Treatment of Peripheral Arterial Occlusive Disease around the Globe: Malta.

INTRODUCTION: Malta is a small island in the middle of the Mediterranean with a population of 514,564 inhabitants and is served by one public tertiary hospital, Mater Dei Hospital. The Vascular unit was set up in 2007. The aim of this review is to analyse the work related to peripheral arterial occlusive disease (PAOD) in Malta with an in-depth focus on amputations and revascularisation procedures since the introduction of the Vascular unit. METHOD: Various sources of data have been interrogated to address this subject. Population and prevalence data on obesity and type II diabetes mellitus from 2003 to 2019 was obtained from the National Statistics Office, the World Health Organization, and the International Diabetes Federation, respectively. The Maltese Vascular Register (MaltaVasc), and in-hospital reports from 2003 to 2019 was used to obtain data on revascularisation procedures, major amputations and minor amputation rates in Malta. RESULTS: Malta has one of the highest rates of obesity in Europe. In 2015, the prevalence rate was 30.6%. Similarly, data from the International Diabetes Federation Atlas showed that the prevalence rate of T2DM among adults was 14% in 2017. There was a mean of 33 open/hybrid procedures per 100,000 population (28-38, 95% confidence interval) between 2005 and 2009 and a mean of 57 endovascular procedures per 100,000 population (46-68, 95% confidence interval) during the same time-period. From 2009 to 2019, there was a mean of 16 major amputations and 78 minor amputations per 100,000 population. CONCLUSION: A significant reduction in major amputation rates with an increase in minor amputation rates and revascularisation rates has been noted since the establishment of the vascular unit in Malta. During this period, there has been an increase in prevalence in obesity and T2DM together with an aging population.

Efficacy of Cyanoacrylate Glue Ablation of Primary Truncal Varicose Veins Compared to Existing Endovenous Techniques: A Systematic Review of the Literature.

Introduction One-third of adults in the United States and United Kingdom suffer from varicose veins. n -butyl-2-cyanoacrylate (NBCA) glue is a novel endovascular, nontumescent, nonthermal ablation technique for treatment of this condition. It has proved effective in multiple studies since its first use in 2013. The aim of this systematic review is to assess the efficacy of NBCA in ablating primary truncal varicose veins and eliminating reflux compared with existing endovascular techniques. Secondary outcomes include complications and quality of life. Methods PRISMA was used as a guide and studies were screened for risk of bias and methodological quality. Subjects had to be ≥18 years of age and followed-up posttreatment with color Duplex ultrasound (DUS). Eligibility criteria included saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) incompetence with reflux down truncal veins lasting >0.5 seconds on DUS interrogation and a Clinical, Etiological, Anatomical, and Pathophysiological classification of venous disorders ranging between C1 and C6. Results Out of 2,910 patients (3,220 veins) in 17 studies, 1,981 were administered NBCA, 445 radiofrequency ablation (RFA), and 484 endovenous laser ablation (EVLA) with mean procedure times of 25.7, 23.2, and 28.7 minutes, respectively. Mean recruitment period was 9 months (1-36 months) and followed-up for an average of 12.3 months (1-36 months). The majority were C2 to C3. Two-year occlusion rates were 93.7, 90.9, and 91.5% for NBCA, RFA, and EVLA, respectively. NBCA-treated patients experienced the least complications, with bruising, phlebitis, and pain being the most prevalent. Quality of life improved equally in all three modalities. Conclusion NBCA is simple to administer, safe, and effective even without compression stockings. Further studies are required to assess longer-term benefit and the effect of anticoagulation on vein obliteration.

A case report of metastatic melanoma in the popliteal fossa.

INTRODUCTION: Metastatic melanoma in the popliteal fossa is extremely rare with less than 5% of metastatic deposits from melanomas in the leg and foot draining into the popliteal region, while the majority drain to the inguinal region. If popliteal spread is clinically overlooked, it may lead to recurrence. Together with the accompanying literature review, this case report emphasises the need for thorough clinical and radiological assessment in the management of malignant melanomas of the lower extremity. PRESENTATION OF CASE: A 66-year-old gentleman presented with metastatic melanoma to the right popliteal fossa three years after the diagnosis of a primary lesion in the right mid-calf with ipsilateral inguinal lymph node metastasis for which he underwent a right wide local excision and complete groin lymph node dissection. DISCUSSION: Studies show that a lesion anywhere below the knee can metastasize to the popliteal fossa. The groin can be the primary or secondary lymphatic drainage site in conjunction with the popliteal fossa. Concurrent popliteal and inguinal drainage may either reflect two separate lymphatic channels with popliteal nodes being the primary drainage site, or a single channel which drains to the popliteal basin as an interval node. Hence, popliteal lymph nodes should be carefully assessed in distal lower extremity lesions including melanomas. Modalities to delineate lymphatic flow and identify micrometastatic deposits should be used and when metastatic popliteal disease is identified, radical popliteal dissection is advised. CONCLUSION: Proper clinical assessment, good surgical technique, a high index of suspicion, and active surveillance are all essential to ensure early detection of metastasis to the popliteal region.

Unusual site for primary arterio-enteric fistula resulting in massive upper gastrointestinal bleeding - A case report on presentation and management.

INTRODUCTION: Communications between an artery and the bowel are termed arterio-enteric fistulae. These are uncommon and mainly involve the aorta and duodenum. They can cause fatal haemorrhage. A primary aorto-enteric fistula has several aetiologies, one of which is post-radiotherapy. CASE REPORT: 75-year old gentleman presented with acute upper gastrointestinal bleeding and haemorrhagic shock. He had a past history of right colonic cancer treated by resection and radiotherapy. At emergency gastroscopy he became critically unstable and the procedure was unsuccessful to achieve haemostasis. After resuscitation, a CT angiogram confirmed a right ilio-duodenal fistula between the right common iliac artery and duodenum. Interventional radiology was performed and a covered stent was inserted in the right common iliac artery. The patient recovered and was subsequently discharged from hospital. Three months later, he presented once again with similar massive haematemesis. Despite all efforts to stabilise him, he passed away a few hours after this second admission. DISCUSSION: This case highlights what could possibly be a limitation of interventional radiology in providing definitive treatment for such a presentation. There are no set guidelines for the management of bleeding aorto-duodenal fistulae and literature is scarce. This makes it difficult to treat and the outcome is relatively unpredictable. CONCLUSION: While minimally invasive radiological techniques are invaluable in many areas and life-saving in countless emergency bleeds, cases like these should ideally not be treated by stenting alone. It would be wise to follow arterio-enteric fisula bleeds by definitive open surgical repair.