Comparison of two bicycle handlebar trauma cases.

Handlebar injury is an uncommon mechanism of blunt injury with a recognised risk of injury to groin vasculature. We describe two cases involving bicycle handlebar injury to the groin and their different respective outcomes. Patient A sustained a significant limb-threatening injury following significant arterial and venous disruption. Surgical intervention was able to restore arterial flow via interpositional vein graft, while venous injuries were ligated. As a result, the patient was discharged with a viable limb and a non-disabling swelling from venous pathology. Patient B, of identical age, also sustained a bicycle handlebar injury to the groin but without the need for surgical intervention. Active observation and the use of repeat imaging suggested spontaneous cessation of any minor arterial bleeding; the patient made a rapid recovery and was discharged soon thereafter. These cases highlight the variability in outcome stemming from this injury mechanism and that early recognition is vital for limb viability.

Carotid artery disease: knowing the numbers.

Ischaemic stroke and transient ischaemic attack are of particular interest to the vascular surgeon as over one-third of all strokes are caused by thromboembolism from a stenotic carotid artery, making carotid artery stenosis the leading cause of stroke. If detected early, stenosis can be managed medically, surgically or endovascularly. However, treatment decisions depend on the timing of the transient ischaemic attack and the degree of stenosis, and must be balanced against procedural risk. This article discusses the evidence outlining the epidemiology, measurement and surgical management of carotid artery stenosis that inform national guidelines. Vascular and non-vascular trainees should understand these guidelines because of the potentially debilitating or fatal consequences of untreated carotid stenosis.

Popliteal arterial aneurysms.

Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.

Acute cerebellar ischaemic stroke secondary to arterial thoracic outlet syndrome.

Arterial thoracic outlet syndrome comprises a collection of symptoms due to compression of the neurovascular structures of the thoracic outlet. Cervical ribs are rare congenital abnormalities that are a cause of thoracic outlet syndrome, leading to upper limb complications depending on the compressed structure. Management tends to be surgical in the form of rib resection. We report a case of arterial thoracic outlet syndrome secondary to a cervical rib in a 45-year-old male who presented with left-sided cerebellar stroke caused by subclavian artery thrombosis. Medical management in the form of anticoagulation was favoured. Oedema in the recent peri-infarct zone due to reperfusion may have caused compression of the fourth ventricle due to anatomical proximity, with the risk of further neurological compromise and coning. At follow-up appointments, the patient had no residual upper limb or neurological symptoms.

Femoral artery aneurysms.

True aneurysms are dilatations of blood vessels, bounded by the tunica intima, tunica media and tunica adventitia. False aneurysms are dilatations bounded by the tunica adventitia only, and are more common than true aneurysms. The femoral artery is the second most common location for true peripheral artery aneurysms, and the most common site of false aneurysms. If left untreated, devastating complications can occur, such as infection, rupture, ischaemia and limb loss. Femoral artery aneurysms should be identified early and managed by a vascular specialist. This article outlines the evidence for the epidemiology, investigation and management of femoral artery aneurysms.

Extensive subcutaneous emphysema from scalp to lower limbs in a 44-year old.

A 44-year-old man was admitted after being found suspended by his ankles from a bridge for 5 days. The events leading to it was not clearly known initially. On examination, the patient was hypotensive and hypothermic, airway was oedematous and both lower limbs were mottled with dusky feet. Both foot pulses were impalpable, with prolonged capillary refill time and sensation barely present. Doppler signals were not heard in the feet, but groin pulses and popliteal signals were present. On CT, the patient had bilateral pneumothoraxes, extensive subcutaneous emphysema throughout the body from the subcutaneous tissue of the scalp to both lower limbs and pneumomediastinum and pneumoperitoneum. CT angiogram showed opacification up to proximal crural vessels and absence beyond. After multispeciality input and optimisation of his physiology, he underwent bilateral below knee amputations as they were non-salvageable.

Abdominal aortic aneurysms.

Vascular surgery is a relatively new surgical sub-speciality in the UK, with treatment of abdominal aortic aneurysms forming a substantial proportion of the emergency and elective caseload. This article summarises the guidance from the National Institute of Health and Care Excellence and the European Society for Vascular Surgery that outlines the epidemiology, diagnosis and management of abdominal aortic aneurysms. This is important for both vascular and non-vascular trainees to understand because of the critical nature of the disease, which can cause catastrophic haemorrhage, limb loss and mortality. However, if discovered in time, abdominal aortic aneurysms are a very treatable condition.

A Review of UK-based National and International Scientific Meeting Published Abstracts in Response to the Draft NICE Aortic Aneurysm Guidelines.

BACKGROUND: UK National Institute for Health and Care Excellence (NICE) draft clinical guidelines (CG) (2018) regarding aortic aneurysm repair were disputed internationally. We aim to appraise the academic response to the draft CG in terms of quantity and scientific quality by reviewing published conference abstracts from three major national and international, UK meetings. METHODS: Abstracts related to aortic practice from The Vascular Societies Annual Scientific Meeting, British Society for Endovascular Therapy (BSET) & Charing Cross (CX) meetings from 2019 were reviewed for methodology, sample size, data collection period, scientific quality and conclusions that supported or conflicted the draft guideline. RESULTS: A total of 549 abstracts were identified from VSGBI, BSET and CX abstract books of which, 226 (41.2%) were related to aortic practices. Of these, 115 (50.9%) were related to EVAR. Twenty-two of these abstracts (19.1%) were identified as having findings relevant to the draft guidelines. Eighteen (15.7%) were identified as findings that potentially conflict the draft CG and 4 (3.5%) that could support the initial recommendations. Six abstracts (5.2%) made direct reference to or challenged the draft CG. The median data collection period was 4 years. The median sample size was 102 patients. In general, scientific quality was poor, with 82% of selected abstracts were graded at level 2b. CONCLUSION: We have demonstrated a concerted response to the draft NICE clinical guidelines relating to the treatment of abdominal aortic aneurysms at three large scientific meetings. As a result of which and other factors, significant changes were made to the finalized NG156. There is still paucity in evidence regarding the long-term safety and cost-effectiveness of EVAR.

First impressions of the foundation interim year 1 postings: positives, pitfalls, and perils.

COVID-19 has placed an increased burden on the NHS. Changes were made to expand patient capacity including hospital restructuring, cancellation of most elective surgeries and early graduation of final year medical students. 1 The UK foundation programme (UKFP) curated a new training position for graduates as foundation interim year 1 (FiY1) doctors, where they voluntarily work in paid positions prior to entering formal foundation year 1 (FY1) roles. 2 Expediting the process of fulfilling these positions, the General Medical Council facilitated early provisional registration of doctors. We discuss the positives, pitfalls, and perils of the new roles and the first impressions of three newly qualified FiY1 s in medical, obstetrics and gynaecology and surgical posts, a surgical FY1 doctor and a clinical supervisor in surgery.

Impact of Frailty on Outcomes in Patients Undergoing Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Frailty is a global state that does not relate directly to comorbidities and is prevalent among patients with vascular disease. The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to independently predict mortality and morbidity after elective open abdominal aortic aneurysm (AAA) repair. METHODS: We retrospectively reviewed our institutional National Vascular Registry (NVR) data to identify all patients who underwent an elective open juxta or infrarenal AAA repair between January 2014 and December 2018. The NVR data set included preoperative risk factors, imaging findings, intraprocedural variables, and postprocedural outcomes. RESULTS: A total of 184 patients were assessed using the CFS before they underwent elective open AAA repair. Among 26 (14%) individuals categorized as vulnerable using the CFS, there was no significant difference in age or preoperative cardiac and respiratory testing compared with nonfrail patients. However, vulnerable patients were significantly more likely to have a longer length of stay (12.2 days vs. 8.8 days, P-value 0.044), suffer from respiratory complications (35% vs. 15%, P-value 0.022) and renal failure (23% vs. 6%, P-value 0.013), or die (23% vs. 2%, P-value 0.0003). The regression analysis identified a vulnerable frailty score to be the only significant predictor of mortality (odds ratio = 36.7, P < 0.001), all other factors were not shown to be independent predictors. CONCLUSIONS: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective open AAA repair and can be used to predict mortality and morbidity after surgery.

The Transposed Femoral Vein Fistula: The Native Choice in Desperate Vascular Access.

BACKGROUND: This is a review of our experience in creating transposed femoral vein (TFV) fistulas and some of the lessons we have learnt while performing this challenging procedure over the last 5 years. METHODS: This is retrospective review of patients who underwent TFV fistula formation between January 2013 and December 2017. RESULTS: Fifteen patients underwent FV fistula formation with 4 cases being excluded from analysis. Median follow-up was 1.17 years (interquartile range 0.19-3.59 years). Primary and primary-assisted patency rates were 75% and 100% at 6 months, respectively, and 66.7% and 100% at 1 year. CONCLUSIONS: Our patient group showed good fistula patency at 1 year and did not experience any incidence of ischemic steal syndrome. We believe this to be due to careful preoperative patient assessment and meticulous surgical technique. Our experience suggests that such procedures should be performed by surgeons with vascular expertise wherever possible to reduce the incidence of complications.

Myriad manifestations of infective endocarditis.

Aneurysmal disease of the visceral arteries is rare, often found incidentally and carries significant mortality when ruptured. Of these, superior mesenteric artery (SMA) aneurysms represent a small minority of visceral artery aneurysms. This case highlights a man in his late 50s who presented to the emergency department with right upper quadrant and lower back pain. A CT scan revealed an aneurysm in the SMA. Increasing abdominal pain and increasing aneurysmal size with concurrent diagnosis of infective endocarditis suggestive of mycotic aneurysm prompted urgent treatment. The man was treated successfully by endovascular method.

Long-term outcomes of bovine pericardial patch angioplasty for recurrent stenosis in vascular access: A UK single-centre experience.

INTRODUCTION:: Stenosis of an arteriovenous fistula or arteriovenous graft for dialysis is a common problem. Stenosis may lead to a number of problems including failure of the fistula. Treatment of stenosis is commonly with percutaneous angioplasty or surgical patch angioplasty with autologous vein or synthetic graft or patch. Here we report the use of bovine pericardial patch angioplasty as an alternative mode of patch angioplasty when percutaneous intervention has failed. METHODS:: Patients with fistulae treated with bovine patch angioplasty between 2013 and 2016 were identified from a prospectively maintained renal access database (Cyberren®). Patient records were reviewed, noting type and location of access, patency, re-interventions and complications post bovine pericardial patch. RESULTS:: A total of 40 patients were identified as having undergone bovine pericardial patch angioplasty between January 2013 and April 2016. The median time from fistula formation to bovine pericardial patch was 15 months (interquartile range (IQR): 5-43). Median duration of follow-up was 14 months (IQR: 5-18). Primary patency at 6, 12, 18 and 24 months was 91%, 66%, 61% and 54%, respectively. Secondary patency was 94%, 91%, 80% and 77% at the same time points, respectively. In total, 15 patients required 23 re-interventions post bovine pericardial patch. There has been no report of infection or aneurysm formation. CONCLUSION:: Bovine pericardial patch angioplasty for recurrent stenosis in arteriovenous fistulae for dialysis access provides a robust alternative to other surgical patches with the added advantage of allowing early needling and relative resistance to infection. Rates of restenosis and failure post bovine pericardial patch are low.

Role of compression therapy in pathophysiology of the venous system in lower limbs.

The management of varicose veins and their sequelae are estimated to cost the NHS approximately £400-600 m annually. Along with interventional procedures, the National Institute for Health and Care Excellence (NICE) also recommends the use of compression therapy. With the vast array of different compression therapies available, prescribing the correct method can be challenging, with patients receiving incorrect compression being a matter of concern. This review summarises the key principles underpinning the management of these patients with particular emphasis on the pathophysiology and different classes of compression.

Simultaneous Iliac Vein Bovine Pericardial Patch Venoplasty and Creation of PTFE Lower Limb Arteriovenous Fistula Graft for Rescue Vascular Access.

BACKGROUND: We present a case of external iliac vein patch venoplasty to accommodate rescue vascular access via a polytetrafluoroethylene loop arteriovenous fistula graft (AVG) for a patient with multiple central venous stenoses. METHODS: A 35-year-old female with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Repeated occlusion and/or thrombosis of long-term central venous access cannulae, to facilitate dialysis, had caused stenosis of brachiocephalic veins: right external iliac vein and occlusion of the left common iliac vein. A previous right brachiobasilic fistula had occluded within 1 year. No other upper limb options for arteriovenous fistula (AVF) were available. A right external iliac vein bovine patch angioplasty concurrently with a polytetrafluoroethylene AV graft between common femoral artery and common femoral vein was performed to restore venous patency and allow rescue dialysis access. RESULTS: At 3-year follow-up, the fistula remains widely patent with 2 L/min flow rates and no recurrent stenosis to the treated iliac vein. She has not required any further surgical or interventional radiological procedures to maintain fistula or central venous patency. Central venous stenosis or occlusion is common for patients requiring dialysis, especially those with multiple previous long-term central venous cannulations. If restriction of outflow is present, AVF may fail. Venous patch angioplasty in these cases is a successful technique, allowing AVF formation and long-term patency. CONCLUSION: Central venous stenosis can be treated successfully with patch venoplasty to accommodate AVF/AVG formation for rescue vascular access; this is a potentially lifesaving intervention for patients requiring dialysis.