A short report on the current landscape of Artificial Intelligence (AI) in vascular surgery in Pakistan.

This study focuses on the current applications, potential, and challenges to Artificial Intelligence (AI) integration in vascular surgery with specific emphasis on its relevance in Pakistan. Despite the benefits of AI in vascular surgery, there is a substantial gap in its adoption in Pakistan compared to global standards. In our context with limited resources and a scarcity of vascular surgeons, AI can serve as a promising solution. It can enhance healthcare accessibility, improve diagnostic accuracy, and alleviate the workload on vascular surgeons. However, hurdles including the absence of a comprehensive vascular surgery database, a shortage of AI experts, and potential algorithmic biases pose significant challenges to AI implementation. Despite these obstacles, the study underscores the imperative for continued research, collaborative efforts, and investments to unlock the full potential of AI and elevate vascular healthcare standards in Pakistan.

Experimental comparative study of a novel drug-eluting arteriovenous graft in a sheep model.

Background: Arteriovenous (AV) grafts often develop severe complications of stenosis due to neointimal proliferation that occurs either at the venous anastomosis site or at the outflow receiving vein. This study compares primary patency during 12 months of follow up for a new experimental Biomodics© interpenetrating polymer network (IPN) drug-eluting graft prototype with state-of-the-art GORE® ACUSEAL (ACUSEAL) in an AV graft model in sheep. Methods and results: An end-to-end bypass from the common carotid artery to the jugularis vein was performed bilaterally in 12 sheep. The usage of ACUSEAL or the IPN, both 6.0 mm in diameter, was determined via randomization. The sheep were followed up every 4 weeks with ultrasonic duplex scanning to determine patency; the experienced observer was blinded to the randomization. One sheep died after 11 days, and the final sample accordingly consisted of 11 animals. When comparing neointimal hyperplasia after 12 months in the two grafts, Fisher's exact test showed a significant difference with none out of 11 in the IPN grafts and 9 out of 11 in the ACUSEAL graft (p < 0.001). However, the Biomodics© IPN exhibited severe deterioration over time. Conclusions: Almost all of the grafts occluded during the 12 months of follow up. Although the zwitterion-bounded interpenetrating drug eluting polymer network showed signs to impair neointimal hyperplasia and thrombosis, age-related degeneration hindered demonstrating a potential improvement in patency.

Arterial Blood Flow and Effects on Limb Tissue Perfusion During Endoshunting of the Common Iliac Artery in an Experimental Porcine Model.

Objective: Temporary arterial shunting is an established method to prevent tissue ischaemia. Although less well established, shunting might also be achieved through endovascular and hybrid techniques, known as endoshunting. Endoshunting offers advantages, for example, enabling minimally invasive access and avoiding complete occlusion of the donor artery. In an ex vivo bench test, volume flow in various interconnected endoshunt systems has been tested previously. This study aimed to investigate the capacity of the best performing endoshunt system in vivo. Methods: Six anaesthetised pigs had their common iliac arteries (CIAs) explored, with the left CIA serving as the experimental and the right CIA as the control. Mean arterial pressure, regional blood flow, endoshunt flow, and regional oxygen extraction and lactate production were recorded. Distal muscle perfusion was monitored using near infrared spectroscopy (NIRS). Each experiment involved baseline registration, cross clamping of the left CIA, a 120 minute endoshunt session, and restoration of native flow. Results: During cross clamping, NIRS values on the experimental side reached the lowest measurable value. Following endoshunt activation, there were no NIRS value differences between the experimental and control extremities whereas the average arterial flow decreased in both the experimental (270-140 mL/min, p = .028) and control extremities (245-190 mL/min, p = .25), with a greater drop on the endoshunted side (48% vs. 22%, respectively). Lactate levels temporarily increased by 42% in the endoshunted limb on endoshunt activation but were normalised within an hour. Oxygen extraction remained constant at 55% on the control side but increased to 70% on the endoshunted side (p = .068). Conclusion: In this animal model, a flow optimised endoshunt system appeared to provide sufficient blood flow and restored stable tissue perfusion. Although arterial flow was slightly lower and oxygen extraction slightly higher on the endoshunted side, the endoshunt seemed to deliver adequate perfusion to prevent significant ischaemia.

Relevance of BEST-CLI trial endpoints in a tertiary care limb preservation program.

OBJECTIVE: Major adverse limb event-free survival (MALE-FS) differed significantly by initial revascularization approach in the BEST-CLI randomized trial. The BEST-CLI trial represented a highly selected subgroup of patients seen in clinical practice; thus, we examined the endpoint of MALE-FS in an all-comers tertiary care practice setting. METHODS: This is a single-center retrospective study of consecutive, unique patients who underwent technically successful infrainguinal revascularization for chronic limb-threatening ischemia (2011-2021). MALE was major amputation (transtibial or above) or major reintervention (new bypass, open bypass revision, thrombectomy, or thrombolysis). RESULTS: Among 469 subjects, the mean age was 70 years, and 34% were female. Characteristics included diabetes (68%), end-stage renal disease (ESRD) (16%), Wound, Ischemia, and foot Infection (WIfI) stage 4 (44%), Global Limb Anatomic Staging System (GLASS) stage 3 (62%), and high pedal artery calcium score (pMAC) (22%). Index revascularization was autogenous vein bypass (AVB) (30%), non-autogenous bypass (NAB) (13%), or endovascular (ENDO) (57%). The composite endpoint of MALE or death occurred in 237 patients (51%) at a median time of 189 days from index revascularization. In an adjusted Cox model, factors independently associated with MALE or death included younger age, ESRD, WIfI stage 4, higher GLASS stage, and moderate-severe pMAC, whereas AVB was associated with improved MALE-FS. Freedom from MALE-FS, MALE, and major amputation at 30 days were 90%, 92%, and 95%; and at 1 year were 63%, 70%, and 83%, respectively. MALE occurred in 144 patients (31%) and was associated with ESRD, WIfI stage, GLASS stage, pMAC score, and index revascularization approach. AVB had superior durability, with adjusted 2-year freedom from MALE of 72%, compared with 66% for ENDO and 51% for NAB. Within the AVB group, spliced vein conduit had higher MALE compared with single-segment vein (hazard ratio, 1.8; 95% confidence interval, 0.9-3.7; P = .008 after inverse propensity weighting), but there was no statistically significant difference in major amputation. Of the 144 patients with any MALE, the first MALE was major reintervention in 47% and major amputation in 53%. Major amputation as first MALE was associated with non-AVB index approach. Indications for major reintervention were symptomatic stenosis/occlusion (54%), lack of clinical improvement (28%), asymptomatic graft stenosis (16%), and iatrogenic events (3%). Conversion to bypass occurred after 6% of ENDO cases, two-thirds of which involved distal bypass targets at the ankle or foot. CONCLUSIONS: In this consecutive, all-comers cohort, disease complexity was associated with procedural selection and MALE-FS. AVB independently provided the greatest MALE-FS and freedom from MALE and major amputation. Compared with the BEST-CLI randomized trial, MALE after ENDO in this series was more frequently major amputation, with relatively few conversions to open bypass.

Experiencia y factores perioperatorios que afectan a los resultados en isquemia mesentérica aguda. Resultados de un hospital terciario chileno / Experience and perioperative factors affecting results in acute mesenteric ischemia. Results of a Chilean tertiary hospital

Introducción y objetivo: la isquemia mesentérica es poco frecuente, pero tiene una alta mortalidad. Existen pocos reportes de esta patología en países subdesarrollados. Este estudio pretende describir los resultados de un centro universitario terciario chileno y los factores que afectan a su morbimortalidad. Material y métodos: análisis retrospectivo de los pacientes intervenidos de urgencia por isquemia mesentérica aguda entre 2016 y 2021 en el Hospital Clínico Universidad de Chile. Se excluyeron los pacientes manejados sin cirugía. Se analizaron factores perioperatorios, detalles operatorios, la mortalidad a 30 días y la estancia hospitalaria, entre otros. Resultados: se incluyeron 32 pacientes. La mediana de edad fue de 73,5 años (45-92). Las comorbilidades más frecuentes fueron hipertensión (62,5 %), diabetes mellitus (28,1 %) y enfermedad cardiovascular conocida: infarto agudo de miocardio, angina crónica, accidente cerebrovascular, isquemia aguda de extremidades y enfermedad arterial oclusiva periférica (34,4 %). El 40,6 % tenía causa arterial trombótica; el 18,8 %, arterial embólica; el 25 %, venosa, y el 15,6 %, no oclusiva (NOMI). El motivo de consulta más frecuente fue el dolor abdominal (84,4 %). En la primera intervención, el 81,3 % requirió resección intestinal. Se realizó una anastomosis en el 53,1 %. El 25 % de los pacientes fueron revascularizados, con un cirujano vascular en el equipo quirúrgico, en el 65,6 %. La mediana de estancia hospitalaria fue de 21 días (2-129). La mediana de tiempo a la cirugía fue de 10,75 horas (4,75-196)... (AU)

Introduction and objective: acute mesenteric ischemia has a low incidence but high mortality. The results of this disease are not well reported in developing countries. This study aims to describe the results of a Chilean tertiary university center and the factors that affect its morbidity and mortality. Material and methods: retrospective analysis of all patients undergoing emergency surgery for acute mesenteric ischemia between 2016 and 2021 at the hospital clínico universidad de chile. Patients managed without surgery were excluded. Demographic characteristics, perioperative factors, details of the first surgery, 30-day mortality, and hospital stay, among others, were analyzed. Results: 32 patients were included. The median age was 73.5 years (45-92). The most frequent comorbidities were arterial hypertension (62.5 %), diabetes mellitus (28.1 %) and known cardiovascular disease 34.4 % (acute myocardial infarction, chronic angina, cerebrovascular accident, acute limb ischemia, peripheral arterial occlusive disease). 40.6 % had a thrombotic arterial cause, 18.8 % embolic arterial, 25 % thrombotic venous and 15.6 % non-occlusive (NOMI). The most frequent reason for consultation was abdominal pain (84.4 %). In the first surgical intervention, 81.3 % required intestinal resection, with an anastomosis performed in 53.1 %. 25% were revascularized, with a vascular surgeon on the surgical team in 65.6 %. The median hospital stay was 21 (2-129) days. The median time from the emergency department to surgery was 10.75 hours (4.75-196). Mortality at 30 days was 40.6 %, with no differences between etiologies...(AU)

Aortobifemoral Bypass in Kidney Transplant Candidates: A Ten-Year Experience.

In patients with severe aorto-iliac calcifications, vascular reconstructions can be performed in order to allow kidney transplantation. The aim of this study was to analyze the outcomes of kidney transplant candidates who underwent an aortobifemoral bypass (ABFB) for aorto-iliac calcifications. A retrospective study including all kidney transplant candidates who underwent an ABFB between 2012 and 2022 was performed. Primary outcome was 30-day morbidity-mortality after ABFB. Secondary outcome was accessibility to kidney transplant waiting list. Twenty-two ABFBs were performed: 10 ABFBs in asymptomatic patients presenting severe aorto-iliac circumferential calcifications without hemodynamic consequences, and 12 ABFBs in symptomatic patients in whom aorto-iliac calcifications were responsible for claudication or critical limb threatening ischemia. Overall 30-day mortality was 0%. Overall 30-day morbidity was 22.7%: 1 femoral hematoma and 1 retroperitoneal hematoma requiring surgical drainage in the asymptomatic group, and 2 digestive ischemia requiring bowel resection and 1 femoral hematoma requiring surgical drainage in the symptomatic group. Among the 22 patients, 20 patients could access to kidney waiting list and 8 patients underwent a kidney transplantation, including 3 living-donor transplantations. Aorto-iliac revascularization can be an option to overcome severe calcifications contraindicating kidney transplantation.

A Tubular Vena Cava Conduit Used to Lengthen a Kidney Transplant Renal Artery Injured During Organ Procurement.

Introduction: Organ transplantation is limited by the supply of transplantable organs, and the supply of organs cannot meet the needs of patients on the waiting list. Ensuring transplantation of any procured organ is therefore mandatory. Organ injury, mostly to the organ's vasculature, can occur during multi-organ procurement, preventing subsequent transplantation. In such a context, vascular reconstructions of arterial or venous organ injuries can be useful. Report: This report describes the case of an obese 64 year old female with a history of diabetic nephropathy who underwent a cadaveric kidney transplant (right kidney with one main renal artery, one inferior polar artery, one vein, and one ureter). The ex situ preparation of the graft revealed that the main renal artery was injured and cut close to the renal hilum (0.8 cm length, 6 mm diameter), not allowing graft implantation. In order to increase the length of the main renal artery, the donor inferior vena cava was used to create a tubular conduit, allowing subsequent graft implantation. Cold and warm ischaemic times were respectively 12 hours and 36 minutes, with immediate graft function. The patient was discharged on day 8 (serum creatinine level was 95 µmol/L). Twelve month follow up was uneventful (serum creatinine level was 108 µmol/L and duplex ultrasonography showed homogeneous blood flow throughout the graft). Discussion: This case report highlights the possibility of overcoming an injured kidney graft artery by creating a tubular vena cava conduit in order to allow subsequent transplantation. Vascular reconstructions of organs injured during procurement should be considered.

Evaluation of the impact of pharmacist-led educational intervention on knowledge and skills of cancer patients with totally implantable venous access port: a single-centre, non-randomised controlled study.

BACKGROUND: Totally implantable venous access port (TIVAP) is a type of implantable medical device that enables repetitive access to the intravenous system through use of a Huber needle. This device facilitates the administration of aggressive or long-term treatments while ensuring the comfort and safety of the patient. To ensure proper use of the medical device and lower the risk of complications, it is essential that patients acquire the necessary knowledge and skills regarding TIVAP. OBJECTIVE: The main objective of the study was to assess the impact of a pharmaceutical interview on patients' knowledge and skills for patients with TIVAP. METHODS: To achieve this goal, a pharmaceutical interview guide and an 18-item questionnaire were developed, based on a three-part competency framework (knowledge, know-how and attitudes) previously constructed by a multidisciplinary team. The intervention consisted of a pharmacist-led interview with every patient on the day of the TIVAP insertion. Patients in the control group received usual care. Patients included were interviewed by telephone 14 days after implantation. χ2 tests were conducted to compare the scores obtained by each group. RESULTS: The average score obtained by the control group (n=30) was 8.97, while the intervention group (n=59) achieved an average score of 12.66 (p<0.001). The intervention group demonstrated increases in correct responses for all items, with eight questions displaying significantly higher scores. Six of these pertained to theoretical knowledge, one to know-how and one to attitudes. CONCLUSION: The interviews had a clear impact on the knowledge and skills of TIVAP patients.

Prognostic factors for femoropopliteal vascular injuries: surgical decisions matter.

Background: Lower limbs are frequently involved in vascular trauma, but it is still not clear which factors lead to unfavorable clinical outcomes. Objectives: To determine the clinical profile of patients with femoropopliteal injuries, the trauma mechanisms, and treatment and identify which factors led to unfavorable outcomes. Methods: A retrospective study based on the medical records of patients treated from 2017 to 2021. The following data were assessed: sex, age, distance to reach the hospital, trauma mechanism, hypovolemic shock, additional injuries, treatment of vascular injuries, whether fasciotomy was needed, inappropriate intraoperative decisions, and injury severity score. Need for surgical reintervention, amputation, and death were defined as unfavorable outcomes. Univariate, bivariate, and logistic regression analyses were conducted. Results: The sample comprised 94 patients; 83% were men; mean age was 30.8 years; combined arterial and venous injuries prevailed (57.5%); and superficial femoral vessels were the most affected (61.7%). Penetrating mechanisms prevailed (80.9%). Arterial injuries were most frequently treated with venous graft (59.6%) and venous injuries underwent ligation (81.4%). In 15% of cases, inappropriate surgical decisions were detected; most often use of the ipsilateral great saphenous vein for arterial reconstruction. Unfavorable outcomes occurred in 44.7%: surgical reintervention was necessary in 21.3% and limb amputation in 25.5%, while 9.5% of the patients died. Conclusions: These injuries mainly involved young men, victims of gunshot wounds. Superficial femoral vessels were the most injured; concomitant non-vascular trauma was frequent, mainly fractures. Inappropriate surgical decisions increased the need for reinterventions by 34 times. Need for fasciotomy, presence of fracture/dislocation, blunt trauma mechanism, and popliteal artery injury increased the risk of amputation.

The Effect of Smoking on the Activated Clotting Time and the Incidence of Complications in Noncardiac Arterial Procedures.

PURPOSE: Smoking is a well-known risk factor for developing arterial diseases and for an increase of complications during and after vascular procedures. Although smoking has a proven effect on hemostasis, no literature is available on the effect of smoking on the activated clotting time (ACT), which is used to monitor the effect of heparin during noncardiac arterial procedures (NCAP). The aim of this study was to examine the effect of smoking on ACT values and the incidence of complications during the same admission or 30 day follow-up of NCAP. MATERIALS AND METHODS: A post hoc analysis of a prospective multicenter cohort study was performed. Patients older than 18 years, who underwent NCAP between December 2016 and April 2021, were enrolled. Patients were divided into 2 groups based on smoking status: never/former smokers and current smokers. Two heparin dosing protocols were used: an initial bolus of 5000 IU or 100 IU/kg bodyweight. RESULTS: In total, 773 patients met the inclusion criteria. Five minutes after administration of 5000 IU of heparin, mean ACT values were 190 and 196 seconds for nonsmokers and smokers, respectively (p=0.078). After 100 IU/kg of heparin, mean ACT values were 229 and 226 seconds for nonsmokers and smokers, respectively (p=0.37). Incidence of complications in the whole study cohort was not significantly different for nonsmokers compared with smokers (arterial thrombo-embolic complication [ATEC] 4.7% vs 5.7% p=0.55; hemorrhagic complications 15% vs 18% p=0.29). In subgroup-analysis, a significant difference between smoking groups was found for hemorrhagic complications after open aneurysm repair (p=0.024). However, after adjusting for confounders, the difference between the smoking groups annulled. CONCLUSION: The results of this study suggest that smoking does not have a significant effect on ACT values or on the incidence of complications in NCAP. Large-scale studies are required to further analyze potential factors having an effect on the ACT and perioperative and postoperative complications, which could help individualize heparinization strategy. CLINICAL IMPACT: There is high variance between patients in their response on administration of heparin, this is not yet fully understood. This study investigated the effect of smoking in a large prospective multicentre cohort. The results suggests that active smoking does not have an effect on the activated clotting time after administration of heparin. Also no significant effect of smoking could be found on the incidence of all registered complications. Monitoring of the effect of heparin remains important to provide patients with safe anticoagulation during vascular procedures.

Prone thoracic endovascular aortic repair via the popliteal artery for inadvertent vascular injury during spondylectomy: a case report.

Background: Vascular injury during spinal surgery is a dreaded complication associated with high morbidity and mortality. Repositioning the patient following such an injury could result in significant time delays and haemorrhage. Endovascular repair via popliteal access has never previously been described in the literature. A novel prone thoracic endovascular aortic repair (TEVAR) technique is described here as a safe alternative to manage vascular injury during posterior spinal surgery. Case Description: Here we describe a 63-year-old male where endovascular repair of vascular injury to the aorta by intercostal artery avulsion was performed via popliteal artery access in the prone position during T11 en bloc spondylectomy and posterior fusion. The patient remained haemodynamically unstable following the vascular injury precluding immediate transfer to the angiography suite. Identification of vascular injury to deployment of TEVAR graft was 90 minutes. The spondylectomy was able to be completed without repositioning the patient. Radiological and clinical follow-up revealed no complications at 1 and 2 months respectively following surgery. Conclusions: TEVAR placement via this novel popliteal access route was able to halt the haemorrhage allowing stabilisation of the patient and completion of the spinal procedure. Clinical teams should be made aware this is a viable technique to address vascular injuries during spinal surgery.

Perprocedural Heparinization in Non-cardiac Arterial Procedures: The Current Practice in the Netherlands.

PURPOSE: Heparin is the most widely-used anticoagulant to prevent thrombo-embolic complications during non-cardiac arterial procedures (NCAP). Unfortunately, there is a lack of evidence and consequently non-uniformity in guidelines on perprocedural heparin management. Detailed insight into the current practice of antithrombotic strategies during NCAP in the Netherlands is important, aiming to identify potential optimal protocols and local differences concerning perprocedural heparinization. MATERIALS AND METHODS: A comprehensive online survey was distributed electronically to vascular surgeons of every hospital in the Netherlands in which NCAP were performed. Data were collected from September 2020 to October 2021. RESULTS: The response rate was 90% (53/59 hospitals). During NCAP, all surgeons generally administered heparin before arterial clamping. In 74% (39/54) of hospitals, a single heparin dosing protocol was used for all types of patients and vascular procedures. In 40%, there was no uniformity in heparin dosing between vascular surgeons. Depending on the procedure, a fixed bolus heparin, predominantly 5000 IU, was administered in 73% to 93%. In the remaining hospitals (7%-27%), a bodyweight-based heparin protocol was used, with an initial dose of 70 or 100 IU/kg. A minority (28%) monitored the effect of heparin in patients using the activated clotting time add (ACT) after activated clotting time. Target values varied between 180 and 250 seconds or 2 times the baseline ACT. CONCLUSION: This survey demonstrates considerable variability in perprocedural heparinization during NCAP in the Netherlands. Future research on heparin dosing is needed to harmonize and optimize heparin dosage protocols and contemporary guidelines during NCAP, and thereby improve vascular surgical care and patient safety. CLINICAL IMPACT: This survey demonstrated persisting intra- and inter-hospital variability in perprocedural heparinization during non-cardiac arterial procedures (NCAP) in the Netherlands. The observed variability in heparinization strategies highlights the need for high quality evidence on perprocedural anticoagulation strategies. This is needed in order to harmonize and optimize heparin dosage protocols and contemporary guidelines and thereby improve vascular surgical patient care. Based on the current results, an international survey will be conducted by the authors to gain additional insight into the antithrombotic strategies used during NCAP, aiming to harmonize anticoagulation protocols worldwide.

Surgical resection of retrohepatic inferior vena cava leiomyosarcoma without vascular reconstruction: case report.

Inferior vena cava leiomyosarcoma (IVCL) is a rare malignant mesenchymal tumor. Surgical treatment is a challenge because it must combine free surgical margins with vascular reconstruction, using prosthetic or autologous grafts, primary suture, or simple ligation without vein reconstruction. The ligation option is possible thanks to the slow growth of the tumor, allowing collateral venous circulation to develop. We present a case of an IVCL treated with radical resection without vascular reconstruction. The patient was a 48-year-old female with abdominal pain in the right upper quadrant, asthenia, and postprandial dyspeptic symptoms. Abdominal tomography revealed a mass with an expansive formation located in the infrahepatic segment of the inferior vena cava and reduced vessel lumen. During surgery, vein clamping did not provoke hemodynamic repercussions, suggesting sufficient collateral circulation formation. It was decided to perform a radical resection of the entire portion of the retrohepatic vena cava and ligate the vena cava without vascular reconstruction. The patient recovered without complications.

The first meta-analysis research on the effects of endovenous laser ablation combined with sapheno-femoral junction high ligation of the great saphenous vein.

Endovenous laser ablation (EVLA) is a common minimally invasive technique used to treat varicose veins. The most commonly used laser wavelengths for EVLA/EVLT of varicose veins are 810 nm and 1470 nm. The laser pulse frequency is typically set to continuous wave (CW) mode, with a pulse duration of a few milliseconds (ms) delivered in a radial mode. The energy delivered per pulse is typically set between 40 and 120 Joules, with a power setting of 10 to 30 watts and an intensity setting of 40 to 120 J/cm2. The controversy exists regarding the benefits of performing saphenofemoral junction (SFJ) ligation prior to EVLA to decrease the recurrence rate of varicose veins. This meta-analysis aims to investigate the effectiveness of combining EVLA with high ligation versus using EVLA alone in treating lower extremity varicose veins. We conducted a systematic search of four databases from their inception until July 1, 2022, for randomized controlled trials and prospective controlled trials evaluating the advantages and disadvantages of EVLA with or without high ligation for the treatment of lower extremity varicose veins. In analyzing binary data, rate difference (RD) is used, while odds ratio (OR) is used for evaluating the confidence interval (CI) of binary data. A P value of less than 0.05 is deemed statistically significant. Heterogeneity is assessed using the chi-square test. If the I2 statistic, which reflects statistical heterogeneity, is greater than 50%, a random-effects model should be used. In the absence of significant statistical heterogeneity, a fixed-effects model should be used if I2 is less than 50%. We used the Cochrane risk-of-bias tool to assess the quality of the studies and Review Manager 5.4 for the primary and secondary outcome analysis. The meta-analysis was conducted in accordance with the Cochrane Handbook. There were no significant differences in the rate of major complications (RR = 1.63; 95% CI, 0.40-6.69; P = 0.50) or in the frequency of minor complications (RR = 1.07, 95% CI, 0.87-1.31; P = 0.52) between the EVLA with high ligation (EVLA/HL) group and the EVLA group. However, the rate of vein occlusion was significantly lower in the EVLA group than in the EVLA/HL group (RR = 1.06; 95% CI, 1.03-1.09; P = 0.0004). Our meta-analysis indicates that combining EVLA with high ligation provides stable long-term clinical efficacy in treating varicose veins of the lower extremities, although it increases the invasiveness of the surgery. The use of EVLA alone may be less effective in preventing vein occlusion.

Five Year Survival in Medicare Patients Undergoing Interventions for Peripheral Arterial Disease: a Retrospective Cohort Analysis of Linked Registry Claims Data.

OBJECTIVE: To justify the up front risks of offering elective interventions for intermittent claudication (IC), patients should have reasonable life expectancy to derive durable clinical benefits. Open surgery for chronic limb threatening ischaemia (CLTI) is maximally beneficial in patients surviving ≥ 2 years. The aim was to assess long term survival after IC and CLTI interventions. METHODS: In a retrospective cohort analysis, the Vascular Quality Initiative (VQI) registry from 1 January 2010 to 31 May 2021 was queried for peripheral vascular intervention (PVI), infra-inguinal bypasses (IIB), and supra-inguinal bypasses (SIB) for IC and CLTI across 286 US centres. VQI linkage to Medicare insurance claims provided five year survival data. Multivariable analysis identified factors associated with five year mortality. RESULTS: There were 31 457 PVIs (44.7% IC, 55.3% CLTI), 7 978 IIBs (26.9% IC, 73.1% CLTI), and 2 149 SIBs (50.1% IC, 49.9% CLTI) recorded in the VQI. Among the PVI, IIB, and SIB cohorts, average ages were 75, 73, and 72 years, respectively. Respective five year mortality after PVI for IC and CLTI was 37.2% and 71.1%; after IIB for IC and CLTI it was 37.8% and 60%; and after SIB for IC and CLTI it was 33.8% and 53.8%. On multivariable analysis, across all procedures, end stage renal disease, CLTI, congestive heart failure, anaemia, chronic obstructive pulmonary disease, and prior amputation were independently associated with increased mortality. Pre-admission home living and pre-operative aspirin use were independently associated with decreased mortality. CONCLUSION: Long term survival in Medicare patients undergoing interventions in VQI centres for peripheral arterial disease is poor. Two thirds of CLTI patients and over one third of IC patients were not alive at five years. Intervening for IC in patients with high mortality risk should be avoided. For CLTI patients identified with decreased survival likelihood, intervention durability may be less important than invasiveness. Pre-operative medical optimisation should always be undertaken.

Reparación del eje carotídeo con injerto autólogo por sangrado recurrente posamigdalectomía en edad pediátrica / Carotid axis repair with autologous vein graft due to recurrent post-tonsillectomy bleeding in a child

Introducción: el sangrado es una complicación común después de una amigdalectomía y habitualmente se tratacon cauterización del lecho quirúrgico. Sin embargo, en algunos pacientes, cuando el sangrado es secundario auna lesión vascular, es necesaria la ligadura o la embolización del vaso lesionado.Caso clínico: presentamos el caso de un paciente de 7 años de edad que requirió reparación y revascularizacióndel eje carotídeo izquierdo con injerto autólogo debido a sangrado recurrente y refractario a embolización de laarteria carótida externa izquierda posamigdalectomía.(AU)

Background: bleeding is a very common complication after tonsillectomy and is often treated through cauter-ization of the tonsillar bed. However, in some cases ligation or embolization of the source of the bleeding due tovascular injury is deemed necessary.Case report: this is the case of a 7-year-old boy that underwent repair and revascularization of his left carotid axiswith an autologous vascular graft due to recurrent bleeding postonsillectomy refractory to previous embolizationof the left external carotid artery.(AU)

Superficial femoral artery-anterior tibial artery bypass with great saphenous vein grafting via the lateral femoropopliteal route for infection after Viabahn placement.

We report a case involving an elderly man who successfully underwent superficial femoral artery-anterior tibial artery bypass via the lateral femoropopliteal route following development of a stent infection after placement of a small-diameter covered stent for a ruptured superficial femoral artery pseudoaneurysm. This report suggests that appropriate treatment strategies for device infection subsequent to device removal are paramount for the prevention of reinfection and preservation of the affected extremity.

Emergent Endovascular Repair For Primary Aortoenteric Fistula.

We report the case of a 64-year-old male with significant cardiac comorbidities who reported three episodes of gastrointestinal bleeding. In the third episode, he presented massive hematemesis, anaemia and hypotension. Despite a standard upper endoscopy, a computed tomography (CT) showed an infrarenal abdominal aortic aneurysm and densification of the aortic fat cover. A primary aortoenteric fistula, with acute bleeding and haemodynamic instability, was assumed, and an emergent endovascular repair was performed. Subsequent CT scans and endoscopies demonstrated control of the enteric lesion. After five months, there was no evidence of infection or rebleeding.