Axillary necklace graft salvage of a locally infected Haemodialysis with Reliable Outflow (HeRO®) graft.

BACKGROUND: A 48-year-old patient presented 4 months after insertion of a right sided Haemodialysis with Reliable Outflow (HeRO®, Merit Medical) graft with a discharging abscess at the site of the brachial artery anastomosis. There was localised involvement of the arterial Gore® Acuseal inflow graft that necessitated its removal. The venous outflow component was thought salvageable as infection was well localised to the region of the antecubital fossa. OBJECTIVES: Alternative access options were limited so we sought to preserve the venous outflow portion of the patient's original graft - minimising tissue damage and avoiding the need for a dialysis line. METHODS: The infected arterial graft was excised, leaving behind the original SuperHero® connector and venous graft. A left sided tunnelled axillary necklace technique was utilised to restore arterial inflow. RESULTS: After a four-day recovery, the patient went on to successfully resume their usual haemodialysis regimen without any complications. Convalescent imaging, repeat blood cultures, and monitoring of inflammatory markers showed no signs of residual infection at 6 weeks. CONCLUSIONS: The originality of this case was the way in which an axillary necklace inflow graft was connected to the pre-existing venous outflow portion of the HeRO® haemodialysis graft system, allowing the excision of the infected inflow graft at the brachial anastomosis. This technique could be viewed as an effective salvage procedure as it allowed the venous outflow portion of the original graft to remain in situ, minimised tissue damage and enabled the patient to swiftly resume haemodialysis without the need for a line.

The Mysterious Risk of Arterial Thrombosis With COVID-19: A Case Series of Acute Limb Ischaemia in Vaccinated Patients.

Introduction Coronavirus-19 (COVID-19) plays a vital role in viral-induced hypercoagulability through the initiation of a cytokine storm. This mechanism has been found to predispose unvaccinated patients to systemic complications including arterial thrombosis (AT) with poor 30-day amputation-free survival rates. There remains, however, little understanding regarding the incidence in patients who have received a COVID-19 vaccination. This study aims to assess the incidence, management and outcomes of vaccinated patients with COVID-19 who develop thrombotic complications to reduce amputation and direct mortality. Methods The case notes of all emergency patients with COVID-19 referred to the vascular services in a tertiary referral centre between November 2021 and April 2022 were reviewed. Patients who were unvaccinated or admitted with stroke or coronary thrombosis were excluded. The study was undertaken to measure 30-day outcomes. Results Between November 2021 and April 2022, 167,290 people tested positive for COVID-19 in Norfolk. Thirty-one patients under the vascular service had COVID-19, of which, one patient was unvaccinated. Only one vaccinated patient was referred with AT and had a positive COVID-19 result two days after admission. Above-knee amputation was performed within 30 days and he survived. Seventeen percent of patients contracted COVID-19 during their hospital admission. Conclusion The incidence of acute limb ischaemia in vaccinated patients is low; however, the 30-day outcomes remain poor. Compared to unvaccinated patients, there was a significant reduction in the presentation of AT in vaccinated patients during that timeframe, despite a higher background number of COVID-19 cases. Therefore, vaccination may minimise the risk of AT.

Outcomes Following Use of Bovine Pericardium (Xenoprosthetic) Grafts for Reconstruction of Mycotic Aortic Aneurysms and Infected Aortic Grafts: A Systematic Review and Meta-Analysis.

BACKGROUND: Infected aortic grafts and mycotic aneurysms represent one of the most complex challenges faced by vascular surgeons. Treatment has progressed from extra-anatomical bypass to in situ reconstruction. Additionally, bovine pericardium reconstruction (BPR) has increased, due to accessibility and reduced lower limb morbidity. There remains, however, limited evidence for its use. The aim is to pool all known data to understand outcomes following BPR of mycotic aneurysms or infected vascular grafts. METHODS: A systematic review was conducted in November 2021 with subsequent computerized meta-analysis of the pooled results and a final search in March 2022. Three databases, Excerpta Medica dataBASE (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), and National Institutes of Health PubMed (PubMed), were searched for the search term "(bovine OR xenoprosthetic) AND (aneurysm)", according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: From 9 studies, there were 133 patients: 67% graft infections and 33% mycotic aneurysms. Fifty-seven percent of reconstructions were in the abdominal aorta and 33% were in the thoracic aorta. One hundred fifty-eight pathogens were identified, including Staphylococcus aureus (23%), Candida albicans (13%), and Escherichia coli (13%). In 12%, no microorganisms were identified. Thirty-day mortality was 19.14% (CI 10.83-28.71), late mortality was 19.08% (confidence interval [CI] 7.76-32.83), and overall mortality was 40.20% (CI 29.82-50.97). One patient died intraoperatively. There were a total of 151 in-hospital complications after 30 days postoperation. Common complications were acute renal failure (17%), pneumonia (14%), delirium (12%), respiratory insufficiency (11%) and renal insufficiency (7%). Lower limb ischemia was low, occurring in 5.66% (CI 0.54-13.82) of patients. Loss of graft patency leading to reintervention occurred in 1.20% (CI 0.00-7.71) of the grafts. Reinfection rate was 0.00% (CI 0.00-1.21). CONCLUSIONS: This meta-analysis highlights low reinfection and high graft patency using BPR with medium-length follow-up; however, there remain limited long-term and comparative data regarding options for aortic reconstruction. As expected in this complex cohort, the complication rate and 30-day mortality remain high.

Characteristics and Trends in Median Arcuate Ligament Syndrome (MALS) Associated Visceral Artery Aneurysms: A Systematic Descriptive Review of the Literature.

Introduction: Median Arcuate Ligament Syndrome (MALS) is associated with true aneurysms, mainly of both the pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA). Although rare, their potential for rupture and adverse clinical outcomes warrants analysis. Prior studies suggest high rupture rates even for smaller aneurysms under 2 cm in this setting. We performed a systematic literature review, synthesising the evidence on visceral artery aneurysms related to MAL syndrome, with a focus on descriptive analyses of aneurysm size, presentation, rupture rates, and management. Methods: Literature search was performed using (Medline, EMBASE, Emcare and CINAHL). Inclusion criteria included true aneurysms secondary to MALS with or without rupture. The cases with pseudoaneurysms, concomitant pathologies eg, pancreatitis, conservatively managed aneurysms and articles with non-granular pooled data were excluded. Cases were assessed according to demographics, clinical presentation, aneurysm diameter, aneurysm rupture and management technique. Results: 39 articles describing 72 patients were identified. Aneurysm diameter in symptomatic patients was not significantly different from asymptomatic patients {21.0 and 22.3 mm respectively, P = .84}. Ruptured aneurysms were overall smaller than non-ruptured at presentation {12.3 mm v 30.8 mm respectively, P = .02}. Patients presented with abdominal pain (75.6%), nausea/vomiting (15.6%), hypotension (33.9%), shock (20.0%) and haemodynamic collapse (8.9%). 56.9% of all cases were managed with an endovascular approach, 19.4% were managed with an open surgical approach, and 23.6% were managed hybrid. Conclusion: This review suggests visceral artery aneurysms associated with median arcuate ligament rupture at variable sizes. Despite inability to clearly correlate size and rupture risk, our data supports prompt intervention irrespective of size, given the adverse outcomes. Further research is critically needed to clarify size thresholds or other predictors to guide management.

Factors Related to Limb Occlusion After Endovascular Abdominal Aortic Aneurysm Repair (EVAR).

BACKGROUND: Limb occlusion is a potentially serious consequence of endovascular abdominal aortic aneurysm (EVAR). This case-control study identifies factors that predispose to limb occlusion. METHODS: A consecutive series of patients from 2 centers undergoing EVAR over an 11-year period 2007-2017 were identified retrospectively. Patient records were interrogated allowing collations of demographics, intraoperative and perioperative data and surveillance data. The preoperative computed tomography angiogram was analyzed to determine EVAR relevant anatomical data. The primary outcome was occlusion of the iliac limb of the implanted EVAR. Raw data are presented as percentages, with comparative data analyzed using Mann-Whitney U-test and binomial logistic regression. RESULTS: A total of 787 patients (702 males; median age 78 years, range 53-94 years old) were analyzed. Fifty patients reached the primary outcome, resulting in an overall limb occlusion rate of 6.35%. Factors predictive of limb occlusion were oversizing by >10% native vessel diameter, with oversizing of >20% in 50% of those that occluded. External iliac artery landing zone (12/50 limb occlusions) 24% and postoperative kinking (5/50 limb occlusions) 10% were also more common in those that occluded. Fifty randomly selected controls with similar baseline characteristics were studied. Oversizing of the iliac endograft was found to be significantly greater in the limb occlusion group compared to the controls (P < 0.001) which remained significant on regression analysis. There was no correlation with iliac tortuosity. The Cook stent graft had a 9% limb occlusion rate across sites. Medtronic and Vascutek endografts had 2.4% and 2.5% limb occlusion rates respectively. CONCLUSIONS: Oversizing of iliac limbs by >20% could be a contributing factor to limb occlusion after EVAR and judicious oversizing should be used.

Predicting Features of Visceral Stent Failure in Fenestrated Endovascular Aortic Aneurysm Repair.

PURPOSE: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. MATERIALS: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. METHODS: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. RESULTS: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. CONCLUSIONS: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. CLINICAL IMPACT: With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.

Patient and Healthcare Professional Priorities for a Mobile Phone Application for Patients With Peripheral Arterial Disease.

Introduction Supervised exercise therapy (SET) is the first-line treatment for the peripheral arterial disease (PAD), however, access and compliance are low. An alternative method of delivering this therapy is through mobile health applications, which can be more accessible and convenient for patients. The aim of this study is to evaluate patient, public and healthcare professional (HCP) priorities with regard to a dedicated mobile phone application to deliver remote SET. Methods Bespoke questionnaires were designed for patients and HCPs to assess app functionality and prioritisations for development. These were distributed through social media and the Norfolk and Norwich University Hospital. Results Functionality questionnaires were completed by 62 patients and 44 HCPs. Eighty-four per cent of patients wanted their therapy to be monitored by their vascular team with the majority (78%) interested in measuring walking distances. Most patients (76%) were interested in watching exercise videos. These views were shared by HCPs. A communication platform was prioritised for messaging and pictures by the patient (74% and 68% respectively), but not so by HCPs (40%). Documenting other forms of physical activity and the use of wearable technology was less valuable to patients but favoured by HCPs (50%). The ability to interact with other users was not prioritised by either group. Conclusion Delivery of a mobile phone application to deliver health programmes for SET in patients with PAD is an acceptable method for patients and HCPs. This data will enable the next stages of mobile phone application development to be appropriately prioritised, focusing on building exercise videos, a communication platform and further walking tests.

The risk of harm whilst waiting for varicose veins procedure.

INTRODUCTION: Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. OBJECTIVE: This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. METHODS: This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. RESULTS: 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56-65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease (p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60-85) and 0.685 (0.566-0.761), respectively. Median AVVQ score was 23.2 (14.9-31.0) and CIVIQ-14 score was 33 (21-44).ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.

A systematic review and meta-analysis of the use of the Omniflow II biosynthetic graft for aortic reconstruction.

OBJECTIVE: Despite the improvements in xenogeneic grafts and surgical techniques, management of aortic graft infection has remained challenging. The optimal graft material has remained controversial, with high rates of reinfection using prosthetic grafts and a limited time for venous harvest in an emergent setting. Recent studies have highlighted an increase in the use of Omniflow II biosynthetic vascular grafts (LeMaitre Vascular, Burlington, MA) for aortic reconstruction. The primary aim of the present study was to review the key outcomes for the Omniflow II graft in terms of reinfection and complications. METHODS: The National Healthcare Service healthcare databases advanced search function was used to search nine databases for the search term "Omniflow." The present study complied with the PRISMA (preferred reporting items for systematic review and meta-analysis) statement. Eligible studies related to aortic graft infection or in situ aortic reconstruction were selected in accordance with prespecified eligibility criteria and included for review. Data on the surgical technique, comorbidities, graft reinfection, mortality, and complications were combined. The data were analyzed using Stata/MP, version 17 (StataCorp, College Station, TX), and the probabilities were pooled using a DerSimonian and Laird random effects model with Freeman-Tukey arcsine transformation. RESULTS: Six studies with 60 patients (44 men; age range, 29-89 years) were included. Of the 60 patients, 25 had undergone surgical reconstruction because of early graft infection (<4 months after the index procedure), 24 for late graft infection, and 3 because of mycotic aneurysms. Eight high-risk patients had undergone surgical reconstruction for prevention of an initial graft infection. Staphylococcus aureus, Escherichia coli, and S. epidermis were the most common organisms. Early mortality was 8.83% (95% confidence interval [CI], 1.12%-20.53%), and late mortality was 18.49% (95% CI, 5.51%-35.34%). Follow-up varied from 9 months to 2 years. No graft rupture or graft degeneration had occurred during follow-up. However, 6.2% (95% CI, 0.39%-15.81%) had experienced early graft occlusion, and 3.83% (95% CI, 0.00%-16.34%) had developed early graft stenosis. Two cases of postoperative reinfection were reported. The freedom from reinfection was 97.71% (95% CI, 87.94%-100.00%). CONCLUSIONS: Use of the Omniflow II graft for aortic reconstruction is a feasible alternative with acceptable mortality and low reinfection rates. However, there is a risk of limb occlusion. Although these studies were of low quality, the Omniflow II graft shows promise in this difficult patient cohort, especially when bifurcated reconstruction is required.

The Mysterious Risk of Arterial Thrombosis With COVID-19: A Case Series and Systematic Review of Acute Limb Ischaemia.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) generates a cytokine storm that predisposes patients to systemic complications including arterial thrombosis (AT) and acute limb ischaemia (ALI). This study reviews our understanding of the incidence and outcomes of patients with COVID-19 who develop AT. METHODS:  The case notes of all emergency patients with COVID-19 referred to the vascular services between March 2020 and March 2021 were reviewed. The study was undertaken to measure 30-day outcomes. Additionally, a literature search was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following search terms: acute limb ischaemia OR arterial thrombosis OR thrombectomy OR embolectomy AND COVID-19. RESULTS: During March 2020 and March 2021, 60,000 people tested positive for COVID-19 in Norfolk. A total of 33 patients were referred to the vascular services, of which 15 had AT (estimated incidence of 0.03%). Of AT patients, 93% had ALI. Fourteen locations of AT were identified. Of ATs, 36% were infrainguinal. The 30-day mortality was 60%. Three patients underwent surgery: two embolectomies (one requiring subsequent below-knee amputation (BKA) and the other died) and one primary BKA requiring subsequent above-knee amputation. The 30-day amputation-free survival (AFS) rate was 29%. The literature search identified 361 studies prior to a thorough full-text review. Nine case series were included with more than 10 participants each. The incidence of AT was reported as high as 15%. In-hospital mortality was 40%, with a significant proportion undergoing amputation or palliative care. Approximately a third of patients undergoing revascularisation subsequently re-occluded. AFS remained as low as 25%. CONCLUSION:  The incidence of AT within the vascular surgery territory in COVID-19 patients is low; however, it is associated with poor 30-day AFS. A computed tomography angiography protocol including the entire major vessels may be indicated in COVID-19 patients.

A Systematic Review and Meta-Analysis of Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery.

Introduction: Open abdominal aortic aneurysm (AAA) surgery is associated with significant morbidity, mortality and high length of stay (LOS). Enhanced recovery is now commonplace and has been shown to decrease these in other non-vascular surgery settings. This systematic review and meta-analysis aimed to assess the benefits of enhanced recovery (ERAS) in aortic surgery. Method: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used to undertake a systematic review via Ovid MEDLINE and Embase on 10.07.2021. The search terms were "aortic aneurysm" and "fast track" or "enhanced recovery". Data was obtained on major complications, 30-day mortality and LOS. Results: 107 papers were identified and 10 papers included for meta-analysis. Complication rates were significantly reduced with ERAS compared to non-ERAS protocols (ERAS n = 709, non-ERAS n = 930) (odds ratio .38, .22 to .65: P = .0005). LOS was also significantly reduced with an ERAS protocol (ERAS n = 708, non-ERAS n = 956) with a mean reduction of 3 .18 days (-5.01 to -1.35 days) (P = .0007: I2 = 97%). There was no significant difference however in 30-day mortality (P = .92). Conclusion: This meta-analysis demonstrates significant benefits to an enhanced recovery programme in open AAA surgery. There is a need for a multi-centre randomized controlled trial to assess this further.

Leg ulcer service provision in NHS hospitals.

AIM: To explore the service provision for compression therapy for inpatients with leg ulcers in UK hospitals. METHODS: An online survey was carried out to explore the service provision in hospital settings. It was distributed to Wounds UK National Conference delegates and to wound care specialist groups using social media. RESULTS: The authors received 101 responses from health professionals in the UK. Of these, 67.3% reported there was no dedicated service for inpatients with leg ulceration and only 32% said compression therapy was provided in their hospitals. CONCLUSION: This survey confirmed there is a significant shortfall in care provision for patients with leg ulcers in secondary care and highlighted the wide variations in service delivery in hospitals. Further research is needed to understand the reasons for these variations.

A randomised controlled clinical trial comparing the effectiveness of bandaging compared to the JuxtaCures™ device in the management of people with venous ulceration: Feasibility study.

INTRODUCTION: The mainstay of treatment for venous ulceration remains compression therapy. Velcro Wrap devices are being increasingly used in these patients despite limited evidence. This feasibility study aimed to compare standard bandaging to the JuxtaCures™ Velcro wrap device. METHODS: A single centre, unblinded RCT compared participants with venous ulceration randomised to either the JuxtaCures™ device or short stretch bandaging. Participants were followed up for 26 weeks. RESULTS: 160 participants were screened with 40 randomised. 3 participants in bandaging and 1 in JuxtaCures™ didn't complete the study. 60% in JuxtaCures™ healed v 55% in bandaging despite larger ulcers in the JuxtaCures™ arm (9.33 cm2 v 6.97 cm2). There was no significant difference in time to healing (12.17 v 13.64 weeks). JuxtaCures™ showed improved ulcer reduction for those that didn't heal (14.91-5.00 cm2 v 14.20-8.62 cm2; P = 0.06). JuxtaCures™ had more consistent sub-bandage pressure dropping from 39-36 mmHg versus 41-25 mmHg in bandaging between application and removal (P < 0.001). Quality of life (EQ5D) was improved in JuxtaCures at 3 months (mean difference 0.14, p = 0.04), but not at 1 and 6 months, or in disease specific quality of life. Cost was lower in JuxtaCures™ £842.47 v £1064.68. Duration of appointment was significantly shorter in JuxtaCures™ (41 minutes v 53 minutes; P = 0.003). CONCLUSION: This study has shown the feasibility and necessity of running a multicentre trial to evaluate the use of Velcro wrap devices for venous ulceration. It highlights the potential benefits of more consistent pressure, increased self-care, and potential with regards to ulcer healing, cost, nursing resource and quality of life.

Ligation Alone Versus Immediate Revascularization for Femoral Artery Pseudoaneurysms Secondary to Intravascular Drug Use: A Systematic Review and Meta-Analysis.

BACKGROUND: Femoral artery pseudoaneurysms (FA-PSAs) remain a common vascular aneurysmal pathology associated with intravascular drug use (IVDU). To date no internationally agreed consensus regarding optimal surgical management of FA-PSAs exists. The aim of this systematic review and meta-analysis was to determine the optimal surgical treatment of FA-PSAs associated with IVDU. METHODS: A systematic search was undertaken following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines identifying original studies reporting outcomes of ligation-debridement and/or excision-revascularization of FA-PSAs secondary to IVDU. Outcomes of interest were 30-day mortality, incidence of amputation at 12 months, chronic limb threatening ischemia (CLTI) at any follow-up appointment, reintervention, and bleeding. RESULTS: A total of 39 cohort studies describing 1,217 FA-PSA operative outcomes met inclusion criteria, 993 (81.6%) treated by ligation-debridement and 224 (18.4%) by excision-revascularization. The incidence of 30-day mortality was 0.8% (n = 8) and 1.3% (n = 3) in the ligation-debridement and excision-revascularization groups, respectively, with only one study reporting mortality in both groups. This meta-analysis found no difference in amputation (8.89% vs. 8.03%, odds ratio (OR) 0.74 95% confidence interval (CI) 0.35-1.56, P = 0.42, 11 studies) or CLTI (21.5% vs. 12.4%, OR 1.24 95% CI 0.35-4.38, P = 0.74, 9 studies) after ligation and debridement compared with excision and revascularization. There was a higher incidence of reintervention (24.7% vs. 10.6%, OR 0.31 [95% CI 0.16, 0.62], P = 0.0009, 13 studies) and rebleeding (7.1% vs. 1.6%, OR 0.61 [95% CI 0.16, 2.38], P = 0.48, 5 studies) after excision and revascularization compared with ligation alone. CONCLUSIONS: For treatments of IVDU-related FA-PSAs, this study suggests no significant difference in association of mortality, incidence of amputation, or CLTI with ligation-debridement or excision-revascularization, but a significantly higher reintervention rate and greater rebleeding rate for revascularized patients.

Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study.

OBJECTIVES: Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. METHODS: A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). 'Good' and 'very good' consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. RESULTS: Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, 'good' and 'very good' consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, 'very good' consensus was achieved for 3/3 statements. CONCLUSIONS: The main findings from this study were that there was 'good' or 'very good' consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Long-term Outcomes Following Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms.

Purpose: To investigate the long-term outcomes of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (rAAA) from a single center over an 11-year period. Materials and Methods: A retrospective analysis was conducted of 121 patients (median age 78 years; 100 men) with rAAA who underwent emergency EVAR at a single tertiary vascular center from January 2006 to December 2016. The study included only ruptures confirmed by evidence of hematoma on preoperative computed tomography; both iliac and aortic aneurysm ruptures were eligible. The primary outcome measures included mortality and reintervention rates. Kaplan-Meier estimates of survival and freedom from reintervention are reported with the 95% confidence interval (CI). Results: In-hospital and 30-day mortality rates for emergency EVAR were 16.5%; 90-day mortality was 24.0%. The mortality estimates were 27.3% (95% CI 20% to 36%) at 1 year and 61.7% (95% CI 51% to 72%) at 5 years. In the observation period to 2017, 63 reinterventions were performed on 37 patients (30.6%). Median time to the first reintervention was 3.2 years. Freedom from reintervention in surviving patients at 1 year was 86% (95% CI 72% to 94%) and 51% (95% CI 26% to 71%) at 5 years. Four patients (3.3%) had a secondary sac rupture over the study period. Conclusion: Emergency EVAR for ruptured AAA can be performed with acceptable short-term outcomes; however, long-term surveillance is necessary, and reintervention is common.

A comparison of inpatients with leg ulceration using published randomised controlled trials.

BACKGROUND: Leg ulcers are a significant burden and reduce patients' quality of life. In recent years, a plethora of information has been issued regarding leg ulcer management and 'the demographics of patients affected in the community. However, little is known about the leg ulcer population and how these patients should be managed in acute hospitals. AIM: To compare the demographic data of inpatients with leg ulcers referred to the tissue viability service in a large teaching hospital with data on leg ulcer populations in acute and community settings. METHODS: Inpatient demographic data were retrospectively obtained from electronic patient records. A literature search identified studies regarding leg ulcer populations in acute and community settings. RESULTS: The patient population in acute settings is around 10 years older than that in community settings, with much greater levels of comorbidity and higher mortality rates. CONCLUSION: An improved understanding of inpatients with leg ulcers would allow investigations and interventions to be targeted better, enabling evidence-based, patient-centred referral and care pathways. Further research is required to understand the aetiology and outcomes of leg ulcers for the inpatient population.