Uptake of Best Medical Therapy: Secondary Prevention of Cardiovascular Disease in Vascular Surgical Patients in Western Australia.

Best medical therapy (BMT) for peripheral arterial disease (PAD), carotid artery stenosis (CAS) and abdominal aortic aneurysm (AAA) involving concomitant use of antiplatelets, lipid-lowering agents, and blood pressure control, improves patient survival and prevents clinical cardiovascular disease (CVD). We performed a single-center cross-sectional study, over a 4-year period, describing BMT use in Western Australian patients with symptomatic PAD, CAS and AAA in the community. Overall, 45.3% of our cohort (n = 1689) were on appropriate BMT (CAS, 58.1%; PAD, 43.1%; AAA, 41.1%). There was highest uptake of blood pressure control at 93.0% (lipid-lowering agents, 65.3%; antithrombotics 63.5%). PAD was associated with highest uptake of blood pressure control (PAD 93.9%; CAS, 91.4%; AAA, 91.1%, P = .092) whilst CAS had highest uptake of antithrombotics (CAS 76.3%; PAD, 61.0%; AAA 60.4%, P < .001) and lipid-lowering agents (CAS 78.7%; PAD, 63.1%; AAA, 60.4%, P < .001). Our study indicates suboptimal use of BMT in patients with vascular disease in the community. The risk of CVD in CAS is likely misperceived as higher than PAD and AAA.

Femoral canal lipoma presenting as chronic venous insufficiency.

Lower limb venous obstruction secondary to a lipoma is a rare occurrence. Patients with these benign soft tissue tumors can be asymptomatic, or may experience symptoms of pain, parasthesia, paralysis and swelling secondary to compression on adjacent neurovascular structures. Duplex ultrasound examination is the first-line investigation, but has its limitations. We report on a case of venous obstruction syndrome misdiagnosed as chronic venous insufficiency on duplex ultrasound examination, from a deep-seated giant lipoma compressing on the common femoral and distal external iliac vein in a patient with Dercum's disease.

Splanchnic venous thrombosis: aetiologies and a review of the literature.

BACKGROUND: Splanchnic vein thrombosis (SVT) is an uncommon yet potentially life-threatening manifestation of venous thromboembolism. The aim of this study was to present a retrospective analysis of a cohort of Western Australian patients diagnosed with SVT on imaging study, and a review of the literature surrounding the aetiology, location, anticoagulation treatment and outcomes of SVT. METHODS: All patients diagnosed with SVT over a five-year period from 2015 to 2020 in three tertiary hospitals in Western Australia were identified by using an electronic search engine of imaging reports. Collected data included patient demographics and co-morbidity, presentation data, location of thrombus, aetiology of thrombus, treatment with anti-coagulation, length of stay and outcome data including mortality. RESULTS: A total of 164 patients met inclusion criteria. The 90-day mortality was 20.1%; 64% of whom were those with portal vein thrombosis. Aetiology was grouped into haematological conditions (4 patients), non-haematological conditions (130 patients), a combination of factors (17 patients) and idiopathic (13 patients). The majority of deaths were due to malignancy, severe pancreatitis or decompensated liver cirrhosis. CONCLUSION: Whilst the prevalence of SVT is rising with the increase in accessibility to radiological studies, it remains a diagnostic and therapeutic challenge for clinicians. With no consensus guidelines available to direct treatment, the management of patients with SVT should be individualized and considered carefully. The potential complications of venous thrombosis, SVT recurrence or extension and the risk of bleeding need to be evaluated before the commencement of anticoagulation therapy.

The effect of comorbidity on early clinical decision making in acute mesenteric ischemia.

INTRODUCTION: Acute mesenteric ischemia (AMI) is a surgical emergency with a high mortality and morbidity rate. Prompt diagnosis and early surgical management are the cornerstones of management. In certain patients, however, treatment is futile and early palliative care, lessens patient, and family distress. The aim of this study was to investigate factors, focusing on patient comorbidity, that may predict futility of treatment and hence, guide clinicians in their decision making. PATIENTS AND METHODS: Consecutive adult patients with AMI diagnosed on imaging were reviewed for demographics, comorbidity, imaging, and biochemical results. RESULTS: Seventy patients were identified with average age of 67 (range 33 - 94). Overall hospital mortality was 72%. Patients were divided into three distinct groups, patients who recovered (27%), patients deceased despite surgical treatment (18%), and patients palliated on presentation (54%). Age was comparable between groups (61 vs. 69 vs. 69; p=.2). Length of stay was highest in the recovered group (41.6 vs. 12.3 vs. 2.8 d). Biochemically, only lactate level differed (3.1 vs. 2.3 vs. 5.3 mmol/L, p=.03). Both deceased and palliative group scored similarly but significantly higher than the recovered group in both the Charlson comorbidity index (CCI) (4.2 and 5.6 vs. 3.4, p=.02) and age-adjusted CCI (ACCI) (6.7 and 8.2 vs. 5; p<.01). Other co-morbidities of atrial fibrillation (AF) and hypertension were comparable. CONCLUSIONS: Raised ACCI confers poor outcomes in AMI despite surgical management. ACCI may be used to aid early decision making in AMI, predicting futility of treatment, and altering management goals to palliative comfort care.

Retrograde Catheterization of the Superior Mesenteric Artery and Celiac Axis as a Bailout Technique in a Complex FEVAR.

INTRODUCTION: A retrograde approach of the celiac trunk (CT) and superior mesenteric artery (SMA) to catheterize the visceral vessels during a fenestrated endovascular aortic reparation (FEVAR) is a feasible option when standard access techniques have failed. REPORT: In this report we describe a patient with a previous endoluminal repair of an infrarenal aortic aneurysm, complicated by a persistent type 1a endoleak despite treatment with endoanchor fixation. A decision was made to proceed with a proximal 4 vessel FEVAR to treat the type 1a endoleak. Due to angulation of the mesenteric vessels, and a rotation of the fenestrated stent graft during deployment, the CT and SMA were unable to be catheterized. A decision was made to perform a median laparotomy for retrograde access of the aforementioned vessels, allowing successful catheterization and stenting. The patient was discharged 30 days following the procedure, without any major post-operative complications. Follow up at 6 weeks with a contrasted enhanced computerized tomography scan showed a stable repair with no residual type 1a endoleak. DISCUSSION: Catheterization of the target vessels during a FEVAR can be difficult, especially in patients with challenging anatomy. Prolonged surgical time in an attempt to catheterize the vessels can result in increased morbidity for the patient, and ultimately may result in the procedure being abandoned or conversion to an open repair of the aneurysm. Retrograde access of the target vessels as a bailout measure during fenestrated stent graft repair due to failure of an antegrade approach has rarely been reported in the literature. Only a few cases are described in the available literature, however, none of them describe retrograde approach of both the CT and SMA as described in this case. A median laparotomy for retrograde access is a feasible alternative in these situations, and should be considered if the patient is suitable.

Outcomes in buried versus non-buried peritoneal dialysis catheters: A retrospective cohort study.

AIMS: To compare the rates of infections (peritonitis and exit site infections) in patients undergoing non-buried versus buried peritoneal dialysis catheterisation for end-stage renal failure. METHODS: A retrospective review of all patients who underwent peritoneal dialysis catheter placement by one primary surgeon between January 2008 and August 2019. Information collected included, catheter characteristics, immediate post-operative complications, date of catheter exteriorisation, date of peritoneal dialysis commencement, rate of successful catheter function at initiation of peritoneal dialysis and rates of catheter-related complications (i.e. infection, revision status and obstruction). RESULTS: 110 peritoneal dialysis catheters were inserted (43 non-buried and 67 buried peritoneal dialysis catheters). The non-buried group was associated with a higher proportion acquiring an infection than the buried group (15% vs 30%, p = 0.054). Patients with buried catheters also had a 72% and 65% decreased likelihood of experiencing a catheter-related infection and peritonitis, respectively, over time compared to patients with non-buried catheters in the unadjusted (crude incidence rate ratio 0.28, 95% confidence interval 0.11, 0.70; P = 0.003). The proportion of catheter function at first use was 85% in the non-buried group and 78% in the buried group. Patients with non-buried versus buried catheters had similar proportions of complications, including: obstructions (25.6% vs 20.9%, p = 0.770), herniation (7.0% vs 4.0%, p = 0.327) and leaks (7.0% vs 1.5%, p = 0.134). CONCLUSION: The use of the buried peritoneal dialysis catheter technique as compared to the standard technique has revealed fewer overall catheter-related infections, particularly episodes of peritonitis and similar rates of mechanical complications in our series. In addition to that, the other benefits of buried peritoneal dialysis catheters such as lower healthcare cost, patient convenience and a viable option for patients in remote communities should prompt physicians to continue assessing suitable candidates for buried peritoneal dialysis catheters.

Ruptured mycotic common iliac aneurysm due to Capnocytophaga canimorsus, acquired from dog saliva: A case report.

INTRODUCTION: Mycotic arterial aneurysm occurs secondary to infection of the arterial wall Dubois et al. (2010). It is a serious clinical condition associated with significant morbidity and mortality. Various pathogens can be responsible but the most commonly isolated causative organisms are Staphylococcus spp. and Salmonella spp. Brown et al. (1984). An extremely uncommon causative pathogen is Capnocytophaga canimorsus, a commensal bacterium found in the normal gingival flora of canines. PRESENTATION OF CASE: We describe the case of a ruptured mycotic common iliac aneurysm presenting with acute haemodynamic instability and femoral nerve impairment due to compression secondary to extensive haematoma. Rupture was preceded by a four-week history of left hip/groin discomfort with an abrasion to the left upper limb exposed to dog saliva in the weeks prior to symptom onset. Open debridement, revascularisation, and aggressive antimicrobial therapy was utilised with microbiological culture revealing Capnocytophaga canimorsus as the causative pathogen. DISCUSSION: Successful repair was achieved surgically with a prosthetic bypass, followed by a 6-week course of intravenous antibiotics. Lifelong oral suppressant antibiotic treatment was then commenced. At 6-month follow up, the patient was free from clinical or radiological recurrence of infection or aneurysm. CONCLUSION: This case highlights an extremely rare aetiology for ruptured common iliac aneurysm in the form of Capnocytophaga canimorsus. It highlights the importance of a thorough history, including pet exposures, for patients with infected aneurysms and the need to ensure appropriate specimens are collected when a mycotic aneurysm is suspected.

Peritoneal dialysis catheter intraluminal fibrin cast: A complication after prolonged placement. Case series with a review of literature and the management of this complication.

Peritoneal dialysis is a renal substitutive therapy used in an increasing number of patients with end-stage renal failure as it allows greater freedom to perform daily activities. Peritoneal dialysis catheter obstruction is a significant non-infectious complication of peritoneal dialysis. We describe three cases of peritoneal dialysis catheter obstruction with complete fibrin casts, its surgical management and a review of the literature in management techniques and have proposed an algorithm to guide clinical practise when a complete intraluminal peritoneal dialysis catheter obstruction is suspected.

Portal venous gas: different aetiologies and their respective outcomes.

BACKGROUND: Historically finding of portal venous gas (PVG) has been considered as an ominous sign and an indication for emergency surgery and reportedly has a high mortality rate. However, with the recent increasing use of imaging studies, cases of PVG associated with benign and non-life-threatening causes are increasing. The purpose of our study was to investigate the different aetiologies associated with PVG and their respective outcomes. METHODS: A consecutive series of patients with PVG was identified in our group of tertiary hospitals in Western Australia over a 10-year period. Collected data included patients' demographic data, comorbidities, blood tests results, underlying aetiology of the PVG, patients' management and their outcomes. RESULTS: During the study period of 2008 to 2018, 164 patients met the inclusion criteria. Male : Female 90 versus 74. Average age was 65.6. A diverse range of underlying causes identified broadly divided into thromboembolic events (n = 70), mechanical bowel obstruction (n = 29), inflammatory conditions (n = 37) and a wide range of other pathologies (n = 28). The overall mortality was 47.5%, however, varied depending on the underlying aetiology (14.3-72.8%). CONCLUSION: Our study demonstrates that PVG is not always a fatal sign and that mortality varies significantly depending on the aetiology. Both the patient's presenting history and the clinical findings have to be considered to recognize benign aetiology of PVG on computed tomography imaging and the treatment should be directed to the underlying disease with consideration of the high mortality rate of PVG associated with ischaemic bowel.

Superficial Femoral Artery Pseudoaneurysm as a Delayed Complication of TurboHawk Atherectomy.

BACKGROUND: Peripheral atherectomy is utilized in the treatment of heavily calcified plaques from peripheral arterial lesions. Commonly reported complications include access site injury, perforations, dissections, embolism, and retroperitoneal hemorrhage. METHODS: We report the case of a 74-year-old Caucasian male who developed a 50 × 43 × 40-mm saccular pseudoaneurysm in the native mid-superficial femoral artery after TurboHawk atherectomy. RESULTS: We describe the diagnostic steps in identifying this complication secondary to directional atherectomy and the successful treatment of this pseudoaneurysm using a Viabahn stent graft. CONCLUSIONS: Pseudoaneurysm is a rare complication associated with the procedure which must be followed up with repeat imaging. Symptoms such as limb pain or swelling or increase in the size of pseudoaneurysm should prompt timely assessment of atherectomy site. Stenting with a Viabahn stent has proven to be a viable and successful treatment option.

Snuffbox fistula - a first-line approach to haemodialysis: A review.

PURPOSE: To examine the feasibility of snuffbox arteriovenous fistula as a first option for haemodialysis. BACKGROUND: Snuffbox arteriovenous fistula is the most distal native anastomosis possible for haemodialysis access. It was described by Rassat et al. This systematic review evaluates all literature investigating the feasibility and efficiency of performing snuffbox arteriovenous fistula. METHODS: PubMed, Cochrane Library and Google Scholar were systematically searched for all English articles related to snuffbox arteriovenous fistula. Included studies were appraised using relevant appraisal tools. RESULTS: Eleven papers were included, one prospective trial and the remaining being retrospective. Two trials compared snuffbox arteriovenous fistula to the standard Cimino-Brescia wrist fistula. Factors predicting success included vessel diameter, diabetes, age <70 years, male gender, palpable radial artery, central venous system patency and surgical technique. Patency rates ranged from 61% to 87% at 1-year follow-up and decreased to 36.3%-87% on longer duration follow-up. Ipsilateral radiocephalic fistula was successfully formed in 45%-100% of snuffbox arteriovenous fistula that failed (average of 73.5%). CONCLUSION: This is a systematic review investigating snuffbox arteriovenous fistula's efficacy. The current literature is scarce and of poor quality; however, it does reflect that, in the well-selected patient, snuffbox arteriovenous fistula is a good and valid option for first-line haemodialysis. It provides a long segment of vessel for needling and also spares the proximal vessels for future use. Ability to effectively convert to wrist fistula in the event of snuffbox arteriovenous fistula failure provides longevity to native haemodialysis access before prosthetic adjuncts are required. This review provides recommendation for well-constructed randomised controlled trials to help delineate snuffbox arteriovenous fistula efficacy and investigate factors that affect success of these fistulas.

Late renal artery stent fracture with pseudoaneurysm after fenestrated endovascular abdominal aortic aneurysm repair.

We report the case of an 81-year-old man incidentally found to have a complete transverse stent fracture of a left renal artery covered stent associated with a pseudoaneurysm while being investigated with digital subtraction angiography for an arterial cause of a nonhealing ulcer on his right great toe. He had a fenestrated endovascular abdominal aortic aneurysm repair 11 years ago with covered stenting of both renal arteries. Although he was asymptomatic, a second left renal artery covered stent was successfully placed across the fractured stent to eliminate the risk of rupture. Follow-up imaging showed patent stent and exclusion of the aneurysm. This case highlights another complication of fenestrated endovascular aneurysm repair that needs to be ruled out on surveillance imaging.

Arterio-venous fistula-expanding role for venous access in mastocytosis patients.

Long-term central venous access is increasingly common as there are growing number of patients suffering from conditions that require repeated infusions for various indications. However, central venous access has its downside where there is a risk of infection and thrombosis (F Pinelli, E Cecero, D Del'Innocenti, V Selmi, R Giua, G Villa et al., 'Infection of totally implantable venous access devices: a review of literature,' J Vasc Access 2018;19: 230-42.). Arterio-venous (AV) fistula is traditionally used for haemodialysis, however in patients requiring repeated access or long-term central venous access it can be considered as an unconventional solution. We report a case where 61-year-old male who has a history of systemic mastocytosis. He presents frequently to the Emergency Department with anaphylactic reaction requiring intravenous adrenaline, antihistamine and steroids. He had multiple issues with central lines as well as ports including line sepsis and thrombosis. On further discussion, an arterio-venous fistula was considered and surgically created to allow the AV fistula to be cannulated directly or under ultrasound guidance with its advantage it can be accessed rapidly in emergency setting.

Management of an enormous inferior mesenteric vein aneurysm.

Venous aneurysms are rare entities, with mesenteric venous aneurysms among the rarest reported. We present a case of a 66-year-old man with abdominal pain secondary to an enormous 7.8-cm inferior mesenteric vein aneurysm. In addition, he had evidence of other venous abnormalities, including bilateral leg chronic venous insufficiency and a right varicocele. This appears to be the only reported case of an isolated inferior mesenteric vein aneurysm. Adding to its significance, this aneurysm is among the largest of any mesenteric vein aneurysm reported. Given the rupture risk, laparoscopic ligation above the aneurysm was performed.

Iatrogenic injury of vertebral artery resulting in stroke after central venous line insertion.

There are many complications of central venous catheter insertion. Iatrogenic injury of the vertebral artery is a rare complication that can result in severe morbidity and mortality. The case presented describes the complication of an acute ischaemic stroke after cannulation of the vertebral artery. There are various techniques when obtaining central access, however the best practice as described by the evidence based guidelines produced by the American Society of Anesthesiologists utilises real-time ultrasound guidance to minimise adverse events.

Primary cutaneous Ewing sarcoma presenting as a chest wall lesion.

A 10-year-old boy presents with a rare case of primary cutaneous Ewing sarcoma. The left-sided chest wall lesion was initially thought to be a benign haemangioma and treated with cryotherapy. Within 4 months, the lesion returned and post excision was found to be primary cutaneous Ewing sarcoma on histology. Few cases of primary cutaneous Ewing sarcoma exist in the literature, and although it is a rare differential for paediatric skin lesions, it is an important consideration due to the associated mortality risk in this young cohort.

Major Lower Limb Amputation: Outcomes are Improving.

BACKGROUND: Outcomes following major lower limb amputation (MLLA) between 2000 and 2002 from the Department of Vascular Surgery at Royal Perth Hospital have been published; mean postoperative length of stay 20 days, inpatient complication rate 54%, and 30-day mortality 10%. The last decade has seen increasing endovascular revascularization techniques, increased focus on MLLA patients, and general improvements in the model of care. The aim of this study is to compare outcomes between 2000-2002 and 2010-2012. METHODS: Data on all patients undergoing MLLA, transtibial or proximal, in the 2 time periods were extracted from the department of vascular surgery database. Medical records, government registries, and phone calls to primary care providers were used to clarify mortality. RESULTS: Limb ischemia remains the most common indication for MLLA with smoking, hypertension, and diabetes being the main comorbid diseases. The rates of wound infections have fallen from 26.4% to 12.4% (P = 0.023), rate of admission to ICU has fallen from 48.3% to 17.5% (P = 0.001), and revision amputation to a higher level has fallen from 11.5% to 7.2% (P = 0.043). Acute hospital, postoperative length of stay has trended down from 15.74 to 20.29 days (P = 0.075). Mortality overall has fallen from 60.92% to 46.39% (P = 0.049). Thirty-day mortality fallen from 10.34% to 5.15% (P = 0.185), 6-month 28.76% to 16.5% (P = 0.046), and 1-year 40.22% to 21.65% (P = 0.006). CONCLUSIONS: Patients undergoing MLLA still carry a high burden of comorbid disease. With changes in revascularization technique, consultant supervision, and multidisciplinary model of care, we have seen the rate of complications fall, length of stay trend down, and overall mortality reduce. Despite improvements, outcomes remain sobering and more can be done.

Cutaneous mucormycosis in an immunocompromised patient: a case report.

Mucormycosis is a rare and highly aggressive fungal infection, with a potential to reach its fulminant phase rapidly. We report a case of a 73-year-old immunocompromised vasculopath with cutaneous mucormycosis. The disease resulted in eventual death despite aggressive surgical debridement, revascularization of his limb and amphotericin-B. This case highlights the need to recognize this disease early as a differential of a necrotic ulcer, to prevent a potentially avoidable fatality.

Leiomyosarcoma of great saphenous vein localised to the calf.

We present the case of a 76-year-old man with a 2-month history of mildly tender swelling in the right calf for which he had an initial excision and then a wide local excision followed by a split skin graft because the initial histopathology confirmed that there was a Grade I leiomyosarcoma of great saphenous vein. A simple lump in the lower limb could be a malignant vascular tumour and should always be considered in the list of differential diagnosis of a lump in the lower limb.