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Summary Background In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding Bill & Melinda Gates Foundation.

Background The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. Methods MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20, 2019. Results Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4–30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. Conclusions Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

This multicenter study aims to describe the injury patterns, emergency management and outcomes of the blast victims, recognize the gaps in hospital disaster preparedness, and identify lessons to be learned.On August 4th, 2020, the city of Beirut, Lebanon suffered the largest urban explosion since Hiroshima and Nagasaki, resulting in hundreds of deaths and thousands of injuries.All injured patients admitted to four of the largest Beirut hospitals within 72 hours of the blast, including those who died on arrival or in the emergency department (ED), were included. Medical records were systematically reviewed for: patient demographics and comorbidities; injury severity and characteristics; prehospital, ED, operative, and inpatient interventions; and outcomes at hospital discharge. Lessons learned are also shared.An estimated total of 1818 patients were included, of which 30 died on arrival or in the ED and 315 were admitted to the hospital. Among admitted patients, the mean age was 44.7 years (range: 1 week-93 years), 44.4% were female, and the median injury severity score (ISS) was 10 (5, 17). ISS was inversely related to the distance from the blast epicenter (r = --0.18, P = 0.035). Most injuries involved the upper extremities (53.7%), face (42.2%), and head (40.3%). Mildly injured (ISS9) patients overwhelmed the ED in the first 2 hours; from hour 2 to hour 8 post-injury, the number of moderately, severely, and profoundly injured patients increased by 127%, 25% and 17%, respectively. A total of 475 operative procedures were performed in 239 patients, most commonly soft tissue debridement or repair (119 patients, 49.8%), limb fracture fixation (107, 44.8%), and tendon repair (56, 23.4%). A total of 11 patients (3.5%) died during the hospitalization, 56 (17.8%) developed at least 1 complication, and 51 (16.2%) were discharged with documented long-term disability. Main lessons learned included: the importance of having key hospital functions (eg, laboratory, operating room) underground; the nonadaptability of electronic medical records to disasters; the ED overwhelming with mild injuries, delay in arrival of the severely injured; and the need for realistic disaster drills.We, therefore, describe the injury patterns, emergency flow and trauma outcome of patients injured in the Beirut port explosion. The clinical and system-level lessons learned can help prepare for the next disaster.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.

The American University of Beirut (AUB)-HAS2 risk index is a recently published tool for preoperative cardiovascular evaluation. It is based on six data elements: history of Heart disease, symptoms of Heart disease (angina or dyspnea), Age ⩾ 75 years, Anemia (hemoglobin < 12 mg/dL), emergency Surgery, and vascular Surgery. This study analyzes the performance of a modified AUB-HAS2 index (excluding the vascular surgery element) in a broad spectrum of vascular surgery procedures. The study population consisted of 90,476 vascular surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database. The performance of the AUB-HAS2 index was studied in seven groups: carotid endarterectomy (CEA), open abdominal aortic aneurysm surgical repair (OAAA), endovascular aortic aneurysm repair, supra-inguinal bypass, infra-inguinal bypass, lower extremity thrombo-endarterectomy, and lower extremity angioplasty. The outcome measure was death, myocardial infarction, or stroke at 30 days after surgery. Each patient was given an AUB-HAS2 score of 0, 1, 2, or > 2 depending on the number of data elements s/he has. The AUB-HAS2 index was able to stratify risk in the majority of patients into low (< 3%, score 0), intermediate (3–10%, score 1–2), and high (> 10%, score > 2) ( p < 0.0001). The receiver operating curve had an area of 0.71 in the overall group and it ranged from 0.60 in CEA patients to 0.75 in OAAA patients. In conclusion, the AUB-HAS2 index is a simple tool that can quickly and effectively stratify the risk of patients undergoing a broad spectrum of vascular surgeries into low, intermediate, and high.

Diabetic Foot Infection (DFI) is a challenging complication of diabetes mellitus with a high burden in the Middle East where there is a marked increase in diabetes prevalence and complications. Early detection of DFI and the infectious organisms could result in the early initiation of appropriate antibiotic therapy and improved outcomes. DFI microbiological profiles differ between countries. In our region, Western guidelines are used when initiating treatment for DFI in the absence of local guidance. The purpose of our study was to determine the microbiologic profile and antimicrobial susceptibility of the DFI admissions at a large tertiary referral centre in Beirut and review other reported series in Lebanon and our region. This is a retrospective observational study of patients with DFI admitted to the American University of Beirut Medical Centre from January 2008 to June 2017. The bacteriologic isolation and antimicrobial susceptibility tests were performed according to standard microbiological methods. Between 2008 and 2017, 319 diabetic patients with DFU were admitted to AUBMC, and deep-tissue cultures were taken for 179 patients. From 179 deep tissue cultures, 314 bacterial isolates were obtained. Fifty-four percent of patients had the polymicrobial infection. Aerobic gram-negative rods (GNR) were more prevalent than gram-positive cocci (GPC) (55%, 39%, respectively). The most common isolate was Escherichia coli (15%) followed by Enterococcus (14%) and Pseudomonas aeruginosa (11%). Staphylococcus aureus isolates accounted for 9% with 50% of them being methicillin-resistant (MRSA). Among Enterobacteriaceae, 37% of isolates were fluoroquinolone-resistant, 25% were ESBL producers, and 2% were carbapenem-resistant. Antibiotic resistance was significantly associated with prior usage of antibiotics. Anaerobes were isolated in 1% and Candida species in 5% of isolates. The sensitivity, specificity, PPV, and NPV of swab culture recovery of pathogens compared with deep tissue culture were (76%, 72%, 76%, 72%) and (94%, 81%, 91%, 86%) for gram-positive and gram-negative organisms, respectively. The microbiological profile of DFI in Lebanon is comparable to other countries in the MENA region with big differences compared with the West. Therefore, it is imperative to develop local guidelines for antimicrobial treatment. The high prevalence of GNR in DFI and the high fluoroquinolone resistance should be taken into consideration when choosing empiric antibiotics. Empiric treatment for MRSA or Pseudomonas does not appear necessary except for patients with specific risk factors.

Background Wound complications following midline laparotomies are common and the main source of postoperative morbidity including superficial or deep wound infection, skin dehiscence, fascia dehiscence, and incisional hernia. Abdominal closure complications are strongly associated with suture technique and material, in addition to other factors related to the patient and type of surgery performed. The traditional technique is to place the fascia sutures 1 cm apart and at least 1 cm away from the fascia edge. A Swedish study described a new technique of placing the sutures 5 mm apart and 5 mm away from the fascia edge, resulting in lower rates of abdominal wound complications. This study has a number of limitations. There is a need for improved quality evidence to convince the surgical community to change the closure technique of abdominal wounds aiming to reduce morbidity, which is exemplified in incisional hernias and other various postop complications. Methods This is a 1:1 randomized, controlled, patient- and assessor-blinded, parallel design, superiority trial, with a primary endpoint of incisional hernia at 1 year. The study will be conducted at AUBMC over a 3-year period. Patients planned for a non-emergent midline laparotomy for general surgery or vascular procedure will be randomized to either fascia closure technique. In order to detect a drop of 12% in the incidence of incisional hernia, with 80% power and an alpha of 0.05, we will need to recruit 114 patients per arm. After adjusting for loss to follow-up, target recruitment is 274 subjects. We will compare both arms for the primary, secondary, and exploratory outcomes, using chi-square or t test as appropriate. Univariate and multivariate logistic regression will be done. Discussion This trial will assess postop complications following abdominal midline wound closures via two different suturing techniques. This trial will generate evidence-based conclusions that will allow surgeons to assess the role of a new abdominal closure technique in decreasing short- and long-term postoperative complications, for a commonly performed procedure. Trial registration ClinicalTrials.gov NCT03527433 . Registered on 17 May 2018 before starting participant enrollment.

Background Traumatic arteriovenous fistula (TAVF) is an uncommon vascular entity that arises in various locations, often from penetrating injuries, with a wide spectrum of signs and symptoms. This case report highlights the importance of suspecting multiple TAVFs after a single gunshot wound, especially if it involves pellets. It also sheds light on adapting treatment, whether endovascular or open repair, to the location and characteristics of each fistula. Case presentation A 35-year-old male, with history of shotgun wound 5 months earlier, presented to our clinic with right lower extremity (RLE) edema and pain. Arterial duplex scan and subsequent angiogram showed two TAVFs at the popliteal and posterior tibial (PT) arteries, both of which could not be exactly localized with a computed tomography angiography (CTA) due to artifacts. The fistula connecting the posterior tibial artery (PTA) and vein was repaired endovascularly using a covered-stent, while the fistula between the popliteal artery and vein was repaired surgically. Postoperative follow-up at 3 months showed no arteriovenous fistula (AVF), patent vessels and distal stent stenosis at the PTA. Conclusions Patients who sustain gunshot injuries with shrapnel or pellets and develop TAVF consequentially need to be followed up with the possibility of multiple AVFs in mind. Arterial duplex scan is highly sensitive to detect those AVFs, yet angiography remains gold standard, particularly with extensive metal artefacts. Endovascular repair, when feasible, should be considered first, unless the patient is unstable or has anatomical constraints that increase the risk of complications. Lastly, surgeons should be weary of deep venous thrombosis (DVT), the Branham effect and arterial aneurysmal dilation postoperatively.

A bioheat model for the elderly was developed focusing on blood flow circulatory changes that influence their thermal response in warm and cold environments to predict skin and core temperatures for different segments of the body especially the fingers. The young adult model of Karaki et al. (Int J Therm Sci 67:41-51, 2013) was modified by incorporation of the physiological thermoregulatory and vasomotor changes based on literature observations of physiological changes in the elderly compared to young adults such as lower metabolism and vasoconstriction diminished ability, skin blood flow and its minimum and maximum values, the sweating values, skin fat thickness, as well as the change in threshold parameter related to core or skin temperatures which triggers thermoregulatory action for sweating, maximum dilatation, and maximum constriction. The developed model was validated with published experimental data for elderly exposure to transient and steady hot and cold environments. Predicted finger skin temperature, mean skin temperature, and core temperature were in agreement with published experimental data at a maximum error less than 0.5 °C in the mean skin temperature. The elderly bioheat model showed an increase in finger skin temperature and a decrease in core temperature in cold exposure while it showed a decrease in finger skin temperature and an increase in core temperature in hot exposure.

This is a case report of a six years old boy who presented with seizure to the emergency department and was admitted for further evaluation. The following day he developed fever and ventricular tachycardia requiring cardioversion. Echocardiography revealed myocarditis and viral PCR was positive for PVB19. During his ICU stay he developed right lower extremity pallor and poikilothermia attributed to DVT and arterial thrombosis found on duplex. Despite IV heparin and therapeutic PTT levels, his lower extremity didn't improve and therefore he underwent thrombectomy. He was discharged six days postoperatively. At three month follow up, he was in good health. Keywords: Thrombosis, Myocarditis, PVB19

Infrarenal abdominal aortic aneurysm (AAA) replacement was performed in 97 patients aged 79 or greater over a 14-year period. Sixty-eight patients had intact aneurysms and 29 had ruptured aneurysms. In the intact aneurysm group, the 30-day mortality rate from 1980 to 1986 was 11.5% and decreased to 2.3% from 1987 to 1994. In the ruptured aneurysm group, the 30-day mortality rate was 73% in the earlier period from 1980 to 1986 and 43% in the later period from 1987 to 1994. In the intact aneurysm group, the median hospital stay was 11 days for the transabdominal approach and 8 days with a retroperitoneal approach. In the ruptured aneurysm group, the median hospital stay was 26 days. The occurrence of a ruptured AAA in a patient over 79 years of age is still associated with a high mortality rate, despite the many advances in aneurysm surgery during the past few decades. Hence, in appropriately selected elderly patients, infrarenal aortic aneurysm replacement should be performed electively as the perioperative mortality is low and late survival is similar to that of agematched controls. Age alone should not be a contraindication for infrarenal aortic aneurysm replacement.

Based on current knowledge, it appears that atherosclerosis is a multifactorial disease. There are differences in the effects of atherosclerotic risk factors between the various vascular beds. More than one risk factor is found in the majority of the patients and, often there is atherosclerotic involvement of several vascular territories. In order to prevent or retard atherosclerotic complications and improve patient survival, it is prudent that all the major modifiable risk factors should be corrected in patients with cardiovascular, cerebrovascular, and peripheral vascular disease.

The arteriovenous graft (AVG) is most often used in hemodialysis patients when an autogenous fistula is not feasible. The optimal location (forearm or upper arm) and configuration (loop or straight) of AVGs are not known. To evaluate relationships of AVG location and configuration with patency, we conducted a secondary analysis using data from a randomized, placebo-controlled trial of dipyridamole plus aspirin for newly placed AVG.Participants of the Dialysis Access Consortium (DAC) Graft Study with newly placed upper extremity prosthetic grafts involving the brachial artery were studied. Multivariable analyses adjusting for trial treatment group, center, gender, race, body mass index, diabetes, current treatment with chronic dialysis, and prior arteriovenous vascular access or central venous catheter were performed to compare outcomes of forearm (fAVG) and upper arm (uAVG) grafts, including loss of primary unassisted patency (LPUP) and cumulative primary graft failure (CGF). Subgroup analyses of graft configuration and outflow vein used were also conducted.A total of 508 of the 649 participants (78%) enrolled in the trial had an upper extremity brachial artery graft placed, 255 with fAVG and 253 with uAVG. Participants with fAVG were less often male (33% vs 43%; P = .03), African American (62% vs 78%; P .001), and receiving dialysis at the time of surgery (62% vs 80%; P .001). Participants with fAVG had a higher mean body mass index (33 vs 29; P .001). The LPUP (fAVG 70% vs uAVG 78%; P = .07) and CGF (33% vs 36%; P = .91) were similar between fAVG and uAVG at 1-year follow-up. In multivariable analysis, AVG location (uAVG vs fAVG) was not associated with LPUP (hazard ratio, 1.21; 95% confidence interval, 0.90-1.63; P = .20) or CGF (hazard ratio, 1.36; 95% confidence interval, 0.94-1.97; P = .10). LPUP did not differ significantly between fAVG and uAVG among subgroups based on AVG configuration (P = 1.00) or outflow vein used (P = .16).Patency was comparable between fAVG and uAVG despite the larger caliber veins often encountered in the upper arm in carefully selected patients. Our findings support the traditional view that, in order to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.

Importance Because of the similarity in clinical outcomes after elective open and endovascular repair of abdominal aortic aneurysm (AAA), cost may be an important factor in choosing a procedure. Objective To compare total and AAA-related use of health care services, costs, and cost-effectiveness between groups randomized to open or endovascular repair. Design, Setting, and Participants This unblinded randomized clinical trial enrolled 881 patients undergoing planned elective repair of AAA who were candidates for open and endovascular repair procedures. Patients were randomized from October 15, 2002, to April 15, 2008, at 42 Veterans Affairs medical centers. Follow-up was completed on October 15, 2011, and data were analyzed from April 15, 2013, to April 15, 2016, based on intention to treat. Main Outcomes and Measures Mean total and AAA-related health care cost per life-year and per quality-adjusted life-year (QALY). Results A total of 881 patients (876 men [99.4%]; 5 women [0.6%]; mean [SD] age, 70 [7.8] years) were included in the analysis. After a mean of 5.2 years of follow-up, mean life-years were 4.89 in the endovascular group and 4.84 in the open repair group ( P = .68), and mean QALYs were 3.72 in the endovascular group and 3.70 in the open repair group ( P = .82). Total mean health care costs did not differ significantly between the 2 groups (endovascular group, $142 745; open repair group, $153 533; difference, −$10 788; 95% CI, −$29 796 to $5825; P = .25). Costs related to AAA, including the initial repair, constituted nearly 40% of total costs and did not differ significantly between the 2 groups (endovascular group, $57 501; open repair group, $57 893; difference, −$393; 95% CI, −$12 071 to $7928; P = .94). Lower costs due to shorter hospitalization for initial endovascular repair were offset by increased costs from AAA-related secondary procedures and imaging studies. The probability of endovascular repair being less costly and more effective was 56.8% when effectiveness was measured in life-years and 55.4% when effectiveness was measured in QALYs for total costs and 31.3% and 34.3%, respectively, for AAA-related costs. Conclusions and Relevance In this multicenter randomized clinical trial with follow-up to 9 years, survival, quality of life, costs, and cost-effectiveness did not differ between elective open and endovascular repair of AAA. Trial Registration clinicaltrials.gov Identifier:NCT00094575

Importance The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. Objective To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. Design Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. Setting and Participants A total of 607 558 adult patients undergoing major surgery in non–Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. Main Outcomes and Measures The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours). Results The sample included 125 192 current (20.6%) and 78 763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. Conclusions and Relevance Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking—and the benefits of its cessation—on morbidity and mortality in the surgical setting.

The purpose of this work was to integrate a new mathematical model with a bioheat model, based on physiology and first principles, to predict thermoregulatory arterio-venous anastomoses (AVA) and cold-induced vasodilation (CIVD) reaction to local cooling. The transient energy balance equations of body segments constrained by thermoregulatory controls were solved numerically to predict segmental core and skin temperatures, and arterial blood flow for given metabolic rate and environmental conditions. Two similar AVA–CIVD mechanisms were incorporated. The first was activated during drop in local skin temperature (

Objectives: We analysed our results with the use of aortic polytetrafluoroethylene (PTFE) grafts over the last 7.5 years. A historical comparison was also made between the results with non-stretch PTFE (NS-PTFE) (1987–91) and stretch PTFE (S-PTFE) grafts (1991–94). Materials: 244 infrarenal aortic replacements or bypasses with PTFE grafts were performed at the University of Iowa Hospitals and Clinics from January 1987 to June 1994. Infrarenal aortic replacement was indicated for aortic aneurysmal disease in 192 patients (elective 151, symptomatic 20, ruptured 21) and bypass for aorto-iliac occlusive disease in 52 patients (disabling claudication 28, limb salvage 24). Patients ranged in age from 37 to 93 years (mean 68 years). There were 161 males and 83 females. Medical risk factors included hypertension (55%), coronary artery disease (31%), COPD (23%), diabetes mellitus (12%), chronic renal failure (9%), and smoking (61%). Aortic replacement or bypass was done with a NS-PTFE graft in 108 patients (44%) and a S-PTFE graft in 136 patients (56%). Postoperative ultrasound (US) scans and/or CT-studies were available in 40 patients with NS-PTFE and 26 patients with S-PTFE grafts. Main results: The 30 day operative mortality was: elective AAA patients (1.3%), symptomatic AAA patients (10%), ruptured AAA patients (48%), limb salvage patients (4.1%) and disabling claudication patients (0%). Graft related complications included five graft limb thromboses (4 NS-PTFE, 1 S-PTFE). Two thromboses occurred perioperatively and the three others at 24, 28 and 30 months postoperatively. Two other graft related complications included a mixed pseudomonas and streptococcus groin infection with a culture negative perigraft fluid collection occurring 3 weeks following surgery (NS-PTFE), and distal aortic anastomotic suture line bleed on the first postoperative day following replacement of a ruptured AAA with a S-PTFE graft. Based on US and/or CT imaging studies, the mean internal diameters of the bodies of 40 NS-PTFE and 26 S-PTFE grafts were 11% and 10% greater than the manufacturer's specified sizes at a mean follow-up duration of 36 and 10 months respectively. Conclusions: These data reveal that a PTFE graft performs satisfactorily in the aortic position with minimal adverse clinical sequelae over a 7.5 year period. Continued long term follow up data will determine the ultimate suitability of aortic PTFE grafts.

Purpose: We analyzed a current 78-month experience with externally supported (ringed) polytetrafluoroethylene (PTFE) axillobifemoral (AxBF) and axillounifemoral (AxUF) bypass grafts to address the controversy about whether the addition of a femorofemoral limb to an axillofemoral bypass graft improves the patency results.Methods: Between January 1988 and June 1994, 36 AxBF and 22 AxUF externally supported PTFE ringed bypass grafts were performed at our institution. The age of the patients in the AxBF group was 67±11 years and 69±11 years in the AxUF group. The male/female ratio was 22:13 (AxBF) and 8:9 (AxUF). In 71% of cases (29/36 AxBF, 12/22 AxUF), the operations were performed for aortoiliac atherosclerotic occlusive disease in patients with significant medical risk factors or a “hostile” abdomen. The remaining 29% were patients requiring revascularization during treatment of an infected aortic graft. Bypass patency was assessed in the follow-up period by clinical evaluation, color-flow duplex imaging, or segmental limb pressure measurements.Results: There was no significant difference in the 30-day operative mortality rate for all AxBF bypasses (11%) and all AxUF bypasses (6%) (p=0.89 by chi-squared testing). The primary and secondary patency rates for the whole group of bypasses were 80% and 89% at 3 years, respectively (SE

Purpose: A variety of vena caval filters (VCFs) are available for usage. The choice of filter type depends on physician preference and certain patient variables. An evaluation of the different VCFs used in our institution was done to compare their efficacy and complication rates.Methods: The medical records of all patients who underwent insertion of a VCF from January 1987 to June 1993 at the University of Iowa Hospitals & Clinics and the affiliated Veterans Administration Medical Center were reviewed. One hundred ninety-nine VCFs were placed in 196 patients (123 males, 73 females), with a mean age of 61 years (range 13 to 87 years). Thirty-five (18%) VCFs (30 stainless steel Greenfield filters [SGFs] and five titanium Greenfield filters with modified hook [TGF-MHs]) were inserted in the operating room via an open technique. The remaining 164 VCFs (82%) were inserted in the radiology suite by a percutaneous technique (38 SGF, 23 TGF-MH, 51 Vena Tech filters [VTFs], 48 Bird's nest filters [BNFs] and 4 Simon Nitinol filters). Thromboembolic risk factors in these 196 patients included malignancy (99), trauma (21), recent surgery (27), cerebrovascular accident with paralysis (6), and miscellaneous conditions (43). Indications for VCF placement included a contraindication to anticoagulation (92), complication of anticoagulation (44), failure of anticoagulation (26), prophylaxis (31), adjunct to pulmonary embolectomy (1), noncompliance (1), hemodynamically unstable patient (1), and prior VCF complication (3). Mean follow-up of the patients was 12 months (range 0 to 87 months). Because there were only four Simon Nitinol filters inserted during the study period, they were excluded from further analysis.Results: A comparative analysis revealed that there was a significantly higher incidence of symptomatic IVC thrombosis with the use of the BNF (n = 7) (14.6%) versus the SGF (n = 0) (0%), TGF-MH (n = 1) (3.6%), or VTF (n = 2) (4%) (p < 0.05 by chi-squared testing). The VCF-related mortality rate was also higher with the BNF (n = 5) (10.9%) versus the SGF (n = 1) (1.5%), TGF-MH (n = 1) (3.6%), or VTF (n = 0) (0%) (p < 0.05 by chi-squared testing). However there was no significant difference in the occurrence of clinically apparent recurrent pulmonary embolism during follow-up between the four different filter types (2 [4.2%] BNF, 3 [4.4%] SGF, 1 [3.6%] TGF-MH, and 1 [2%] VTF).Conclusion: These data indicate that the use of the BNF was associated with increased morbidity and mortality rates compared with the use of the SGF, TGF-MH, and VTF filters. (J VASC SURG 1995;21:235-46.)

A canine model of end-to-end anastomosis between the iliac arteries and polytetrafluoroethylene grafts was developed; a self-expanding Wallstent was placed across one anastomosis. The opposite limb acted as a control. Animals were killed at 4 or 12 weeks. Sections were taken and the intimal thickness and luminal area calculated. At 12 weeks intimal thickness was significantly greater at anastomoses in control sections (P = 0·007), and at the interface between the proximal stent and graft in stented graft limbs (P = 0·01). Control graft limbs had significantly enhanced intimal thickness at the anastomotic level at 12 weeks compared with that at 4 weeks (P = 0·0002), while there was no such increase for the stented side. There was no significant difference in luminal area between control and stented graft limbs. Anastomotic neointimal hyperplasia in a canine graft-artery bypass model is modified by endovascular stenting.

Purpose : Newer approaches to the patient with an infected aortic graft are available. We reviewed a recent 10-year experience with a more traditional approach to evaluate its outcome in the 1990s. Methods: From January 1983 to January 1993, 27 patients with an aortic graft infection were treated at our institution. There were 18 paraprosthetic infections, eight graft enteric erosions, and one aortoduodenal fistula. The involved bypasses included 20 aortofemoral (74%), five aortoiliac (18%), and two aortic tube grafts (8%). Nineteen aortic replacements were done originally for aneurysmal disease (70%). We reviewed the outcome of each patient treated as it related to the method of management. The therapy for graft infection consisted of aortic graft removal and axillofemoral bypass in 20 patients (74%), treatment by an in situ method in four patients (15%), excision of an aortofemoral limb and extraanatomic bypass in two patients (7%), and extraanatomic bypass alone in one patient (4%). In the group treated by graft removal and extraanatomic bypass, four patients (20%) had staged operations (extraanatomic bypass followed by interval aortic graft removal), nine (45%) had single operations with extraanatomic bypass preceding graft removal, and seven (35%) had single operations with graft removal preceding extraanatomic bypass. Results: The 30-day operative mortality rate was 3.7%. There were no instances of aortic stump blowout. The 3-year primary patency rate for axillofemoral bypass limbs was 80.2%, and the secondary patency rate was 87.4%. No limbs were lost as a result of ischemic complications. There was one late amputation for an unrelated problem. Conclusions: The results of alternate approaches to the management of patients with infected aortic grafts were equivalent both in terms of perioperative mortality and morbidity rates in this group of patients. Complete excision of the aortic graft with axillofemoral bypass provided a satisfactory long-term outcome and remains the standard with which other approaches must be compared. (J VASC SURG 1994;19:844-50.)

ObjectiveTo evaluate our experience with the endovascular treatment of total occlusions of the mesenteric and celiac arteries.MethodsWe performed a retrospective review of endovascular stenting of 27 nonembolic total occlusions of the superior mesenteric artery (SMA) and celiac artery (CA) between July 2004 and July 2011 (26 patients, 16 females; mean age, 62 ± 13 years). A variety of demographic, lesion-related and procedure-related variables were evaluated for potential impact of technical success and patency. The follow-up protocol included clinical assessment, and color and spectral Doppler evaluation of the stented vessel(s).ResultsThe clinical presentation was chronic mesenteric ischemia in 12 patients, acute mesenteric vascular syndromes in 10 patients, foregut ischemia/ischemic pancreatitis in three patients, and prior to endovascular repair of aortic aneurysm in one patient. The treated vessel was SMA in 22 procedures, CA in three, and both SMA and CA in one. Technical success was achieved in 23 of the 27 attempted recanalizations (85%). Three patients who failed the attempt underwent open bypass, and another one underwent retrograde recanalization and stenting of the SMA. Procedure success was only significantly related to patient age

Factor V Leiden (Factor V G1691A), prothrombin gene mutation G20210A, and homozygous C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene are known to predispose venous thromboembolism (VTE). We present herein a rare case of a young woman heterozygous for these mutations and taking oral contraceptive pills for less than 2 months, diagnosed to have massive deep venous thrombosis and bilateral pulmonary embolism. The patient was managed for 10 days in the hospital and discharged home on oral anticoagulants. This case suggests that screening for these factors in people with family history of thrombosis and in relatives of patients with these mutations is highly recommended to prevent fatal consequences. In addition, a new guideline for treatment and prophylaxis with anticoagulant for these patients and others who are at risk of developing VTE (American College of Chest Physicians [ACCP] guidelines-Chest 2008) has been published recently. Our recommendation is to promote for the internationally published algorithms through their application, where necessary, to prevent any future thrombotic morbidity or mortality incidents.

The use of axillary femoral grafting in the treatment of patients at high risk for aortoiliac reconstruction has become a widely accepted treatment modality. Ischemia and even loss of the donor upper extremity have been reported to occur early after graft occlusion. This report describes three patients who developed emboli to the upper extremity at nine, 15, and 34 months following occlusion of their axillary femoral graft. Based on our experience, we consider an occluded axillofemoral graft a permanent threat to the viability of the donor upper extremity. Anatomic changes suggestive of potential ischemia include: presence of a blind pouch in the graft stump, or "Y" elongation of the artery with proliferative changes in the intima.

Purpose: To evaluate prospectively 42 lower extremity arm vein bypasses with use of color duplex surveillance (CDS). Methods: Twenty-seven bypasses (64%) were to tibial arteries, 12 (29%) were to popliteal arteries, and three (7%) were to superficial femoral arteries. Twelve bypasses were composed of a single arm vein segment, and 30 were composite vein bypasses. Bypasses were evaluated with CDS and ankle-brachial indexes before the patients were discharged from the hospital, at 1 month, and then every 3 months during the first year; every 6 months during the second year; and annually thereafter. The median follow-up period was 17 months, and the median number of scans performed per bypass was seven. Each examination consisted of a scan of the entire bypass with velocity measurements taken routinely at the proximal and distal anastomoses and at a proximal and distal bypass segment in addition to any high-velocity area identified on the CDS. Peak systolic velocity greater than three times that of an adjacent graft segment or peak systolic velocity less than 45 cm/sec throughout the vein conduit were indications for arteriography. Results: Thirteen arteriograms were performed because of abnormal duplex findings on surveillance. Extension or interposition vein grafts (9), vein patch angioplasty (1), or inflow procedures (3) were used to maintain secondary patency. The 24-month primary and secondary patency rates were 46% and 85%, respectively. Three patients required amputation of a major extremity. Conclusions: Arm veins are satisfactory conduits for lower extremity revascularization. However, preocclusive lesions that require correction are commonly found on surveillance, especially when composite bypasses are required. Vein bypass surveillance with CDS allows identification and appropriate correction of preocclusive lesions. (J VASC SURG 1994;19:279-88.)

During the past decade splenic salvage procedures rather than splenectomy have been considered the preferred treatment for traumatic splenic injuries. Splenic preservation has been most often accomplished by splenorrhaphy and more recently by a controversial nonoperative approach. This report delineates indications, contraindications, and results with splenectomy, splenorrhaphy, and nonoperative treatment based on an 11-year experience (1978 to 1989) in which 193 consecutive adult patients with splenic injuries were treated. One hundred sixty-seven patients (86.5%) underwent urgent operation. Of these, 111 (66%) were treated by splenorrhaphy or partial splenectomy and 56 (34%) were treated by splenectomy. During the last 4 years, 26 additional patients (13.5%) were managed without operation. Patients considered for nonoperative treatment were alert, hemodynamically stable with computed tomographic evidence of isolated grades I to III splenic injuries. Overall 24% of the injuries resulted from penetrating trauma, whereas 76% of the patients sustained blunt injuries. Complications were rare, with two patients in the splenorrhaphy group experiencing re-bleeding (1.8%) and one patient (4%) failing nonoperative treatment. The mortality rate for the entire group was 4%. This report documents that splenorrhaphy can safely be performed in 65% to 75% of splenic injuries. Splenectomy is indicated for more extensive injuries or when patients are hemodynamically unstable in the presence of life-threatening injuries. Nonoperative therapy can be accomplished safely in a small select group (15% to 20%), with a success rate of nearly 90% if strict criteria for selection are met.

Surgical Decision Making (fourth edition), edited by Norton, Stiegman, and Eisman is a welcome textbook that provides guidance in the form of algorithms for the management of common surgical problems. In keeping with the format of the previous editions, a text on one page and an algorithm on another adjacent page are provided for each selected surgical problem. The algorithm outlines the various acceptable management options, while the text provides concise explanatory paragraphs tied to the algorithm along with a list of related references. In the algorithm, the authors utilize solid lines to indicate conventional therapy and broken lines to point out unconventional alternatives. The vast majority of the authors in the fourth edition are well-recognized experts in their fields, and are different from those that contributed to the previous edition, thus providing a fresh and updated look to the management of the topic.

We report two patients with perigraft hygromas after open abdominal aortic aneurysm replacement treated with relining the existing graft by covered stents with subsequent decrease in the size of the hygroma and disappearance of symptoms on follow-up. To our knowledge, these two patients are the first reported cases of successfully treated perigraft hygromas after open repair of abdominal aortic aneurysm using endograft relining of the existing grafts. This endovascular treatment avoids the need for aortic graft excision and replacement, which may be a challenging undertaking.

Purpose: This study evaluated the value of preoperative cardiac screening with dipyridamole thallium scintigraphy and radionuclide ventriculography in vascular surgery patients.Methods: From July 1, 1989, to Dec. 31, 1991, we routinely (irrespective of the patient's cardiac history or symptomatology) performed dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography (RVG) in 394 patients being considered for an elective vascular operation. Patients with reversible defects on DTS underwent coronary arteriography.Results: DTS results were normal in 146 patients (37%), showed a fixed defect in 75 (19%), and showed a reversible defect in 173 (44%). Patients with and without a history of angina or myocardial infarction had identical rates of reversible defects. Normal left ventricular function (>50%) was noted in 76% of the patients; 17% had moderate dysfunction (35% to 50%) and 7% had a low ejection fraction (

Highlights • Liver injuries can be managed conservatively but operative management is needed once patients are hemodynamically unstable. • Peri-hepatic packing is considered a life-saving procedure in complex liver injuries; however, it is not very efficient in case of significant liver injury. • Intra-operative liver bed bleeding was initially controlled by high beam cauterization, surgicel and some Argon beam. • The liver was later wrapped with a polyester mesh with collagen barrier; the mesh was wrapped completely over the right lobe of the liver and was sutured to itself and to the diaphragm surface as well as to the falciform ligament. • Using an absorbable mesh on a traumatized and fragmented liver appears to be a safe and effective approach to high grade liver injury., Introduction Major liver trauma is a potentially fatal injury. Management of liver injuries has considerably changed over the past decades with a trend towards a multidisciplinary approach. Most liver injuries can be managed conservatively; however, some cases need operative management. Presentation of case We present a case of a 73 year old female who underwent laparoscopic cholecystectomy that was complicated by a life-threatening liver fracture and was successfully managed by staged laparotomies and liver mesh-wrapping. Discussion Mesh wrapping is an effective approach for achieving hemostasis by a temponading effect. An alternative to liver packing would be the resection of the affected segmented, however this should be assessed based on the extent of the injury as well as on the hemodynamic stability of the patient who, in majority, are hemodynamically compromised. The advantage however of liver wrapping is that there is no need for reoperation to remove the mesh, the hazard of re-bleeding is diminished because the mesh is left in place, and the incidence of septic complications is low. In this case, the mesh was sutured to the diaphragmatic crus as well as to the falciform ligament to secure the mesh on two anchoring points. Conclusion Using an absorbable mesh on a traumatized and fragmented liver appears to be a safe and effective approach to high grade liver injury. The judicious use of cauterization, beaming or suturing to the liver bed to control oozing or bleeding should be advocated in order to avoid this highly morbid complication.