Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications.

OBJECTIVES: Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. METHODS: This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. RESULTS: After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%. CONCLUSION: To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.

Are venous thromboembolism risk assessment tools reliable in the stratification of microvascular risk following lower extremity reconstruction?

INTRODUCTION: The incidence of flap failure is significantly higher in the lower extremity compared to free tissue transfer in the head, neck and breast. The most common cause of flap failure is venous thrombosis. The aim of this study was to assess the reliability of venous thromboembolism (VTE) risk assessment tools in this high-risk cohort and to assess the ability of such tools to identify patients at risk of developing microvascular venous thrombosis and venous thromboembolism following lower extremity free flap reconstruction. METHODS: A single centre retrospective cohort study was conducted between August 2012-August 2019. Adult patients who had undergone free tissue transfer following open lower extremity fractures were eligible for inclusion. All patients were retrospectively risk assessed using the Department of Health (DoH), Modified Caprini and Padua VTE risk assessment tools. RESULTS: Fifty-eight patients were included; all were at high risk of DVT according to the DoH (mean score ± SD, 3.7 ± 0.93), Caprini (10.2 ± 1.64) and Padua (5.4 ± 0.86) risk assessment tools. All patients received appropriate thromboprophylaxis; the incidence of symptomatic hospital acquired VTE was 3.5%. Micro-anastomotic venous thrombosis occurred in 4 patients resulting in one amputation. Partial flap necrosis occurred in 7 patients. There were no significant differences in scaled Caprini (median score, 10 vs 9, z = 1.289, p = 0.09), DoH (3 vs 3, z = 0.344, p = 0.36), and Padua (5 vs 5.5, z= -0.944, p = 0.17) scores between those with and without microvascular venous thrombosis. CONCLUSION: This data suggests that current VTE risk assessment tools do not predict risk of microvascular venous thrombosis following lower extremity reconstruction. Further prospective studies are required to optimise risk prediction models and thromboprophylaxis use in this cohort.

Lower extremity arterial interventions in England.

INTRODUCTION: The increasing prevalence of diabetes mellitus and advances in endovascular therapies continue to have an impact on the epidemiology and management of lower extremity arterial disease. This study describes trends in lower extremity revascularisation and major lower limb amputation in NHS England over the past two decades (2000-2019). METHODS: Numbers of lower extremity endovascular interventions, open surgical procedures and major lower limb amputations performed in NHS England between 2000 and 2019 were extracted from publicly available hospital admitted patient care activity reports. Trends in intervention were assessed with linear regression models and chi-square tests for trend. RESULTS: Over this period, 527,131 revascularisations and 92,053 amputations were performed. The mean age of patients was 67.5 years (standard deviation 1.6 years) and 65.3% were male. The number of lower limb revascularisation procedures increased by 402.4 units/year (95% confidence interval, CI, 290.1-514.6, p < 0.001). The number of endovascular interventions rose by 43.5% (10,912 in 2000 vs 15,657 in 2019; ß = 359.5.0, 95% CI 279.3-439.8, p < 0.001) compared with no significant increase in the number of open surgical procedures (8,483 in 2000 vs 7,872 in 2019; ß = 42.8, 95% CI -8.3 to 94.0, p = 0.095). The number of major lower limb amputations has decreased by 9.4% (5,418 in 2000 vs 4,907 in 2019; ß = -31.0; 95% CI -49.6 to -12.5, R2 = 0.42, p = 0.003). CONCLUSIONS: There has been a significant increase in the rate of lower limb revascularisation procedures associated with decreased numbers of major lower limb amputations over the past two decades. These changes in overall trends may affect both service provision and vascular surgery training planning.

Surgical and non-surgical approaches in the management of lower limb post-thrombotic syndrome.

Introduction: Post-thrombotic syndrome (PTS) is a common lifelong condition affecting up to 50% of those suffering from deep vein thrombosis (DVT). PTS compromises function and quality of life with subsequent venous ulceration in up to 29% of those affected.Areas covered: A literature review of surgical and non-surgical approaches in the prevention and treatment of PTS was undertaken. Notable areas include the use of percutaneous endovenous interventions and the use of graduated compression stockings (GCS) after acute proximal DVT.Expert opinion: In patients with acute iliofemoral DVT, we think it is important to have a frank conversation with the patient about catheter-directed thrombolysis, aiming to reduce the severity of PTS experienced. We advocate ultrasound-accelerated thrombolysis with adjunctive procedures, such as deep venous stenting for proximal iliofemoral DVT. For patients with isolated femoral DVT, we believe that anticoagulation and GCS should be recommended. In patients with established PTS, we recommend GCS for symptomatic relief. We recommend that patients engage in regular exercise where possible with the prospect of gaining symptomatic relief. For those with severe PTS that has a significant effect on quality of life, we discuss the patient's case at a multi-disciplinary team meeting to plan for endovenous intervention.

Effect of footplate neuromuscular electrical stimulation on functional and quality-of-life parameters in patients with peripheral artery disease: pilot, and subsequent randomized clinical trial.

BACKGROUND: Supervised exercise programmes for intermittent claudication have poor access and limited compliance. Neuromuscular electrical stimulation (NMES) may be an effective alternative. A proof-of-concept study and RCT were conducted. METHODS: In study 1, eligible patients underwent baseline assessment; treadmill testing for initial (ICD) and maximum (MCD) claudication distance; EuroQoL Five Dimensions five-level instrument (EQ-5D-5L™) and Intermittent Claudication Questionnaire (ICQ) assessment; and measurement of ultrasound haemodynamics of the superficial femoral artery. After familiarization with the NMES device, participants underwent a 30-min session of stimulation with concomitant recording of haemodynamic measures at 15 min, and after device cessation. Measurements were repeated after 6 weeks of daily use of NMES. In study 2, consecutive patients underwent baseline assessment before online randomization to a supervised exercise programme only, or adjunctive NMES treatment for 6 weeks, followed by repeat measurements. RESULTS: Study 1 (20 patients) showed a significant improvement in MCD (46 per cent; P < 0·001) and ICD (71 per cent; P < 0·001). The RCT (42 patients) showed a significant adjunctive benefit of NMES in ICD (46 per cent; P = 0·014). Improvements were seen in the ICQ (9 points; P = 0·009) and EQ-5D-5L™ (P = 0·007) in study 1, and there was a significant adjunctive benefit of NMES on the ICQ score in patients who did supervised exercise (11·2 points; P = 0·031). Blood volume flow and time-adjusted mean velocity increased significantly with the device on (P < 0·050). Overall, NMES compliance exceeded 95 per cent. CONCLUSION: Footplate NMES significantly improved walking distance in patients with intermittent claudication when used independently and also as an adjunct to supervised exercise. Registration number: trial 1, NCT02436200; trial 2, NCT02429310 (http://www.clinicaltrials.gov).

ANTECEDENTES: Los programas de ejercicio supervisado (supervised exercise programmes, SEP) para la claudicación intermitente (intermittent claudication, IC) tienen un acceso y un cumplimiento deficientes. La estimulación eléctrica neuromuscular (neuromuscular electrical stimulation, NMES) puede ser una alternativa clínicamente efectiva. Se realizó un estudio de prueba de concepto y un ensayo controlado aleatorizado. MÉTODOS: Estudio 1: Veinte pacientes elegibles se sometieron a una evaluación inicial que incluía una prueba en la cinta de correr para la distancia inicial de claudicación (initial claudication distance, ICD) y la distancia máxima de claudicación (maximum claudication distance, MCD), EuroQoL-5D (EQ-5D), valoración mediante el cuestionario de claudicación intermitente (intermittent claudication questionnaire, ICQ), y hemodinámica por ecografía de la arteria femoral superficial. Después de familiarizarse con el dispositivo NMES, los participantes se sometieron a una sesión de estimulación de 30 minutos con el registro concomitante de medidas hemodinámicas a los 15 minutos y después del cese del dispositivo. Se realizaron mediciones repetidas después de 6 semanas de uso diario de NMES. Estudio 2: Se reclutaron 42 pacientes que tras una evaluación inicial y posterior aleatorización al azar en línea, se asignaron al Grupo A, utilizando SEP solamente; o al el Grupo B, con tratamiento NMES complementario durante 6 semanas seguido de medidas repetidas. RESULTADOS: El estudio 1 mostró una mejoría significativa de la MCD (46%, P < 0,0001) y de la ICD (71%, P < 0.004). El ensayo clínico mostró un beneficio coadyuvante significativo de NMES en la ICD (46%, P = 0,014). Se observaron mejorías en la puntuación del ICQ (9 puntos, P < 0,01) y del EQ-5D (P < 0,05) en el estudio 1, con un beneficio coadyuvante significativo de NMES en la puntuación del ICQ (11 puntos, P < 0,05). El flujo de volumen de sangre (CC/min) y TAMV (cm/s) aumentaron significativamente con el dispositivo en funcionamiento (P < 0,05). El cumplimiento global de la NMES superó el 95%. CONCLUSIÓN: La plataforma de NMES para el pie mejora significativamente las distancias de caminar en la claudicación intermitente cuando se usa de forma independiente y también proporciona un beneficio complementario al ejercicio supervisado en la distancia caminada sin dolor. La mejora del flujo sanguíneo puede ser un mecanismo para explicar estos resultados.

Nutcracker Syndrome: An Update on Current Diagnostic Criteria and Management Guidelines.

BACKGROUND: Nutcracker syndrome (NCS) describes left renal vein compression between the superior mesenteric artery and the aorta. Although uncommon, it is an important diagnosis due to the important morbidity associated with it, including the risk of chronic kidney disease from long-term left renal vein (LRV) hypertension and the risk of LRV thrombosis. METHODS: This article reviews the literature on NCS, particularly with respect to the diagnostic accuracy of different imaging modalities and the success rates, complications, and long-term follow-up data associated with various surgical interventions. RESULTS AND DISCUSSION: The diagnosis of this condition is based on a stepwise work-up with history and clinical examination, followed by Doppler ultrasonography, computed tomography, magnetic resonance imaging, intravascular ultrasound (IVUS) and phlebography with measurement of the renocaval pressure gradient. Management is determined by symptom severity; often symptom resolution occurs following a conservative approach. However, in some cases, surgical management is required, particularly when conservative management is unsuccessful. When it comes to the surgical management of NCS three main pathways exist: open surgery, laparoscopic surgery and endovascular approaches, with the latter 2 becoming increasingly popular due to their minimal invasiveness. Additionally, cases involving the use of robotic surgery in the management of NCS have been reported. CONCLUSION: Despite the rarity of NCS, its recognition and management are important. This article has explored the evidence basis for conservative, medical and surgical options.

Factors impacting on patient perception of procedural success and satisfaction following treatment for varicose veins.

BACKGROUND: Patient-reported outcome measures (PROMs) have been collected from patients undergoing varicose vein treatments in the National Health Service since 2009. The aim of this retrospective cohort study was to examine PROMs for varicose vein interventions, characterizing factors that might predict patient-reported perception of procedural success and satisfaction. METHODS: Centrally compiled PROMs data for varicose vein procedures carried out from 2009 to 2011 were obtained from the Hospital Episode Statistics data warehouse for England. As data were not distributed normally, non-parametric statistical tests were employed. RESULTS: Data for 35 039 patient episodes (62·8 per cent women) were available for analysis. Some 23·4 per cent of patients reported a degree of anxiety or depression before treatment; a formal diagnosis of depression was present in 7·8 per cent. Quality of life, measured by generic EQ-5D-3L™ index and the Aberdeen Varicose Vein Questionnaire (AVVQ) improved after intervention by 11·7 per cent (0·77 to 0·86) and 40·1 per cent (18·95 to 11·36) respectively. No significant improvement was found in EQ-5D™ visual analogue scale scores. There was a significant improvement in self-perceived anxiety or depression after the intervention (P < 0·001, McNemar-Bowker test). Both preoperative and postoperative depression or anxiety had a statistically significant relationship with self-reported success and satisfaction (both P < 0·001, χ(2) test). CONCLUSION: This analysis of PROMs is evidence that treatment of varicose veins improves quality of life, and anxiety or depression. Preoperative and postoperative anxiety or depression scores impact on patient-perceived success and satisfaction rates.

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.

Position of the European college of phlebology.

Chronic venous disease is a common condition, bearing significant morbidity to patients. It is predicted that the population suffering from this disease will significantly increase in the coming years, with a growing demand for specialists in the field of phlebology. Training and delivery of services are highly heterogeneous in the European Union. The establishment of the European College of Phlebology marks the opportunity to address these differences from a European perspective, with the aim of providing all patients with standardised, high-quality, accessible medical care. In this paper, we review the current status of phlebology from a European and an international perspective, as well as highlighting the current and future roles of the European College of Phlebology.

A systematic review and meta-analysis on the role of varicosity treatment in the context of truncal vein ablation.

BACKGROUND: With the advent of endovenous truncal ablation under local anaesthetic for the treatment of varicose veins, the fate of varicosed tributaries has become controversial, with centres offering different timings of treatment, if offered at all. This study aims to review the literature assessing delayed and simultaneous varicosity treatment during truncal ablation. METHODS: Randomised trials and cohort studies concerning varicosity treatment timing were identified through a systematic literature search. Requirements for further treatment, quality of life and rate of venous thrombotic events were assessed for meta-analysis. RESULTS: Four studies were identified assessing need for further varicosity procedure, with no significant difference seen between simultaneous or delayed treatment (p = 0.339). Two studies assessed quality of life, with simultaneous treatment providing significantly improved outcomes at six weeks (p = 0.029) but not at 12 weeks (p = 0.283). Studies examining venous thrombotic events showed no difference in venous thromboembolism rate between simultaneous or delayed treatment approaches (p = 0.078). CONCLUSION: The evidence base regarding timing of varicosity treatment is sparse; however, it does show that simultaneous treatment of varicosities leads to early gains in quality of life, with a non-significant trend for fewer further procedures but more venous thrombotic events.

Single-port hernia repair: a prospective cohort of 102 patients.

BACKGROUND: Single-port laparoscopic surgery (SPLS) for totally extraperitoneal (TEP) groin hernia repair is a novel procedure, ensuring safe and effective repairs. The aim of this study was to assess the intra-operative and post-operative outcome for 102 patients undergoing SPLS TEP inguinal hernia repair at the Royal Surrey County Hospital in Guildford, UK. This follows on from our previously published series of 16 patients, demonstrating the safety and feasibility of SPLS in our cohort (Agrawal et al. in Surg Endosc 24:952-956, 2010). METHODS: Between October 2008 and August 2010, we performed hernia repairs on 102 patients (98 men, 4 women) aged between 21 and 89 years (median 60). Patient demographics, type of hernia, incision length, operating time, complications, post-operative hospital stay, and recurrence were collected prospectively. Post-operative outcome was measured in terms of days to return to normal activities, work, and analgesia required. RESULTS: Sixty patients had unilateral and 39 bilateral hernias, with 2 femoral hernias and one lipoma of cord. Operating time was 15-120 min (median 35 for unilateral and 45 for bilateral repairs). The incision length ranged between 15 and 40 mm (median 25). There was 1 intra-operative complication (major peritoneal incursion) and 13 minor post-operative complications, with 8 urinary retentions. There were no mortalities and one recurrence at follow-up (up to 713 days). CONCLUSION: The authors' experience has shown that SPLS TEP groin hernia repair is a feasible and safe alternative to three-port laparoscopic hernia repairs in a large patient cohort. There were minimal post-operative complications and good post-operative outcome. Recurrence rate was 0.98 %. Further studies are required to assess the long-term outcome of SPLS hernia repairs in direct comparison with three-port technique.

Unexpected findings at diagnostic laparoscopy: caecal incarceration with concurrent appendicitis in a patient with bilateral broad ligament defects.

Internal herniations through broad ligament defects are very rare. We present the first report of the triad of broad ligament defect, internal herniation of the caecum and appendicitis. A 36-year-old woman with phocomelia presented with right iliac fossa pain and vomiting. The patient had no previous history of trauma or surgery. Abdominal ultrasound showed a small amount of free fluid. At laparoscopy, bilateral broad ligament defects were found, with herniation of the caecum and an inflamed appendix through the right-sided defect. A laparoscopic salpingo-oophorectomy was required for reduction of the herniated bowel, and an appendicectomy was performed. Broad ligament defects may be congenital or acquired. In this case, in light of the limb abnormality and absence of previous surgery, a congenital aetiology is more likely. Ultrasound scan is not reliable and, although computed tomography may be of help, a diagnostic laparoscopy is the best investigation.