Frailty Assessment in Vascular OUtpatients Review (FAVOUR) protocol: single-centre prospective cohort study comparing feasibility and prognostic value of commonly used frailty assessment tools.

INTRODUCTION: Frailty has consistently demonstrated associations with poorer healthcare outcomes. Vascular guidelines have recognised the importance of frailty assessment. However, an abundance of frailty tools and a lack of prospective studies confirming suitability of routine frailty assessment in clinical practice has delayed the uptake of these guidelines. The Frailty Assessment in Vascular OUtpatients Review study speaks to this evidence gap. The primary aim is to assess feasibility of implementing routine frailty assessment in a reproducible outpatient setting. Secondary objectives include comparing prognostic values and interuser agreement across five frailty assessment tools. METHODS AND ANALYSIS: This single-centre prospective cohort study of feasibility is conducted in a rapid-referral vascular surgery clinic, serving a population of 2 million. Adults with capacity (>18 years), attending a clinic for any reason, are eligible for inclusion. Five assessments are completed by patient (Rockwood Clinical Frailty Scale (CFS) and Frail NonDisabled Questionnaire), clinician (CFS, Healthcare Improvement Scotland FRAIL tool and 'Initial Clinical Evaluation') and researcher (11-item modified Frailty Index). Consistent with feasibility objectives, outcome measures include recruitment rates, frailty assessment completion rates, time-to-complete assessments and interuser variability. Electronic follow-up at 30 days and 1 year will assess home-time and mortality as prognostic indicators. Patients treated surgically/endovascularly will undergo additional 30-day and 1-year postoperative follow-up, outcome measures include: surgical procedure, mortality, complications (according to Clavien-Dindo Classification), length of stay, readmission rates, non-home discharge, home-time, higher social care requirements on discharge and amputation-free survival. Prognostic value will be compared by area under receiver operating characteristic curves. Continuous outcome variables will be analysed using Spearman's rank correlation coefficient. Interuser agreement will be compared by percentage agreement in Cohen's kappa coefficient.  ETHICS AND DISSEMINATION: The study is sponsored by National Health Service Greater Glasgow and Clyde (R&IUGN23CE014). London-Riverside REC (23/PR/0062) granted ethical approval. Results will be disseminated through publication in peer-reviewed vascular surgery and geriatric medicine themed journals and presentation at similar scientific conferences. TRIALS REGISTRATION NUMBER: NCT06040658. Stage of study: pre-results.

A systematic review of frailty assessment tools used in vascular surgery research.

OBJECTIVE: Frailty is common in vascular patients and is recognized for its prognostic value. In the absence of consensus, a multitude of frailty assessment tools exist. This systematic review aimed to quantify the variety in these tools and describe their content and application to inform future research and clinical practice. METHODS: Multiple cross-disciplinary electronic literature databases were searched from inception to August 2022. Studies describing frailty assessment in a vascular surgical population were eligible. Data extraction to a validated template included patient demographics, tool content, and analysis methods. A secondary systematic search for papers describing the psychometric properties of commonly used frailty tools was then performed. RESULTS: Screening 5358 records identified 111 eligible studies, with an aggregate population of 5,418,236 patients. Forty-three differing frailty assessment tools were identified. One-third of these failed to assess frailty as a multidomain deficit and there was a reliance on assessing function and presence of comorbidity. Substantial methodological variability in data analysis and lack of methodological description was also identified. Published psychometric assessment was available for only 4 of the 10 most commonly used frailty tools. The Clinical Frailty Scale was the most studied and demonstrates good psychometric properties within a surgical population. CONCLUSIONS: Substantial heterogeneity in frailty assessment is demonstrated, precluding meaningful comparisons of services and data pooling. A uniform approach to assessment is required to guide future frailty research. Based on the literature, we make the following recommendations: frailty should be considered a continuous construct and the reporting of frailty tools' application needs standardized. In the absence of consensus, the Clinical Frailty Scale is a validated tool with good psychometric properties that demonstrates usefulness in vascular surgery.

Anesthetic, Sedation, and Analgesic Technique for Successful Local Anesthetic EndoSuture Aneurysm Repair.

Purpose: We aimed to describe our technique for and experience with elective endovascular aneurysm repair using EndoAnchors under local anesthesia. Materials and Methods: We included seven patients with abdominal aortic aneurysms who underwent endovascular aneurysm repair using EndoAnchors with a standard regimen consisting of local anesthesia, intravenous sedation, and analgesia. The procedural and follow-up details were retrospectively reviewed. Results: Six out of seven infrarenal abdominal aortic aneurysms were successfully treated with endovascular aneurysm repair using primary EndoAnchors under local anesthesia. One patient was converted to general anesthesia due to acute aneurysm thrombosis independent of EndoAnchor deployment during the procedure. Remifentanyl infusions of up to 3.2 mg/min, morphine doses up to 6 mg (median, 0.5 mg), and midazolam doses of up to 4 mg (mean, 1.4 mg) were used. The mean theater time was 83 minutes (range, 60-130 minutes). Two patients were discharged on day 0, and the mean hospital stay was one day. All patients were alive between 484 and 1,128 days post-procedure, with no aneurysm-specific reintervention. Conclusion: The combination of local anesthesia, intravenous sedation, and analgesia is a viable strategy for timely and effective endovascular aneurysm repair using EndoAnchors. This technique may allow endovascular repair of more ruptured aneurysms using EndoAnchors with potential survival benefits.

The impact of renal artery stenting on therapeutic aims.

Renal artery stenosis manifests as poorly-controlled hypertension, impaired renal function or pulmonary oedema, therefore the success of treatment is dependent on indication. This study aims to determine the outcomes of patients undergoing renal artery stenting (RASt) based on therapeutic aim compared to criteria used in the largest randomised trial. Retrospective case-note review of patients undergoing RASt between 2008-2021 (n = 74). The cohort was stratified by indication for intervention (renal dysfunction, hypertension, pulmonary oedema) and criteria employed in the CORAL trial, with outcomes and adverse consequences reported. Intervention for hypertension achieved significant reduction in systolic blood pressure and antihypertensive agents at 1 year (median 43 mmHg, 1 drug), without detrimental impact on renal function. Intervention for renal dysfunction reduced serum creatinine by a median 124 µmol/L, sustained after 6 months. Intervention for pulmonary oedema was universally successful with significant reduction in SBP and serum creatinine sustained at 1 year. Patients who would have been excluded from the CORAL trial achieved greater reduction in serum creatinine than patients meeting the inclusion criteria, with equivalent blood pressure reduction. There were 2 procedure-related mortalities and 5 procedural complications requiring further intervention. 5 patients had reduction in renal function following intervention and 7 failed to achieve the intended therapeutic benefit. Renal artery stenting is effective in treating the indication for which it has been performed. Previous trials may have underestimated the clinical benefits by analysis of a heterogenous population undergoing a procedure rather than considering the indication, and excluding patients who would maximally benefit.

Pre-emptive or reactive treatment, angioplasty or stent-graft? The outcome for interventions for venous stenosis in early-cannulation arteriovenous grafts.

BACKGROUND: Early-cannulation arteriovenous grafts (ecAVG) have good initial patency, but frequent episodes of reintervention for venous stenosis (VS) and thrombosis limit their use. Stent grafts (SG) have shown promise in reducing re-interventions and improving functional patency for dysfunctional ecAVG and recurrent VS. There is little data on the impact of stent grafts as the first elective procedure for VS. The aim of this study was to determine firstly, if treating VS whilst asymptomatic has a better outcome than treating after presentation with thrombosis; and secondly, to determine the best initial treatment for asymptomatic VS: SG or angioplasty. METHODS: A retrospective study was performed of 259 ecAVG with a sutured anastomosis. The case-mix and outcomes of 153 who presented with VS was analysed by presentation (elective at surveillance or emergency following thrombosis), and then for only elective patients, by treatment (SG vs angioplasty). RESULTS: There was no significant difference in case-mix and time to presentation by mode of presentation (100 elective and 53 with thrombosis) other than a higher rate of pro-thrombotic disorders in thrombosed ecAVG. Thrombosed ecAVG had poorer outcomes with increased re-intervention rates and thrombosis in the following year, and reduced long-term functional patency. In patients presenting electively, primary SG rather than angioplasty led to significantly reduced thrombosis rates, a longer time to re-intervention in the following year, and superior long-term functional patency. The use of SG was the same in both groups. Both the mode of presentation and the type of intervention performed were independently predictive of a poorer subsequent functional patency. CONCLUSIONS: Primary elective stent-grafting may be the optimal strategy to reducing maintenance costs with ecAVG.

Dysregulation of Connexin Expression Plays a Pivotal Role in Psoriasis.

BACKGROUND: Psoriasis, a chronic inflammatory disease affecting 2-3% of the population, is characterised by epidermal hyperplasia, a sustained pro-inflammatory immune response and is primarily a T-cell driven disease. Previous work determined that Connexin26 is upregulated in psoriatic tissue. This study extends these findings. METHODS: Biopsies spanning psoriatic plaque (PP) and non-involved tissue (PN) were compared to normal controls (NN). RNA was isolated and subject to real-time PCR to determine gene expression profiles, including GJB2/CX26, GJB6/CX30 and GJA1/CX43. Protein expression was assessed by immunohistochemistry. Keratinocytes and fibroblasts were isolated and used in 3D organotypic models. The pro-inflammatory status of fibroblasts and 3D cultures was assessed via ELISA and RnD cytokine arrays in the presence or absence of the connexin channel blocker Gap27. RESULTS: Connexin26 expression is dramatically enhanced at both transcriptional and translational level in PP and PN tissue compared to NN (>100x). In contrast, CX43 gene expression is not affected, but the protein is post-translationally modified and accumulates in psoriatic tissue. Fibroblasts isolated from psoriatic patients had a higher inflammatory index than normal fibroblasts and drove normal keratinocytes to adopt a "psoriatic phenotype" in a 3D-organotypic model. Exposure of normal fibroblasts to the pro-inflammatory mediator peptidoglycan, isolated from Staphylococcus aureus enhanced cytokine release, an event protected by Gap27. CONCLUSION: dysregulation of the connexin26:43 expression profile in psoriatic tissue contributes to an imbalance of cellular events. Inhibition of connexin signalling reduces pro-inflammatory events and may hold therapeutic benefit.

Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis.

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

Endovascular salvage of an aortic anastomotic pseudoaneurysm following deep vein reconstruction.

Aortoiliac reconstruction using autologous deep femoral vein (neoaortic iliac system bypass [NAIS]) is a therapeutic option for management of prosthetic aortic graft infection. Complications after NAIS are complex and reported management strategies few. Endovascular procedures offer a minimally invasive alternative to high-risk, complex open surgery. We report a case of early aortic anastomotic failure after NAIS associated with a pseudoaneurysm and significant retroperitoneal hemorrhage, which was successfully treated by endovascular stent grafting.

Thrombolysis for acute graft occlusion during elective endovascular aortic aneurysm repair.

A 65-year-old man developed acute arterial thrombosis with stent graft occlusion, during elective endovascular aneurysm repair, with bilateral acute lower limb ischaemia. We describe successful endovascular and pharmacological management using a combination of mechanical disruption of the thrombus (using the access sheaths) followed by intra-arterial thrombolysis (Actilyse) infusion. Within 4-h the endograft had completely re-canalized. The patient made an uncomplicated recovery and was discharged on the second post-operative day.

Pulmonary hypertension and severe right heart failure following lumbar spinal surgery.

Pulmonary hypertension is a disease process affecting the pulmonary circulation and is defined by an increase in pulmonary artery pressure subsequently causing right ventricular failure. Vascular complications, including arteriovenous fistulae, are recognised, but are uncommon complications of spinal surgery. Arteriovenous fistulae increase venous return to the right heart and can induce a high-output cardiac state, mimicking pulmonary arterial hypertension and right heart failure. We present a 47-year-old man with a 1 year history of worsening dyspnoea, exertional pre-syncope and leg swelling presenting with severe right heart failure. The previous year, he had complex spinal surgery, which included discectomy, laminectomy and bilateral nerve reconstruction at L5-S1 level. Initial non-invasive investigations including echocardiography and chest imaging raised the possibility of right heart failure presumed secondary to pulmonary vascular disease. Clinical examination and right heart catheterisation were in keeping with a high cardiac output state, and invasive saturation monitoring was suggestive of a sub-diaphragmatic shunt. Subsequent imaging confirmed the presence of an iatrogenic ilio-iliac arteriovenous fistula. The patient underwent urgent endovascular repair, which resulted in resolution of his symptoms and haemodynamics. We describe the case and present a review of the relevant literature.

Changes in the demographics of intravenous drug users with mycotic common femoral artery pseudoaneurysm as a consequence of self-injection does not influence outcome following emergency ligation.

Objectives The reported annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users has been estimated at 0.03%. Over the past 5 years in Scotland, the proportion of people receiving specialist attention for heroin use over the age of 40 years has increased from 15 to 22%. Although routinely managed with arterial ligation (without reconstruction), some series have reported rates of major limb amputation of up to 10%. We sought to define whether this management strategy was still acceptable in an older population. Methods Retrospective review of patients presenting to a tertiary vascular service with mycotic pseudoaneurysm of the common femoral artery due to arterial injection by intravenous drug users between October 2010 and March 2016. Variables of interest included patient demographics and requirement for major amputation. Results There were 55 patients identified. The annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users was 2.1%. It was more common in men (3:1) and the mean age at presentation was 41 years (standard deviation ± 8 years). Three patients underwent major limb amputation during the index admission for severe limb ischaemia (two transfemoral amputations; one hip-disarticulation). Following discharge two patients were readmitted (134 and 200 days, respectively, following primary ligation) for major limb amputation due to of critical limb ischaemia. Conclusions Despite the increasing age of intravenous drug users presenting with mycotic pseudoaneurysm of the common femoral artery primary ligation of pseudoaneurysm would seem to remain an appropriate therapeutic intervention.

Metastatic Angiosarcoma Presenting as Ischemic Anterior Circulation Stroke.

BACKGROUND: Angiosarcoma is a rare malignant neoplasm that can arise from vascular endothelium. We report a case of angiosarcoma that presented as thromboembolic stroke, review the current literature, and discuss the management challenges. CASE REPORT: A 77-year-old man presented with a right anterior circulation stroke with a history of multiple, recent transient ischemic attacks. The diagnosis was confirmed on computed tomography and subsequent investigation revealed thrombus within the distal common carotid artery, with an atherosclerotic plaque causing a significant stenosis of the origin of the internal carotid artery above this. In the context of the presentation with recurrent events, carotid endarterectomy was recommended and subsequently performed. At the time of surgery, the common, internal, and external carotid arteries had macroscopic evidence of atherosclerotic disease but appeared otherwise normal. Intraoperatively friable thrombus adherent to the common carotid endothelium was retrieved and sent for histologic assessment. Subsequent immunohistochemistry evaluation revealed changes pathognomic with angiosarcoma. RESULTS: It is unclear in this case whether the pathology originated in the carotid artery or was the result of embolization from a proximal source. There was no extraluminal carotid pathology identified at the time of surgery, and no abnormalities identified on cross-sectional imaging. Similarly, there was no evidence of a proximal source that may have resulted in tumor embolization. As such, it has proved impossible to define an optimal therapeutic pathway for this patient.

Contemporary treatment for critical ischemia: the evidence for interventional radiology or surgery.

This article is a review of the evidence regarding the management of patients with critical limb ischemia. The aim of the study is to discuss the definition, incidence, and clinical importance of critical limb ischemia, as well as the aims of treatment in terms of quality of life and limb salvage. Endovascular and surgical treatments should not be viewed as competing therapies. In fact, these are complementary techniques each with strengths and weaknesses. The authors will propose a strategy based on the available evidence for deciding the optimal approach to management of patients with critical limb ischemia.

Using centrally held data to validate carotid surgery outcome data.

BACKGROUND AND PURPOSE: Outcome audit data for peer group comparison must be transparent, objective, and independently reproducible. Personal data sets are difficult to maintain and often lack complete follow-up. Local coding difficulties make initial retrieval of centrally held data unreliable. However starting with a complete list of interventions, reliable identification of patients who have experienced an adverse postoperative event may be possible using record linkages. METHODS: A surgical database, augmented by a hand-search of all theater registries and personal logbooks, identified 378 carotid endarterectomies performed for stroke prevention in symptomatic patients, in a single hospital between 2002 and 2009. A list of the names, unique patient identifiers, and operation dates was sent to the Information Services Division of National Health Service Scotland. Data were requested pertaining to all deaths and potential diagnoses of stroke after surgery. Every identified case was scrutinized. RESULTS: There were 30 (8%) readmissions or transfers of care identified within 30 days of surgery. From this, 12 strokes were identified with another 2 strokes, occurring without readmission, diagnosed in the outpatient clinic. Only 6 of the postoperative strokes were identified during the index admission. There were 2 early deaths resulting in a combined stroke and death rate of 4.2% (95% confidence intervals, 2.4%-6.9%). CONCLUSIONS: These outcome data are similar to the outcomes of the major carotid surgery trials. Record-linked data retrieval seems to be an appropriate starting point for outcome-based audit. This has the potential to generate robust, transparent data for comparison between individuals and centers for a specific procedure.

Nail gun injuries to the hand.

BACKGROUND: Aberdeen Royal Infirmary is a teaching hospital serving a population of over 500,000. A number of nail gun injuries to the hand prompted a review of our management of these injuries and a review of the literature. These are deep penetrating injuries, often contaminated by particles of skin, oil, paper or glue, or caused by nails that are barbed. METHODS: Fifty-five cases of nail gun injury to the hand were reviewed in a retrospective study of injuries presenting to the hospital between January 2000 and June 2004. RESULTS: The population at risk is almost entirely men and involved in the construction industry. Twenty-five percent of cases were found to have tendon, nerve or joint involvement at operation. None of the injuries required anything more than meticulous wound toilet. CONCLUSIONS: To our knowledge, this is the first large study to clinically document the actual hand injuries caused by nail guns. An analysis of our treatment patterns suggests a low risk from surgical exploration with several potential benefits.