Poor patient awareness of peripheral arterial disease, it is time to optimize the clinical visit.

INTRODUCTION: Peripheral arterial disease (PAD) is a growing public health burden. The development and progression of PAD is influenced by vascular risk factor management and lifestyle changes. However, public awareness of PAD is low compared with other conditions such as heart disease and stroke, which have been the subject of widespread public health campaigns. This study aimed to determine current levels of PAD awareness among hospital patients. METHODS: This cross-sectional, tertiary hospital-based, descriptive study was conducted over 6 months in 2019. Two investigators administered the survey in face-to-face interviews to patients attending 3 different hospital-based settings including vascular clinics (VC), cardiology clinics (CVC), and Emergency Department (ED). RESULTS: A total of 150 patients were interviewed. Participants demonstrated low overall awareness of vascular disease (32% PAD and 21% AAA) compared to cardiovascular disease including stroke (71%) and myocardial infarction (63%). Awareness of PAD was higher in vascular patients (51%) compared to CVC and ED patients (p=<0.01). Of the total population, 77% and 71% identified the contributory role of smoking and limited exercise to the development of PAD respectively. VC patients were more informed of intermittent claudication (78%) and amputation (80%) (p < 0.01) compared to CVC and ED patients. CONCLUSION: In the global drive to reduce vascular morbidity, this study highlights the poor knowledge of PAD among the public. In addition, there is poor awareness about the incidence, risk factors and complications of PAD. These results highlight the need for accessible and easily understood information regarding PAD in both the clinic setting and public health campaigns.

Effects of Ischemic Preconditioning on Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-analysis.

BACKGROUND: Ischemic preconditioning is an innate mechanism of cytoprotection against ischemia, with potential for end-organ protection. The primary goal of this study was to systematically review the literature to determine the effect of ischemic preconditioning on outcomes after open and endovascular abdominal aortic aneurysm (AAA) repair. METHODS: The methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included randomized clinical trials that evaluated the effect of remote ischemic preconditioning (RIPC) in reducing morbidity and mortality in patients undergoing open or endovascular AAA repair surgery. The primary outcomes were death, myocardial infarction, and renal impairment. Outcomes were addressed separately for open AAA repair and endovascular AAA repair (EVAR). Data were collected on patient characteristics, methodology, and preconditioning protocol for each trial. RESULTS: Nine trials of ischemic preconditioning in aortic aneurysm surgery were included with a total of 599 patients; 336 patients were included in the open AAA repair meta-analysis, and 263 patients were included in the EVAR meta-analysis. For both open and endovascular repairs, ischemic preconditioning did not have a significant effect on death, myocardial infarction, or renal impairment requiring dialysis. CONCLUSIONS: The randomized clinical trials investigating the effect of ischemic preconditioning on outcomes after open and endovascular AAA repair that have been completed to date have not been adequately powered to evaluate improvements in patient-important outcomes. The evidence is insufficient to support the use of ischemic preconditioning for AAA repair in clinical practice. The variability in treatment effect across studies may be explained by clinical and methodological heterogeneity.

A Systematic Review and Meta-analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein.

OBJECTIVES: A systematic review and meta-analysis was performed to determine the incidence of thrombotic events following great saphenous vein (GSV) endovenous thermal ablation (EVTA). METHODS: MEDLINE, Embase and conference abstracts were searched. Eligible studies were randomised controlled trials and case series that included at least 100 patients who underwent GSV EVTA (laser ablation or radiofrequency ablation [RFA]) with duplex ultrasound (DUS) within 30 days. The systematic review focused on the complications of endovenous heat induced thrombosis (EHIT), deep venous thrombosis (DVT), and pulmonary embolism (PE). The primary outcome for the meta-analysis was deep venous thrombotic events which were defined as DVT or EHIT Type 2, 3, or 4. Secondary outcomes for the meta-analysis were EHIT Type 2, 3, or 4, DVT and PE. Subgroup analyses were performed for both the RFA and EVLA groups. Pooled proportions were calculated using random effects modelling. RESULTS: Fifty-two studies (16,398 patients) were included. Thrombotic complications occurred infrequently. Deep venous thrombotic events occurred in 1.7% of cases (95% CI 0.9-2.7%) (25 studies; 10,012 patients; 274 events). EHIT Type 2, 3, or 4 occurred in 1.4% of cases (95% CI 0.8-2.3%) (26 studies; 10,225 patients; 249 events). DVT occurred in 0.3% of cases (95% CI = 0.2%-0.5%) (49 studies; 15,676 patients; 48 events). PE occurred in 0.1% of cases (95% CI = 0.1-0.2%) (29 studies; 8223 patients; 3 events). Similar results were found when the RFA and EVLA groups were analysed separately. CONCLUSION: Thrombotic events occur infrequently following GSV EVTA. Given the large numbers of procedures worldwide and the potential for serious consequences, further research is needed on the burden of these complications and their management.

Wound drainage for lower limb arterial surgery.

BACKGROUND: Drains are often used in leg wounds after vascular surgery procedures despite uncertainty regarding their benefits. Drains are placed with the aim of reducing the incidence and size of blood or fluid collections. Conversely, drains may predispose patients to infection and may prolong hospitalisation. Surgeons need robust data regarding the effects of drains on complications following lower limb arterial surgery. OBJECTIVES: To determine whether routine placement of wound drains results in fewer complications following lower limb arterial surgery than no drains. SEARCH METHODS: In June 2016 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies.There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We considered randomized controlled trials (RCTs) that evaluated the use of any type of drain in lower limb arterial surgery. DATA COLLECTION AND ANALYSIS: Two authors independently determined study eligibility, extracted data and performed an assessment of bias. An effort was made to contact authors for missing data. The methods and results of each eligible study were summarised and we planned to pool data in meta-analyses when it was considered appropriate, based upon clinical and statistical homogeneity. MAIN RESULTS: We identified three eligible trials involving a total of 222 participants with 333 groin wounds. Suction drainage was compared with no drainage in all studies. Two studies were parallel-group, randomized controlled trials, and one was a split-body, randomized controlled trial. Trial settings were not clearly described. Patients undergoing bypass and endarterectomy procedures were included, but none of the studies provided details on the severity of the underlying arterial disease.We deemed all of the studies to be at a high risk of bias in three or more domains of the 'Risk of bias' assessment and overall the evidence was of very low quality. Two out of three studies had unit of analysis errors (with multiple wounds within patients analysed as independent) and it was not possible to judge the appropriateness of the analysis of the third. Meta-analysis was not appropriate, firstly because of clinical heterogeneity, and secondly because we were not able to adjust for the analysis errors in the individual trials. One trial yielded data on surgical site infections (SSI; the primary outcome of the review): there was no clear difference between drained and non-drained wounds for SSI (risk ratio 1.33; 95% confidence interval 0.30 to 5.94; 50 participants with bilateral groin wounds; very low quality evidence). It was not possible to evaluate any other outcomes from this trial. The results from the other two studies are unreliable because of analysis errors and reporting omissions. AUTHORS' CONCLUSIONS: The data upon which to base practice in this area are limited and prone to biases. Complete uncertainty remains regarding the potential benefits and harms associated with the use of wound drains in lower limb arterial surgery due to the small number of completed studies and weaknesses in their design and conduct. Higher quality evidence is needed to inform clinical decision making. To our knowledge, no trials on this topic are currently active.

Can a Neutrophil-Lymphocyte Ratio Derived from Preoperative Blood Tests Predict Arteriovenous Fistula Maturation?

BACKGROUND: To evaluate the association between inflammatory markers expressed as neutrophil-lymphocyte ratio (NLR) and process of arteriovenous fistula (AVF) maturation. METHODS: A retrospective review of patients with end-stage renal disease referred for formation of a new AVF in one center. Patients referred to the vascular service in the University Hospital of Limerick for creation of vascular access between 2009 and 2013. The association between NLR, calculated from preoperative blood tests, and functional fistula maturation, as determined by successful use of the AVF for 6 consecutive hemodialysis sessions, was investigated using univariate and logistic regression analyses. A logistic regression analysis was carried out to assess potential influence from other factors related to AVF maturation. Stepwise regression test was performed including the NLR. RESULTS: Overall AVF functional maturation rate in our study was 53.7% (66/123). Patients with matured AVFs had an NLR of 4.850 (1.8-15.7) compared with 3.554 (1.7-15.0); this difference was found to be significant (P = 0.024). Female gender (P = 0.008) and a history of kidney transplant (P = 0.004) were the only independent factors of fistula maturation outcome in a logistic regression model. CONCLUSION: Increased level of NLR was found to be associated with fistula maturation; however, more studies are needed to validate this finding.

Remote ischemic conditioning and renal function after contrast-enhanced CT scan: A randomized trial.

PURPOSE: Remote ischemic conditioning has been shown to protect against kidney injury in animal and human studies of ischemia-reperfusion. Recent evidence suggests that conditioning may also provide protection against kidney injury caused by contrast medium. The purpose of this study was to determine if conditioning protected against increases in serum creatinine (SCr) after contrast-enhanced computed tomography (CECT). METHODS: A randomised controlled trial (NCT 01741896) was performed with institutional review board approval and informed patient consent. Adult in-patients undergoing abdomino-pelvic CECT were allocated to conditioned or control groups. Conditioning consisted of four cycles of five minutes of cuff-induced arm ischemia with three minutes of reperfusion applied ~40 minutes before CECT. The primary outcome was SCr change after CECT. RESULTS: Baseline characteristics were similar in both groups. For all patients, conditioning reduced the risk ratio (RR) of increased SCr; RR 0.65 (95% confidence intervals 0.41 to 1.04). The protective effect was greater and the evidence for protection stronger when analysis was restricted to patients with pre-scan reduced renal function (eGFR.

Aspirin in the primary prophylaxis of venous thromboembolism in surgical patients.

INTRODUCTION: Venous thromboembolism (VTE) is a common complication in surgical patients, especially those undergoing lower limb orthopaedic procedures as well as oncological resectional surgery. Numerous studies have evaluated the role of acetylsalicylic acid (ASA, aspirin) in primary VTE prevention, with contradictory results reflected in divergent guidelines. We reviewed current evidence for ASA as primary VTE prophylaxis. METHODS: English language studies meeting our inclusion criteria were retrieved from PubMed, EMBASE and Cochrane databases. Six studies (3 meta-analyses and 3 randomized trials) comparing ASA with placebo and 7 studies (1 meta-analysis, 5 randomized trials, and 1 prospective) comparing ASA with other anticoagulants were included in the final analysis. Retrospective studies and case reports were excluded. RESULTS: ASA is more effective than placebo in primary VTE prevention. Although there is clinical equipoise when ASA is compared with other anticoagulants, studies specific to orthopaedic surgery suggest that ASA appears as effective as low molecular weight heparin (LMWH) and may reduce bleeding risk. Extended prophylaxis up to 4 weeks post surgery reduces VTE episodes. CONCLUSIONS: ASA may be considered as a potential strategy in primary VTE prophylaxis in orthopaedic patients at high-risk of bleeding complications. Further studies comparing ASA with LMWH/oral anticoagulants in primary thromboprophylaxis following non-orthopaedic surgery are warranted.

Systematic review and meta-analysis of routine total body CT compared with selective CT in trauma patients.

BACKGROUND: Full-body CT scanning is increasingly being used in the initial evaluation of severely injured patients. We sought to analyse the literature to determine the benefits of full-body scanning in terms of mortality and length of time spent in the emergency department (ED). METHODS: A systematic search of the Pubmed and Cochrane Library databases was performed. Eligible studies compared trauma patients managed with selective CT scanning with patients who underwent immediate full-body scanning. Using random effects modelling, the pooled OR was used to calculate the effect of routine full-body CT on mortality while the pooled weighted mean difference was used to analyse the difference in ED time. RESULTS: Five studies (8180 patients) provided mortality data while four studies (6073 patients) provided data on ED time. All were non-randomised cohort studies and were prone to several sources of bias. There was no mortality difference between groups (pooled OR=0.68; 95% CI 0.43 to 1.09, p=0.11). There was a significant reduction in the time spent in the ED when patients underwent full-body CT (pooled effect size of weighted mean difference=-32.39 min; 95% CI -51.78 to -13.00; p=0.001). CONCLUSIONS: We eagerly await the results of randomised controlled trials. Firm clinical outcome data are expected to emerge in the near future, though data on cost and radiation exposure will be needed before definitive conclusions can be made.

Effectiveness of negative-pressure wound therapy to standard therapy in the prevention of complications after vascular surgery.

Wound complications are common after vascular surgery and many may be preventable. Negative pressure wound therapy (NPWT) dressings may be able to reduce wound complications relating to closed incisions following vascular surgery and several devices are currently available along with a large body of literature. This review article will describe the use of NPWT dressings in vascular surgery. We will summarize the currently available systems, the likely mechanism of action of NWPT, the published studies to date and we will give our recommendations regarding the priorities for future research on this topic.

A systematic review of preoperative duplex ultrasonography and arteriovenous fistula formation.

BACKGROUND: Arteriovenous fistula (AVF) formation for dialysis access is a common procedure. Fistula maturation is unpredictable. Preoperative duplex mapping may increase procedural success. We undertook a systematic review to assess the effect of preoperative duplex mapping on subsequent AVF patency. METHODS: The published literature was searched on PubMed and the Cochrane Library using the following keywords: 'arteriovenous fistula,' 'venous mapping,' 'ultrasound,' 'hemodialysis,' 'vascular access,' and 'perioperative vessel mapping.' Conference proceedings were hand searched for otherwise unpublished trials. Only randomized controlled trials in which preoperative duplex mapping was compared with clinical evaluation were eligible. RESULTS: Three trials (402 patients) were identified. More patients who underwent ultrasound successfully started using their fistula for dialysis access, although the difference did not reach statistical significance (174/214 vs 130/188; pooled odds ratio, 1.96; P = .11). CONCLUSIONS: Preoperative duplex mapping may improve fistula maturation rates. However, the results do not reach statistical significance and there are no cost-effectiveness data. Further work is required.

Suprapubic versus transurethral bladder catheterization following pelvic surgery.

PURPOSE OF REVIEW: There is uncertainty regarding the optimal method of achieving bladder drainage at the time of gynaecologic surgery. As both transurethral catheterization (TUC) and suprapubic catheterization (SPC) have the potential to cause harm, it is important that gynaecologists have accurate evidence upon which to base their bladder drainage policy. RECENT FINDINGS: Several clinical trials and meta-analyses have compared TUC with SPC in abdominal and pelvic surgery. Most recently, a large meta-analysis pooled the results of 12 gynaecological trials and found that the use of SPC leads to fewer urinary tract infections (UTIs) without any major complications and without increasing the duration of catheterization or length of hospital stay. SUMMARY: Robust evidence shows that SPC use leads to fewer UTIs when compared with TUC use in gynaecologic surgery. However, SPC use is associated with an increased incidence of minor complications. Future research should aim to assess the acceptability of both SPC and TUC to patients who are undergoing gynaecologic surgery. The quality of similar data in relation to rectal pelvic surgery is poor in comparison to the data on gynaecologic surgery.

Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis.

BACKGROUND: Establishing intravenous access is often vital in an acute hospital setting but can be difficult. Ultrasound-guided cannulation increases success rates in prospective studies. However, these studies have often lacked a comparative group. This systematic review and meta-analysis aimed to determine the clinical effectiveness of Ultrasound-guided peripheral intravenous cannulation compared with the standard technique in patients known to have difficult access. METHODS: Electronic abstract databases, trial registries, article reference lists and internet repositories were searched using the following search terms: 'peripheral venous cannulation', 'peripheral venous access'. Studies meeting the following criteria were included: randomised controlled trial patients of all ages who required peripheral intravenous access; interventions were Ultrasound-guided versus standard cannulation technique; patients were identified as having difficult venous access; inclusion of at least one defined outcome (procedural success time to cannula placement; number of attempts). RESULTS: 7 trials were identified (289 participants). Ultrasound guidance increases the likelihood of successful cannulation (pooled OR 2.42; 95% CI 1.26 to 4.68; p=0.008). There were no differences in time to successful cannulation, or number of percutaneous skin punctures. CONCLUSION: Ultrasound guidance increases the likelihood of successful peripheral cannulation in difficult access patients. We recommend its use in patients who have difficult venous access, and have failed venous cannulation by standard methods. Further randomised controlled trials (RCTs) with larger sample sizes would be of benefit to investigate if Ultrasound has any additional advantages in terms of reducing the procedure time and the number of skin punctures required for successful venous cannulation.

A systematic review of spinal cord injury and cerebrospinal fluid drainage after thoracic aortic endografting.

BACKGROUND: The use of thoracic endovascular aneurysm repair (TEVAR) is increasing. Similar to open repair, TEVAR carries a risk of spinal cord ischemia (SCI). We undertook a systematic review to determine whether preoperative cerebrospinal fluid (CSF) drainage reduces SCI. METHODS: PubMed, the Cochrane Library, and conference abstracts were searched using the keywords thoracic endovascular aortic repair, cerebrospinal fluid, spinal cord ischaemia, TEVAR, and aneurysm. Studies reporting SCI rates and CSF drain rates for TEVAR patients were eligible for inclusion. SCI rates across studies were pooled using random-effects modeling. Study quality was evaluated using the Downs and Black score. RESULTS: Study quality was generally poor to moderate (median Downs and Black score, 9). The systematic review identified 46 eligible studies comprising 4936 patients; overall, SCI affected 3.89% (95% confidence interval, 2.95.05%-4.95%). Series reporting routine prophylactic drain placement or no prophylactic drain placement reported pooled SCI rates of 3.2% and 3.47%, respectively. The pooled SCI rate from 24 series stating that prophylactic drainage was used selectively was 5.6%. CONCLUSIONS: Spinal chord injury is uncommon after TEVAR. The role of prophylactic CSF drainage is difficult to establish from the available literature. High-quality studies are required to determine the role of prophylactic CSF drainage in TEVAR.

Systematic review on the incidence and management of endovenous heat-induced thrombosis following endovenous thermal ablation of the great saphenous vein.

OBJECTIVE: A systematic review and meta-analysis was performed to determine the incidence of endovenous heat-induced thrombosis (EHIT) and evaluate its management after endovenous thermal ablation of the great saphenous vein (GSV). METHODS: MEDLINE and Embase were searched for studies with at least 100 patients who underwent great saphenous vein endovenous thermal ablation and had duplex ultrasound follow-up within 30 days. Data were gathered on the incidence of thrombotic complications and on the management of cases of EHIT. The primary outcome for the meta-analysis was EHIT types 2 to 4 and secondary outcomes were deep venous thrombotic events (which we defined as types 2-4 EHIT plus deep vein thrombosis [DVT]), DVT, and pulmonary embolism (PE). Pooled proportions were calculated using random effects modelling. RESULTS: We included 75 studies (23,265 patients). EHIT types 2 to 4 occurred in 1.27% of cases (95% confidence interval [CI], 0.74%-1.93%). Deep venous thrombotic events occurred in 1.59% (95% CI, 0.95%-2.4%). DVT occurred in 0.28% (95% CI, 0.18%-0.4%). Pulmonary embolism occurred in 0.11% (95% CI, 0.06%-0.18%). Of the 75 studies, 24 gave a description of the management strategy and outcomes for EHIT and there was inconsistency regarding its management. Asymmetrical funnel plots of studies that reported incidence of EHIT 2 to 4 and DVT suggest publication bias. CONCLUSIONS: The recently published guidelines on EHIT from the Society for Vascular Surgery/American Venous Forum provide a framework to direct clinical decision-making. EHIT and other thrombotic complications occur infrequently and have a benign course.

STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery.

INTRODUCTION: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. METHODS: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. RESULTS: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. CONCLUSION: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery.

A systematic review and meta-analysis comparing the effectiveness of negative-pressure wound therapy to standard therapy in the prevention of complications after vascular surgery.

INTRODUCTION: Negative pressure wound therapy (NPWT) dressings reduce wound complications in a variety of settings but it is unclear whether they reduce groin wound complications in closed incisions after vascular surgery. Therefore, we performed a systematic review and meta-analysis. METHODS: Randomised controlled trials on the use of negative pressure wound dressings on closed groin incisions following vascular surgery were identified from an electronic search of abstract databases, conference proceedings and article reference lists. The primary outcome was surgical site infection (SSI) and secondary outcomes were seromas, readmissions within 30 days postoperatively, reoperations and length of stay. RESULTS: 7 exploratory trials involving 935 incisions and an unclear number of patients were identified. 4 trials yielded primary outcome results that favoured NPWT. Meta-analysis found that NPWT dressings reduced SSIs (RR 0.47; 95%CI 0.31-0.70; 3 studies, 422 patients). No other meta-analyses could be performed. CONCLUSION: NPWT dressings are a promising intervention that may reduce the incidence of groin wound complications following vascular surgery. However, further large-scale well-designed studies are needed before NPWT dressings can become the standard of care.

Remote Preconditioning and Vascular Surgery.

Remote ischemic preconditioning (RIPC) is a theoretically attractive strategy for organ protection; and phase 2 studies in a variety of settings have yielded promising results. In this article, we review the existing clinical studies on RIPC in vascular surgery. We examine aspects of design that may potentially be optimized in future vascular surgery studies and we highlight some challenges that have emerged since the publication of the Remote Ischaemic Preconditioning for Heart Surgery (RIPHeart) trial and the Effect of Remote Ischaemic Preconditioning on Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery (ERICCA) trial.

Remote preconditioning and cardiac surgery: regrouping after Remote Ischemic Preconditioning for Heart Surgery (RIPHeart) and Effect of Remote Ischemic Preconditioning on Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery (ERICCA).

Remote ischaemic preconditioning (RIPC) is an attractive cardioprotective strategy. Although results from animal studies and phase II study on humans are convincing, it cannot have a role in clinical practice until benefits in clinical outcomes are proven in phase III study. Two phase III studies were recently published [Remote Ischemic Preconditioning for Heart Surgery (RIPHeart) and Effect of Remote Ischemic Preconditioning on Clinical Outcomes in Patients Undergoing Coronary Artery Bypass Surgery (ERICCA)] and this article discusses their design, results and implications.

Perforated jejunal diverticulum: a rare case of acute abdomen.

Jejunal pseudo-diverticulosis is a rare acquired herniation of the mucosa and submucosa through weakened areas of the muscularis mucosa of the mesenteric aspect of the bowel. They are asymptomatic in the majority of cases; however, they can present with a wide spectrum of non-specific symptoms such as chronic abdominal discomfort, postprandial flatulence, diarrhoea, malabsorption and steattorhoea. In up to 15% of cases, more serious acute complications may arise such as the development of intestinal obstruction, haemorrhage or as in our case, localized peritonitis secondary to perforation. Perforation carries an overall mortality rate of up to 40% and exploratory laparotomy followed by copious lavage with segmental resection and primary anastomosis remains the mainstay of managing such sequalae of jejunal pseudo-diverticulosis. Our case report highlights the importance of maintaining a high clinical suspicion of a perforated jejunal diverticulum in an elderly patient presenting with an acute abdomen.