Prognostic value of left ventricular systolic function before vascular surgery: a systematic review.

BACKGROUND: Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery. METHODS: This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE. RESULTS: Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist. CONCLUSION: The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.

The epidemiology and outcomes of vascular trauma in Gold Coast, Australia: Institutional experience at a level 1 trauma centre.

BACKGROUND: Vascular trauma is a complex and evolving area. Unlike internationally, the epidemiology of vascular trauma is not well documented in Australia; the most recent study was published in 2013. Gold Coast University Hospital (GCUH) is a level 1 trauma centre in Queensland, Australia. The aim of this study was to describe the epidemiology and outcomes of vascular trauma at a level 1 trauma centre, and compare these with the Australian and international literature. METHODS: All individuals who presented to GCUH between January 2014 and December 2019 with vascular injury were retrieved from the GCUH prospective trauma database. A descriptive analysis was undertaken on this cohort. RESULTS: The incidence of vascular trauma as a percentage of total trauma remained stable over the study period. The study included 5454 trauma admissions to GCUH, of which 213 sustained vascular injuries. Males were more likely to be injured and blunt trauma was more common than penetrating. Blunt trauma was associated with increased injury complexity. The mortality rate was 8.5% and 10 patients required amputation. CONCLUSIONS: The proportion of vascular injuries as a percentage of total trauma in Australia is higher than in previous studies. Vascular trauma causes significant injuries and has a higher mortality rate than general trauma.

Infected Abdominal Aortic Aneurysm After Transrectal Ultrasound-Guided Biopsy of the Prostate: A Report of Two Cases.

Primary infected abdominal aortic aneurysm (AAA) is an uncommon presentation which can be associated with significant morbidity and mortality. In this report, we present 2 cases of infected AAAs less than 10 days after a transrectal ultrasound-guided (TRUS) prostate biopsy. A 63-year-old male presenting with sepsis and back pain 9 days after TRUS biopsy was found to have a 27-mm ectatic abdominal aorta which expanded to 59 mm in the course of a week, despite antibiotic therapy. He underwent successful surgical excision of the infected aortic aneurysm and reconstruction using a vein. A 55-year-old male presented similarly, 7 days after prostate biopsy with a 60-mm aortic aneurysm. His aneurysm ruptured 2 days before planned intervention-he did not survive an emergency repair. In both cases, aortic tissue biopsies confirmed growth of Escherichia coli. Preexistence of an aortic aneurysm was not known in either case as neither patient had imaging of the abdominal aorta. We postulate the pathophysiology was due to hematogenous spread.

Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease.

OBJECTIVE: Diabetic foot disease poses a significant and rising financial burden on health care systems worldwide. This study investigated the effect of a new multidisciplinary diabetic foot clinic (MDDFC) in a large tertiary hospital on patient outcomes and treatment cost. METHODS: Patients' records were retrospectively reviewed to identify all patients who had been managed in a new MDDFC between July 2014 and July 2017. The wound episode-the period from initial presentation to the achievement of a final wound outcome-was identified, and all relevant inpatient and outpatient costs were extracted using a fully absorbed activity-based costing methodology. Risk factor, treatment, outcome, and costing data for this cohort were compared with a group of patients with diabetic foot wounds who had been managed in the same hospital before the advent of the MDDFC using a generalized linear mixed model. RESULTS: The MDDFC and pre-MDDFC cohorts included 73 patients with 80 wound episodes and 225 patients with 265 wound episodes, respectively. Compared with the pre-MDDFC cohort, the MDDFC group had fewer inpatient admissions (1.56 vs 2.64; P ≤ .001). MDDFC patients had a lower major amputation rate (3.8% vs 27.5%; P ≤ .001), a lower mortality rate (7.5% vs 19.2%; P ≤ .05), and a higher rate of minor amputation (53.8% vs 31.7%; P ≤ .01). No statistically significant difference was noted in the rate of excisional débridement, skin graft, and open or endovascular revascularization. In the MDDFC cohort, the median total cost, inpatient cost, and outpatient cost per wound episode was New Zealand dollars (NZD) 22,407.465 (U.S. dollars [USD] 17,253.74), NZD 21,638.93 (USD 16,661.97), and NZD 691.915 (USD 532.77), respectively. The MDDFC to pre-MDDFC wound episode total cost ratio was 0.7586 (P < .001). CONCLUSIONS: This study is the first to compare the cost and treatment outcomes of diabetic foot patients treated in a large tertiary hospital before and after the introduction of an MDDFC. The results show that an MDDFC improves patient outcomes and reduces the cost of treatment. MDDFCs should be adopted as the standard of care for diabetic foot patients.

The financial burden of surgical and endovascular treatment of diabetic foot wounds.

OBJECTIVE: The cost of treating diabetes-related disease in New Zealand is increasing and is expected to reach New Zealand dollars (NZD) 1.8 billion in 2021. The financial burden attached to the treatment of diabetic foot wounds is difficult to quantify and reported costs of treatment vary greatly in the literature. As of yet, no study has captured the true total cost of treating a diabetic foot wound. In this study, we investigate the total minimum cost of treating a diabetic foot ulcer at a tertiary institution. METHODS: A retrospective audit of hospital and interhospital records was performed to identify adult patients with diabetes who were treated operatively for a diabetic foot wound by the department of vascular surgery at Auckland Hospital between January 2009 and June 2014. Costs from the patients' admissions and outpatient clinics from their first meeting to the achievement of a final outcome were tallied to calculate the total cost of healing the wound. The hospital's expenses were calculated using a fully absorbed activity-based costing methodology and correlated with a variety of demographic and clinical factors extracted from patients' electronic records using a general linear mixed model. RESULTS: We identified 225 patients accounting for 265 wound episodes, 700 inpatient admissions, 815 outpatient consultations, 367 surgical procedures, and 248 endovascular procedures. The total minimum cost to the Auckland city hospital was NZD 10,217,115 (NZD 9,886,963 inpatient costs; NZD 330,152 outpatient costs). The median cost per wound episode was NZD 29,537 (NZD 28,491 inpatient costs; NZD 834 outpatient cost). Wound healing was achieved in 70% of wound episodes (average length of healing, 9 months); 19% of wounds had not healed before the patient's death. Of every 3.5 wound episodes, one required a major amputation. Wound treatment modality, particularly surgical management, was the strongest predictor of high resource utilization. Wounds treated with endovascular intervention and no surgical intervention cost less. Surgical management (indiscriminate of type) was associated with faster wound healing than wounds managed endovascularly (median duration, 140 vs 224 days). Clinical risk factors including smoking, ischemic heart disease, hypercholesterolemia, hypertension, and chronic kidney disease did not affect treatment cost significantly. CONCLUSIONS: We estimate the minimum median cost incurred by our department of vascular surgery in treating a diabetic foot wound to be NZD 30,000 and identify wound treatment modality to be a significant determinant of cost. While readily acknowledging our study's inherent limitations, we believe it provides a real-world representation of the minimum total cost involved in treating diabetic foot lesions in a tertiary center. Given the increasing rate of diabetes, we believe this high cost reinforces the need for the establishment of a multidisciplinary diabetic foot team in our region.

External aortic wrap for repair of type 1 endoleak.

INTRODUCTION: Type 1 endoleak is a rare complication after endovascular abdominal aortic aneurysm repair (EVAR) with a reported frequency up to 2.88%. It is a major risk factor for aneurysmal enlargement and rupture. PRESENTATION OF CASE: We present a case of a 68 year old gentleman who was found to have a proximal type 1 endoleak with loss of graft wall apposition on routine surveillance imaging post-EVAR. An initial attempt at endovascular repair was unsuccessful. Given the patient's multiple medical co-morbidities, which precluded the possibility of conventional graft explantation and open repair, we performed a novel surgical technique which did not require aortic cross-clamping. A double-layered Dacron wrap was secured around the infra-renal aorta with Prolene sutures, effectively hoisting the posterior bulge to allow wall to graft apposition and excluding the endoleak. Post-operative CT angiogram showed resolution of the endoleak and a stable sac size. DISCUSSION: Several anatomical factors need to be considered when this technique is proposed including aortic neck angulation, position of lumbar arteries and peri-aortic venous anatomy. While an external wrap technique has been investigated sporadically for vascular aneurysms, to our knowledge there is only one similar case in the literature. CONCLUSION: Provided certain anatomical features are present, an external aortic wrap is a useful and successful option to manage type 1 endoleak in high-risk patients who are unsuitable for aortic clamping.

First bite syndrome following ipsilateral carotid endarterectomy.

First bite syndrome (FBS) is characterized by unilateral pain in the parotid region after the first bite of each meal, usually following ipsilateral neck surgery. The proposed mechanism is sympathetic denervation of the parotid gland, from iatrogenic injury to the sympathetic trunk supplying this gland. Local botulinum toxin injection has emerged as a promising treatment option with favorable results. To date, there are 3 published cases in the literature describing FBS after carotid endarterectomy. We present a case of a 75-year-old gentleman who developed FBS after carotid endarterectomy, to raise the awareness of this unusual and uncommon complication.

Antegrade superficial femoral artery versus common femoral artery punctures for infrainguinal occlusive disease.

PURPOSE: To compare the outcomes of planned superficial femoral artery (SFA) and common femoral artery (CFA) antegrade punctures in patients undergoing endovascular interventions for infrainguinal occlusive arterial disease in a single center. MATERIALS AND METHODS: Between August 2010 and July 2011, consecutive patients who underwent antegrade puncture of CFA or SFA for infrainguinal occlusive disease were studied. Data including sheath size, rate of closure device usage, and complications relating to the arterial puncture were classified according to Society of Interventional Radiology (SIR) classification and analyzed retrospectively. RESULTS: There were 199 antegrade arterial punctures, of which 28 (14%) were planned SFA punctures, performed in 184 patients. All patients had ultrasound-guided puncture. The sheath size ranged from 4 F to 8 F. In 2 of 28 (7%) SFA punctures, a closure device was deployed compared with 43 of 171 (25%) CFA punctures. Six bleeding complications were noted in the CFA puncture group (6 of 171 [3.5%]), of which 2 required urgent operations (repair of a pseudoaneurysm and evacuation of retroperitoneal hematoma). In comparison, only one minor groin hematoma was noted in the SFA puncture group; this did not require any further treatment. No thromboembolic complications were associated with SFA puncture. CONCLUSIONS: Planned antegrade SFA puncture under ultrasound guidance can be performed safely in selected cases with no added morbidity. Interventionalists should have a low threshold for considering antegrade SFA puncture as a first-line access site, especially in patients with a hostile groin.