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Background: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO)., Methods: A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts., Results: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib)., Conclusions: Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments., Competing Interests: Disclosures None., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

This review details the utility of intravascular ultrasound (IVUS) for the management of peripheral artery and venous disease. The purpose of this document is to provide an update in the use of IVUS in peripheral arterial and venous pathology and demonstrate the use of IVUS as a practical diagnostic imaging procedure to evaluate and treat peripheral vascular disorders. IVUS, a diagnostic tool that relies on sound waves to produce precise images of the vessel being evaluated, was originally introduced to the medical community for the purposes of peripheral artery imaging, though it was quickly adapted for coronary interventions with positive outcomes. The utility of IVUS includes vessel measurement, pre- and post-procedural planning, treatment optimisation, and detection of thrombus, dissection or calcium severity. While angiography remains the standard imaging approach during peripheral intervention, multiple observational studies and small prospective trials have shown that in comparison, IVUS provides more accurate imaging detail, which may improve procedural outcomes. IVUS can also address limitations of angiography, including the need to administer contrast medium and eliminate the ambiguity associated with other forms of imaging. This review provides contemporary examples of where IVUS is being used during peripheral intervention as well as representative imaging to serve as a resource for the practising clinician.

Aims: COVID-19 had a devastating impact on patients with severe aortic stenosis (AS). Like many cardiac procedures, transcatheter aortic valve replacement (TAVR) services were suspended during the first wave of COVID-19. We took the opportunity to evaluate the clinical outcomes and identify any delays at different stages of the TAVR pathway during the COVID-19 pandemic., Methods: Prospectively collected data on 210 consecutive TAVR patients between March 2019 and March 2021 were analysed. We compared the clinical outcomes and 30-day mortality rates of TAVR cases pre-pandemic and during the pandemic. We also looked to identify any time lags from the initial referral to respective stages of the TAVR workup., Results: A total of 134 patients underwent TAVR prior to the national lockdown (March 2019-March 2020), compared to 76 patients during COVID-19 (April 2020-April 2021). Success rates of TAVR were similar (99% prior to the pandemic and 97.4% during COVID-19). The 30-day survival rates were 98.6% and 94.7%, respectively. Median length of stay post TAVR was 2 days during COVID-19 and 2.5 days prior to the pandemic (p = 0.064). Patients were seen quicker in clinic (median of 33 days) during COVID-19, compared to 51 days before COVID-19 (p = 0.044). No significant difference in times from referral to discussion at TAVR multidisciplinary team (MDT) meetings, CT Aortogram and TAVR implantation, in both groups., Conclusions: Reconfiguring the patient pathway during COVID-19 allowed TAVR to be performed safely, with a similar success rate and no excess complications or increased 30-day mortality. There proved to be no delay in the respective stages of patient TAVR workup, during the pandemic., Competing Interests: Conflicts of interest None declared., (Copyright © 2022 Hellenic Society of Cardiology. All rights reserved.)

Background: There has been growing use of intravascular ultrasound (IVUS) during lower extremity arterial and venous revascularization. Observational data suggest that the use of IVUS can improve periprocedural and long-term outcomes, but largescale prospective data remain limited. Consensus opinion regarding the appropriate use of IVUS during peripheral intervention is needed., Objectives: The purpose of this consensus document is to provide guidance on the appropriate use of IVUS in various phases of peripheral arterial and venous interventions., Methods: A 12-member writing committee was convened to derive consensus regarding the appropriate clinical scenarios for use of peripheral IVUS. The group iteratively created a 72-question survey representing 12 lower extremity arterial interventional scenarios. Separately, a 40-question survey representing 8 iliofemoral venous interventional scenarios was constructed. Clinical scenarios were categorized by interventional phases: preintervention, intraprocedure, and postintervention optimization. Thirty international vascular experts (15 for each survey) anonymously completed the survey instrument. Results were categorized by appropriateness using the median value and disseminated to the voting panel to reevaluate for any disagreement., Results: Consensus opinion concluded that IVUS use may be appropriate during the preintervention phase for evaluating the etiology of vessel occlusion and plaque morphology in the iliac and femoropopliteal arteries. IVUS was otherwise rated as appropriate during iliac and femoropopliteal revascularization in most other preintervention scenarios, as well as intraprocedural and postprocedural optimization phases. IVUS was rated appropriate in all interventional phases for the tibial arteries. For iliofemoral venous interventions, IVUS was rated as appropriate in all interventional phases., Conclusions: Expert consensus can help define clinical procedural scenarios in which peripheral IVUS may have value during lower extremity arterial and venous intervention while additional prospective data are collected., Competing Interests: Funding Support and Author Disclosures Dr Secemsky is funded in part by National Institutes of Health/National Heart, Lung, and Blood Institute grant K23HL150290. This review was funded in part by unrestricted educational grants from Boston Scientific and Philips IGT. These companies have not seen or participated in the creation of this manuscript, including no contribution in the writing of the manuscript, significant edits, or the decision whether to submit. Dr Secemsky is a consultant and Speakers Bureau and/or advisory board member for Abbott, Bayer, Becton, Dickinson and Company, Boston Scientific, Cook, Cardiovascular Systems, Inc., Endovascular Engineering, Inari, Janssen, Medtronic, Philips, and VentureMed; has received grants to the institution from the National Institutes of Health/National Heart, Lung, and Blood Institute (K23HL150290), the U.S. Food and Drug Administration, Harvard Medical School (Shore Faculty Development Award), AstraZeneca, BD, Boston Scientific, Cook, Cardiovascular Systems, Inc., Laminate Medical, Medtronic, and Philips. Dr Kohi is a board member at VIVA Physicians; and is a global principal investigator of the ELEGANCE (Drug-Eluting Registry: Real-World Treatment of Lesions in the Peripheral Vasculature) registry with Boston Scientific but is not being personally compensated. Dr Rosenfield is a consultant and scientific advisory board member for Angiodynamics, Boston Scientific, Contego, InspireMD, Magneto, Mayo Clinic, Neptune Medical, Philips, Summa Therapeutics, Surmodics, Thrombolex, and Truvic; has received grants to the institution from the National Institutes of Health and Boston Scientific; holds equity in Accolade, Access Vascular, Althea Medical, Contego, Cruzar Systems, Embolitech, Endospan, JanaCare, Magneto, Orchestra, PQ Bypass, Shockwave, Thrombolex, Truvic, and Valcare; and is a board member for the National PERT Consortium, a not-for-profit 501(c)(3) organization dedicated to advancing treatment and improving outcomes in pulmonary embolism. Dr Lichtenberg has received honoraria for lectures from Cagent Vascular, CR Bard, Boston Scientific, AB Medica, Philips, Terumo, Biotronik, Veryan, and Medtronic; has received honoraria for advisory board activities from Cagent Vascular, Biotronik, Veryan, Boston Scientific, Philips, Soundbite, Limflow, Covellus, and Medtronic; has participated in clinical trials for Cagent Vascular, Biotronik, CR Bard, Verya, Boston Scientific, LimFlow, Terumo, and Philips; and has received research funding from Cagent Vascular, Biotronik, Boston Scientific, Veryan, plusMedica, Philips, and CR Bard. Dr Meissner has served as a consultant for Cook Medical for a project using a Delphi consensus panel for venous stenting; Dr Varcoe consults for Medtronic, Abbott, BD Bard, Philips Healthcare, Intervene, and Surmodics; Dr Holden is a medical advisory board member for Medtronic, Gore, and Boston Scientific; and is a clinical investigator for Bard/BD, Boston Scientific, Cagent Medical, Cook Medical, Endologix, Endospan, Gore Medical, Intact Vascular, Medtronic, Philips, Reflow Medical, Shockwave Medical, and TriReme Medical. Dr Jaff is a part-time employee at Boston Scientific; is a consultant at Glide Healthcare; and holds equity investments in R3 Vascular, Nectero, Vactronix, and EFemoral. Dr Chalyan is an employee at Philips IGT. Dr Clair discloses his involvement with Boston Scientific, Elastimed, Endologix, and Medtronic and clarifies that he does not receive any income from these relationships, as all the income goes to the organization by which he is employed; and serves as a data and safety monitoring board member for Bard/Becton, Dickinson and Company and Boston Scientific (all income goes to the medical group). Dr Hawkins is a consultant at Baim; and conducts institutional research at Behring, Hemostemix, and the National Institutes of Health/National Heart, Lung, and Blood Institute. Dr Parikh is an advisory board member for Abbott, Boston Scientific, Medtronic, Philips, and Cordis; has conducted research for Abbott, Boston Scientific (data and safety monitoring board), Shockwave, Surmodics, TriReme, Veryan Medical, Acotec, and MedAlliance; and is a consultant for Abiomed, Canon, Inari, Penumbra, and Terumo. Dr Mosarla has reported that she has no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of chronic venous disease. Approximately 40% of patients with VLU present with the underlying deep venous disease (DVD). Although the data are scarce, these deep venous disease-related VLU (DRV) are thought to have higher recurrence rates and a substantial economic burden. The objective of this study was to assess the economic burden of DRV across Australia, France, Germany, Italy, Spain, the UK, and the USA., Methods: A comprehensive literature review was undertaken to identify publications documenting the incidence and prevalence of VLU and DRV, medical resource utilization, and associated costs of DRV. Findings from this literature review were used to estimate the economic burden of illness, including direct medical costs over a 12-month interval following initial presentation of a newly formed DRV., Results: Total annual incidence of new or recurrent DRV in Australia, France, Germany, Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000, 253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019. Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated annual direct medical costs for patients managed conservatively in these geographies total ~ $10.73 billion (USD) or $5527 per person per year., Conclusion: The availability of published data on the costs of VLU care varies widely across countries considered in this analysis. Although country-specific VLU practice patterns vary, there is a uniform pattern of high-cost care.

Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder characterised by an excessive heart rate on standing and orthostatic intolerance. We present a rare case of a 38-year-old man who underwent open repair of a thoracoabdominal aortic aneurysm for a chronic Stanford type B aortic dissection whose recovery was complicated by POTS. He received blood transfusions and was commenced on metoprolol, fludrocortisone and ivabradine with significant improvement in his symptoms. Correct assessment of postoperative tachycardia including postural telemetry is the key to identifying this condition and its successful management., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021.)

Objectives: This study sought to compare the local tissue response and subsequent volume of intimal hyperplasia (IH) that develops throughout the maturation of an arteriovenous fistula created using continuous/interrupted polypropylene with that of a novel, metal-alloy, penetrating anastomotic clip device., Materials and Methods: Forty-six fistulae were created in 23 sheep under a paired design using the nitinol U-Clip (n = 23) in one hind limb and continuous (n = 20) or interrupted (n = 3) polypropylene suture for the other. Animals were killed at 4 (n = 3), 14 (n = 3), 28 (n = 10), 42 (n = 3), and 180 (n = 4) days. Histological sections were evaluated for quantitative histology and immunohistochemistry., Results: Compared with continuous polypropylene, U-Clip specimens demonstrated less intima-media area per unit length (IMA/L), proliferating cells, and tissue necrosis at all time points (MANOVA, F = 9.8-24.1, all p ≤ .005; observed power >82%). Specifically, values of IMA/L were reduced by 5% (p = .97), 37% (p = .02), 33% (p < .01), 9% (p = .42), and 14% (p = .22) at the time points of 4, 14, 28, 42, and 180 days respectively. Proliferating cells were reduced by 75% (p < .01), 72% (p = .03), 76% (p = .03), 27% (p = .31), and 60% (p = .01) and tissue necrosis by 67% (p < .01), 58% (p = .02), 40% (p = .33), 21% (p = .43), 77% (p = .11). In a 28-day comparison between U-Clip and interrupted polypropylene the U-Clip group demonstrated a 4% (p = .65) reduction in IMA/L, 74% (p < .01) in proliferating cells and 49% (p < .05) in tissue necrosis., Conclusions: These results provide evidence of reduced local tissue necrosis, proliferating cells, and IH, favouring arteriovenous fistulae created using the U-Clip anastomotic device over conventional polypropylene suture techniques most evident over the first 4 weeks., (Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to create an ovine arteriovenous fistula (AVF) model which would closely replicate a human forearm fistula and use this to quantify the degree of intimal hyperplasia in those created with the U-Clip compared to a conventional sutured anastomosis., Materials and Methods: Twenty AVFs were created in 10 Border Leicester-Merino sheep between the superficial femoral artery and vein of each hind limb. On one side the U-Clip and on the other a continuous polypropylene suture was used to perform the anastomosis. The animals were sacrificed at 2 (n = 3), 4 (n = 4), 6 (n = 3) weeks and histological slices were taken of each AVF in cross section to determine the intimal media area per unit length (IMA/L)., Results: Intimal hyperplasia (IH) was observed at all time points with one AVF found occluded with thrombus at the time of harvest. The IMA/L was significantly lower in the U-Clip groups by 24% at 2 weeks, 32% at 4 weeks and 23% at 6 weeks (Two-way ANOVA, p = 0.019, observed power = 0.825, time or side p ≥ 0.766, type p = 0.001; Paired t-test, p < 0.001 between matched anastomotic types). Time taken to perform the anastomosis was similar between the two anastomotic techniques (Polypropylene 14(8-18) vs. U-Clip 15.3(11-23) min; p = 0.47)., Conclusion: This ovine AVF model results in IH similar to that seen in a human AVF. The IH that occurs with the U-Clip is less than that of continuous polypropylene suture., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Objectives: Considerable evidence exists for the use of arm vein conduit in lower limb bypass surgery. The use of arm vein in preference to synthetic conduit as a last autogenous option was assessed for patency and limb salvage outcomes., Materials and Methods: A prospective database was interrogated and checked against TQEH operating theatre database to detect all infrainguinal arm vein bypasses performed between 1997 and 2005. Patency, limb salvage and survival data for 37 arm vein bypasses was calculated using the Kaplan-Meier survival estimate method., Results: There were no perioperative deaths. 30 day patency rates were 89% primary, 95% secondary and 95% limb salvage. 12 month patency rates were 56% primary, 79% secondary and 91% limb salvage. 5 year patency rates were 37% primary, 76% secondary and 91% limb salvage. There was no significant patency advantage for primary vs. "redo" grafts (p=0.54), single vessel vs. spliced conduits (p=0.33) or popliteal vs tibial outflow (p=0.80). Patient survival rate was 92% and 65% at 1 and 5 years respectively., Conclusion: Lower limb bypasses using arm vein can be performed with favourable patency and limb salvage compared to synthetic conduits. However, secondary interventions are frequently required to maintain patency. We recommend a vigilant surveillance program for early identification of patency threatening disease.