Moving forward with elective vascular work: a reflection on the impact of COVID-19 on a regional vascular hub.

INTRODUCTION: Following the initial COVID-19 surge in the UK, there was a national incentive for elective vascular surgery to be restricted to 'clean' sites to reduce perioperative cross-infection and subsequent mortality. We assessed the risk of dying from perioperatively acquired COVID-19 during the peak of the London outbreak. METHODS: Forty-three consecutive patients who had vascular (n=48) procedures in March and April 2020 at a regional hub serving five London hospitals were analysed. The patients were screened for COVID-19 in the 30-day postoperative period and the main outcome measure was mortality from COVID-19. A comparison was then made with patients who underwent minimally invasive procedures in our integrated interventional radiology department. Median follow-up was 41 days (interquartile range 8-58) overall. RESULTS: Three patients (7%) in the vascular group (median age 61 years, all diabetic, two male) died from COVID-19, all of whom tested positive postoperatively. Two others became positive but recovered. In comparison, two patients (2%) in the interventional radiology group died from COVID-19; however, one was positive prior to their procedure. CONCLUSION: Only urgent vascular cases should be performed during a COVID-19 surge. However, with growing waiting lists for elective surgery following the pandemic's second wave, further restrictions may not be a viable long-term solution. When prevalence of the disease is lower and if resources allow, resumption of care at 'hot' sites should be considered, if safety measures can be implemented. The advantages of minimally invasive surgery may also reduce risk.

Propionibacterium acnes endocarditis: a case series.

OBJECTIVES: Propionibacterium acnes remains a rare cause of infective endocarditis (IE). It is challenging to diagnose due to the organism's fastidious nature and the indolent presentation of the disease. The purpose of this study was to describe the clinical presentation and management of P. acnes IE with an emphasis on the methods of diagnosis. METHODS: We identified patients from the Cleveland Clinic Infective Endocarditis Registry who were admitted from 2007 to 2015 with definite IE by Duke Criteria. Propionibacterium acnes was defined as the causative pathogen if it was identified in at least two culture specimens, or identified with at least two different modalities: blood culture, valve culture, valve sequencing or histopathological demonstration of microorganisms. RESULTS: We identified 24 cases of P. acnes IE, 23 (96%) of which were either prosthetic valve endocarditis or IE on an annuloplasty ring. Invasive disease (71%) and embolic complications (29%) were common. All but one patient underwent surgery. Propionibacterium acnes was identified in 12.5% of routine blood cultures, 75% of blood cultures with extended incubation, 55% of valve cultures, and 95% of valve sequencing specimens. In 11 of 24 patients (46%), no causative pathogen would have been identified without valve sequencing. CONCLUSIONS: Propionibacterium acnes almost exclusively causes prosthetic valve endocarditis and patients often present with advanced disease. The organism may not be readily cultured, and extended cultures appear to be necessary. In patients who have undergone surgery, valve sequencing is most reliable in establishing the diagnosis.

Modified Sandwich-graft Technique Employing Aorfix and Viabahn Stent-grafts to Preserve Hypogastric Flow in Cases of Complex Aortoiliac and Isolated Common Iliac Artery Aneurysms Including the Internal Iliac Artery Ostium.

OBJECTIVE: The aim was to assess the early and mid-term safety and clinical outcomes of a modified sandwich-graft technique (MSGT) that employed the Aorfix and Viabahn stent-grafts to preserve hypogastric flow in cases of complex aortoiliac and isolated common iliac artery (CIA) aneurysms including internal iliac artery (IIA) ostium who were not suitable for an iliac branch device (IBD). METHODS: A review of prospective collected data of all consecutive cases of treatment of complex aortoiliac or isolated CIA aneurysms including IIA ostium using the MSGT to preserve the hypogastric flow in three European centres between April 1, 2010, and December 31, 2013, was performed. All patients included were unfit for open repair and not suitable for an IBD. RESULTS: During the study period, 21 patients met the study criteria and had 25 MSGTs. The mean follow-up duration was 17.2 months. The technical success rate was 100%, with no perioperative mortality and stent-graft or MSGT-treated IIA occlusions. There were two cases with Type Ib endoleaks and one Type III endoleaks intraoperatively that were successfully managed. There was also no reported early and late pelvic ischaemia. The primary patency rate was 90.5%, and two cases of MGST treated IIA occlusions with no reported symptoms of pelvic ischaemia during follow-up. CONCLUSIONS: MSGT was a safe and feasible strategy to preserve hypogastric flow in cases of complex aortoiliac and isolated CIA aneurysms including IIA ostium and who were not suitable for IBD, with encouraging early and mid-term outcomes.

Day-case inguinal hernia repair in the elderly: a surgical priority.

PURPOSE: To compare patients over 70 years old with those under 50 years old undergoing inguinal hernia repair. PATIENTS AND METHODS: Fifty patients aged >70 years (group A) and 50 patients age <50 years (group B) underwent local anaesthetic mesh repair. The mean age for group A was 77.2 years (range 70-85) and for group B it was 40.2 years (range 17-49). There were 46 patients with comorbidities in group A and seven in group B. There were 30 patients with cardiac comorbidities in group A and two in group B. RESULTS: There were no major complications, infections, haematomas or unplanned admissions in either group. Patients >70 years of age had less post-operative discomfort and recovered more quickly than patients aged <50 years. The number of days of analgesic use and time to return to normal activities was longer in the younger group, 6.0 versus 3.4 and 21 versus 13, respectively. There was no significant difference between the groups in patients having discomfort at 3 months post-operatively. More patients were satisfied in the older group, though the difference was not statistically significant. CONCLUSION: Elective inguinal hernia repair under local anaesthetic in the elderly has a good outcome, even if there are significant comorbidities. Ambulatory surgery is feasible in this age group and age alone or co-existing disease should not be a barrier to elective day-case inguinal hernia repair.

Current management of popliteal fossa incompetent superficial venous systems.

OBJECTIVES: Controversy exists regarding the management of varicose veins at the level of the popliteal fossa. This questionnaire reviews the current practice of vascular surgeons. METHODS: A postal questionnaire was sent to 440 consultant surgeon members of the Vascular Society of Great Britain and Ireland. Recipients were asked to indicate their current practice of investigation and management of small saphenous (SSV), gastrocnemius and Giacomini varicosities. RESULTS: We have received 296 (67%) responses to the questionnaire. Duplex scanning is utilized by 275 (93%) for the initial assessment of patients. Preoperatively, 188 (64%) reuse duplex scanning to mark the saphenopopliteal junction (SPJ) site, 53 (18%) mark with hand-held Doppler only and 24 (8%) do not mark the SPJ. At operation, 198 (67%) flush ligate the SPJ and 87 (29%) tie the SSV 2-3 cm from the junction. A total of 101 (34%) usually strip the SSV to various levels. In symptomatic patients, 158 (53%) ligate the SPJ when an incompetent segment of SSV with a competent SPJ exists. One hundred and sixty-nine (57%) disconnect incompetent gastrocnemius veins during SPJ surgery and 172 (58%) regularly look for the Giacomini vein. Routine follow-up after surgery is practised by 172 (58%), most commonly at six weeks. This is mostly (88%) by clinical examination, with 14 (8.1%) using duplex scanning and six (4.7%) using a nurse-run clinic for the follow-up. CONCLUSIONS: This review suggests marked variation in the management of popliteal fossa venous incompetence. There is a clear need for further research to clarify the role of ablation in the management of symptoms and skin changes.

Can preoperative duplex marking of the saphenopopliteal junction be avoided?

OBJECTIVES: Patients undergoing saphenopopliteal junction (SPJ) surgery are currently subjected to two duplex scans. The first is to confirm the reflux, and the second is done preoperatively to accurately mark the SPJ for surgery. The aim of this study was to assess whether the use of hand-held Doppler (HHD) can substitute the second duplex scan. METHODS: Sixty limbs with suspected SPJ reflux were studied. Patients underwent an initial duplex scan. The report detailed the position of SPJ in relation to popliteal crease. Guided by this, a HHD was then used to mark the SPJ. Deviation of the HHD mark from the duplex one of < or =10 mm was considered acceptable for surgical accuracy. RESULTS: HHD accurately localized all 27 patients with SPJ reflux (100% accuracy). The distances between the HHD and duplex points in this group ranged between 0 and 5 mm (median=0). Twenty-five patients had SPJ with no reflux, and 22 of them were accurately localized (88%). The distances between the two points in the latter group ranged between 0 and 16 mm (median=3). CONCLUSION: HHD, guided by the routine duplex scan, can accurately mark SPJ with reflux. A second duplex is not required for marking prior to surgery. This will reduce the workload of the vascular laboratory.

The case for saphenous ablation versus simple proximal ligation.

New modalities of treatment for primary varicose veins are being increasingly used. This is because traditional stripping and sapheno-femoral junction ligation is requires a general anaesthetic and is associated with postoperative pain and bruising. This article aims to address the evidence and long-term follow up of the new surgical techniques and compare them to traditional sapheno-femoral ligation.

Aortic aneurysm replacement with Dacron graft in a 34 year old man. How long will the graft last?

A unique case of an abdominal aortic aneurysm replacement in a young man of Caribbean descent is presented. The initial working diagnosis was of a mycotic aneurysm, which has recently shown resurgence with intravenous drug abuse. Blood tests and subsequent biopsy ruled that out. There was also a clinical suspicion of a connective tissue abnormality. Histological examination of the aneurysm, skin biopsy, and blood tests also ruled out this possibility. The graft used in this patient was from a new generation of grafts. In the absence of any studies on such grafts, there is the question of long term durability of the graft.

Vestibular evidence for the evolution of aquatic behaviour in early cetaceans.

Early cetaceans evolved from terrestrial quadrupeds to obligate swimmers, a change that is traditionally studied by functional analysis of the postcranial skeleton. Here we assess the evolution of cetacean locomotor behaviour from an independent perspective by looking at the semicircular canal system, one of the main sense organs involved in neural control of locomotion. Extant cetaceans are found to be unique in that their canal arc size, corrected for body mass, is approximately three times smaller than in other mammals. This reduces the sensitivity of the canal system, most plausibly to match the fast body rotations that characterize cetacean behaviour. Eocene fossils show that the new sensory regime, incompatible with terrestrial competence, developed quickly and early in cetacean evolution, as soon as the taxa are associated with marine environments. Dedicated agile swimming of cetaceans thus appeared to have originated as a rapid and fundamental shift in locomotion rather than as the gradual transition suggested by postcranial evidence. We hypothesize that the unparalleled modification of the semicircular canal system represented a key 'point of no return' event in early cetacean evolution, leading to full independence from life on land.

Skeletons of terrestrial cetaceans and the relationship of whales to artiodactyls.

Modern members of the mammalian order Cetacea (whales, dolphins and porpoises) are obligate aquatic swimmers that are highly distinctive in morphology, lacking hair and hind limbs, and having flippers, flukes, and a streamlined body. Eocene fossils document much of cetaceans' land-to-water transition, but, until now, the most primitive representative for which a skeleton was known was clearly amphibious and lived in coastal environments. Here we report on the skeletons of two early Eocene pakicetid cetaceans, the fox-sized Ichthyolestes pinfoldi, and the wolf-sized Pakicetus attocki. Their skeletons also elucidate the relationships of cetaceans to other mammals. Morphological cladistic analyses have shown cetaceans to be most closely related to one or more mesonychians, a group of extinct, archaic ungulates, but molecular analyses have indicated that they are the sister group to hippopotamids. Our cladistic analysis indicates that cetaceans are more closely related to artiodactyls than to any mesonychian. Cetaceans are not the sister group to (any) mesonychians, nor to hippopotamids. Our analysis stops short of identifying any particular artiodactyl family as the cetacean sister group and supports monophyly of artiodactyls.

An observational study of 256 cases of vascular trauma in the north western province of Pakistan.

During the past 10 years Peshawar has dealt with increasing casualties with penetrating trauma inflicted by a wide variety of missiles. The aim of this study was to assess whether delay in arrival and mode of presentation affects the outcome of patients with penetrating vascular trauma. Prospective data were collected on 256 vascular injuries in 248 patients (median age, 29 years; range, 7-60 years) between January 1995 and June 1998. Early presentation (group A, 55 cases, < 12 h) was compared with late presentation (group B, 201 cases, > 12 h). The majority of injuries (93%) were caused by fire-arms. Arterial injuries accounted for 71% of the total, venous injuries accounted for 10% and 19% were mixed. The site of injury was the lower limb (61%), upper limb (32%), abdominal cavity (5%) and neck (2%). Patients presented with absent pulses (56%), haemorrhage (46%), false aneurysms (8%), A-V fistula (5%) and 11% presented with more than one sign. There were significantly more lower limb amputations in group A than group B (23% versus 5%; P < 0.05), with fractures having a positive association with lower limb amputations (odds ratio, 0.32; 95% CI, 0.13-0.94; P < 0.05). Group A had a higher mortality than group B (18% versus 7%; P < 0.05). This study shows that patients with vascular trauma can be managed successfully with clinical assessment alone. Patients with fractures were more likely to suffer eventually from lower limb loss. Due to self-selection, arrival at the hospital less than 12 h after sustaining vascular injury was associated with a higher mortality than those presenting after 12 h.

Blood flow measurements in lower limb arteries using duplex ultrasound.

The increase in blood flow in exercise is to provide more oxygen to tissues. The kinetics of flow at the common femoral artery bifurcation were established in normal subjects together with its relationship with oxygen uptake. Furthermore, the changes in flow were evaluated in patients undergoing superficial femoral artery angioplasty. After a known anaerobic test (Wingate test), normal subjects underwent a preferential increase in profunda femoris artery flow (ninefold increase), compared with superficial femoral artery flow (fourfold increase), indicating predominantly thigh exercise. The relationship between oxygen uptake and lower limb blood flow was studied before, during and after moderate intensity exercise. Oxygen uptake was measured by mass spectrometry and assessed by breath-by-breath analysis. The rate of increase for limb blood flow, as indicated by the time constant, was faster (28.8 +/- 4.4 s; mean +/- sem) than oxygen uptake (41.5 +/- 7.2 s) at the onset of exercise. This implies that limb blood flow is in excess of the oxygen requirements of muscle and therefore not the critical determinant for oxygen uptake by muscle. Flow in the lower limb arteries was measured before and after superficial femoral artery angioplasty in 22 patients. In addition, collateral blood flow was estimated using a mathematical model. Follow-up was carried out to 1 year. At 1 month, a significant decrease in profunda femoris artery flow (from 224 +/- 84 to 98 +/- 43 ml min-1, P < 0.05, paired t test) and a marked diminution in collateral flow (from 186 +/- 34 to 18 +/- 8 ml min-1, P < 0.05) was noted with no change in total limb blood flow. As expected, a significant increase in superficial femoral artery blood flow was seen (148 +/- 79 to 312 +/- 94 ml min-1, P < 0.05). From the studies, it can be seen that non-invasive duplex ultrasound flow measurements can reliably be obtained in the lower limb, allowing the kinetics of flow after exercise and the changes in flow after surgical intervention to be evaluated. This work provides a foundation for the study of oxygen kinetics and limb blood flow in athletes, the elderly and patients with peripheral vascular disease.