safe to achieve. The aim of this study was to determine whether hospitals in the region were compliant with the guidelines. METHODS: Data were prospectively collected from seven hospitals across the East of England region from 1st October 2017 to 31st March 2018 (6 months) in all people with DM undergoing elective day case procedures in General and Vascular surgery for benign disease. RESULTS: A total of 181 people with DM were included in the study, of whom 77.9% were male patients and the median age was 63 years. The three most commonly performed operations were laparoscopic cholecystectomy (20.9%, n = 38/181), inguinal hernia repair (20.4%, n = 37/181) and umbilical/para-umbilical hernia repair (11.0%, n = 20/181). In keeping with the national guidelines, only 86.7% (n = 157/181) of patients had an HbA1C tested within 6 months prior to their surgery date. Of the patients who had a preoperative HbA1C, 14 (n = 14/157, 8.9%) had an HbA1C ≥ 69 mmol/mol, and 12 (n = 12/14, 85.7%) of these proceeded to surgery without optimisation of their HbA1C. CONCLUSION: A significant proportion of people with diabetes undergoing elective day case procedures in our region do not have HbA1C testing within 6 months of their procedure as recommended by the national guidelines. In patients who do have a high HbA1C, the majority still undergo surgery without adequate control of their DM. Greater awareness amongst healthcare workers and robust pathways are required for this vulnerable group of patients if we are to reduce the risk of developing postoperative complication rates.

The clinical utility of the IRAC component of the Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP).

Aims and methodThe clinical utility of the multidimensional Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) has not previously been examined. We sought to establish whether referral accuracy and ability to achieve the reason(s) for referral to our liaison service improved after incorporating the Identify and Rate the Aim of the Contact (IRAC) scale of this tool into our referral process. We carried out a retrospective analysis of electronic case notes of all appropriate referrals to the team before and after this adaption. RESULTS: Accuracy of referrals to our team improved from 73.8 to 93.7% following intervention. Referral requests that were fully achieved improved from 57.4 to 77.8%, and referral requests that were not achieved decreased from 26.2 to 6.4%.Clinical implicationsThe IRAC component of the FROM-LP measures what it was developed for, and thus has clinical utility supporting its widespread adoption across liaison services in the National Health Service.Declaration of interestNone.

Non-infectious aortitis in an immunosuppressed renal transplant recipient with IgA nephropathy.

A 54-year-old woman presented with atypical chest pain, fever and malaise. She was immunosuppressed with three agents following a living-donor kidney transplant 1 year previously. Her native kidney failure was secondary to biopsy-demonstrated crescentic IgA nephropathy, with systemic involvement. A CT pulmonary angiogram revealed an inflammatory cuff of soft tissue around the descending thoracic aorta suggesting aortitis. Inflammatory markers were elevated. Given her immunosuppression, the patient was screened extensively for infective causes and was empirically commenced on intravenous meropenem. After 72 hours of no clinical or serological response to antibiotic therapy, negative microbiological investigations and worsening inflammation on serial imaging, she was commenced on high-dose methylprednisolone for presumed inflammatory aortitis. Symptoms and inflammatory markers rapidly normalisedand the patient was discharged home on oral prednisolone. A clinical diagnosis of IgA-related aortitis was made. Imaging 3 months later showed complete resolution of the aortitis.

Extracorporeally irradiated clavicle as an autograft in tumour surgery.

We report the case of a 45-year-old woman who presented with a lump in the mid-third of the left clavicle, which had recently increased in size to 10 cm in diameter. Plain X-ray, computed tomography and bone scans suggested that the lump was a parosteal osteosarcoma. Due to the expected 30% functional loss from claviculectomy [Wood in The results of total claviculectomy. Clin Orthop Relat Res 1986; 207: :186-90.], the patient opted for excision of the tumour plus the adjacent clavicle, irradiation and reimplantation of the bone with internal fixation. On 2-year follow-up, there was no evidence of recurrence or complications, with a good range of movement of the joint. On 4-year follow-up, the patient was found to have discomfort, and X-rays showed that the clavicle had fractured, which was managed symptomatically.