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Vascular surgery trainees often do not get to perform carotid endarterectomy (CEA) directly on the patients as it requires meticulous surgical technique and has a high risk of procedure-related complications. Hence, the role of simulation in training future vascular surgeons becomes essential. This review aims to assess the types and utility of simulators available for CEA. In this systematic review, all the studies performed on CEA simulation were included. The purpose of this review was to assess different types of simulators and their usefulness for CEA. We identified 122 articles, of which 10 were eligible for review. A variety of simulators, ranging from animal models, virtual reality simulators and commercially designed models with high fidelity options were used. Technical competence was the major domain assessed in the majority of the studies (n=8), whereas four studies evaluated anatomical and procedural knowledge. Blinding was done in five studies for assessment purposes. The majority of studies (n=9) found the simulation to be an effective tool for achieving technical competence. This review shows the potential usefulness of simulation in acquiring technical skills and procedural acumen for CEA. The available literature is unfortunately too diverse to have a common recommendation.
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Up to 10% of patients suffer from various degrees of dialysis access-associated steal syndrome (DASS) after surgery for hemodialysis access. This systematic review was conducted to find out optimal intra-operative techniques to prevent DASS in high-risk patients. This systematic review is registered with PROSPERO (2017:CRD42017060804). It was conducted at Department of Surgery, Aga Khan University Hospital, Karachi. All types of studies conducted on intra-operative techniques to prevent DASS in high-risk population (Age > 60 years, female gender, diabetes mellitus, peripheral arterial disease and previous DASS) undergoing access creation from January 1990 till April 2019 were included in the systematic review. Thorough search was conducted on Pubmed, Google Scholar and Cochrane databases to identify relevant articles. Included studies reviewed for success of various techniques to prevent dialysis access steal syndrome are summarized. Out of 125 studies in the initial search, six met the inclusion criteria. Five were retrospective case series while one was a case report. The largest study sample size was 32. All but one study had arterio-venous access creation on an arm. "Proximalization of arterial inflow" was described in three and "prophylactic distal revascularization and interval ligation (DRIL) procedure" in two studies to prevent DASS. Only one patient out of these studies developed DASS at an overall follow-up of 7-42 months. Proximalization of inflow has been reported as the most common procedure performed to prevent DASS followed by extension technique and DRIL procedure. All three procedures have satisfactory outcome with no clear superiority of one over the other.
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Introduction Native veins are an ideal option for dialysis in a patient with chronic kidney disease (CKD) as compared to a prosthetic graft. Femoral vein (FV) translocation to the upper arm is also an alternative to a prosthetic graft as reported in the literature when all options of using the native veins of the arms are exhausted. Thus, we aimed to compare the patency of the upper limb translocated FV arteriovenous fistula (AVF) with a prosthetic arteriovenous bridge graft (AVBG). Methods It is a retrospective cohort study that was conducted in the Department of Vascular Surgery, Aga Khan University Hospital. It included adult patients who underwent either upper arm translocation of FV or prosthetic AVBG using the consecutive purposive sampling technique. There were a total of 10 patients who underwent FV translocation AVF and 20 patients who had AVBG in the upper arms. Results A total of 30 patients were included in the study. Of these 30 patients, 10 underwent FV translocation AVF and the remaining 20 had AVBG. There was a significant difference in the mean operating time of the two surgeries. The mean operating time in FV translocation was 223 (± 41.5) minutes and in those with AVBG, the mean operating time was 100 (±26.5) (p= <0.001). There was no significant difference in the total length of hospital stay in both procedures performed. The primary patency rate for FV translocation was 90% and 95% in AVBG (p=1.00). Ten percent of FV translocation had a primary failure rate compared with that of AVBG, which was 5% (p=1.00). The mean follow-up period was 61 weeks in the FV translocation group and 64 weeks in the AVG group. Conclusion There was no significant difference in both groups in terms of patency, length of hospital stay, and fewer complications were observed in the FV translocation group as compared with the AVBG group.
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BACKGROUND: Basilic vein transposition via single long incision is a renowned technique despite its known wound-related complications. Contrary to that, multiple skip incisions technique is thought to have relatively lower wound-related complications. But to the best of our knowledge, these 2 techniques have never been formally compared. Therefore, we conducted this study to compare both. MATERIAL AND METHODS: This was a retrospective cohort study. Patients who underwent basilic vein transposition arteriovenous fistula (AVF) from January 2011 till May 2016 at Aga Khan University Hospital, Pakistan were eligible for inclusion in the study. Study population was divided into 2 groups; one group comprising of patients who underwent fistula formation through single long incision and the other group had the procedure carried out via multiple skip incisions. Wound-related complications including wound infection and dehiscence, fistula maturation time, duration of surgery, and primary patency at a follow-up of 12 months were recorded. RESULTS: Both the groups were comparable regarding baseline variables. Incidence proportion of wound infection, hematoma, and dehiscence was higher in long incision group; however, it was statistically insignificant. Primary patency at 12 months in skip versus long incision group was 73.0% vs. 69.7% (P-value: 0.62). The mean maturation time for fistula was 42.8 ± 9.5 days and 44.3 ± 10.4 days in skip and long incision group, respectively (P-value:0.31). Duration of surgery was comparable in both. CONCLUSIONS: Although skip technique does not have significant benefit over long incision technique based on these results, but it is a valid alternative. Randomized control trial is required to better differentiate between these two.