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Objective The early twenty first century witnessed a decrease in mortality from abdominal aortic aneurysms (AAA), which was associated with variations in the prevalence of cardiovascular risk factors. This study investigated whether these trends continued into the second decade of the twenty first century. Methods Information on AAA mortality (2001 − 2015) using International Classification of Diseases codes was extracted from the World Health Organization (WHO) mortality database. Data on risk factors were extracted from the Institute of Health Metrics and Evaluation and WHO InfoBase, and data on population from the World Development Indicators database. Regression analysis of temporal trends in cardiovascular risk factors was done independently for correlations with AAA mortality trends. Results Seventeen countries across four continents met the inclusion criteria (Australasia, two; Europe, 11; North America, two; Asia, two). Male AAA mortality decreased in 13 countries (population weighted average: −2.84%), while female AAA mortality decreased in 11 countries (population weighted average: −1.64%). The decrease in AAA mortality was seen in both younger ( 65 years) patients. The decrease in AAA mortality was more marked in the second decade of the twenty first century (2011 – 2015) compared with the first decade (2001 – 2005 and 2006 – 2010). Trends in AAA mortality positively correlated with smoking (males: p = .03X, females: p = .001) and hypertension (males: p = .001, females: p = .01X). Conversely, AAA mortality negatively correlated with obesity (males: p = .001, females: p = .001), while there was no significant correlation with diabetes. Conclusion AAA mortality has continued to decline and seems to have declined at an even faster rate in the second decade of the twenty first century, albeit with heterogeneity among countries. These variations are multifactorial in origin but further efforts targeting smoking cessation and blood pressure control will probably contribute to continued reductions in AAA mortality.

Introduction: Endovenous cyanoacrylate glue (CAG) ablation for the treatment of chronic venous insufficiency (CVI) and varicose veins has shown non-inferior outcomes with an excellent safety profile, high patient satisfaction rate, and excellent efficacy when compared to the gold standard of endothermal ablation. A review of the current literature for CAG use in CVI showed that most studies and longer-term data are from Caucasian-based populations, which are subject to different anatomical venous variations and socio-economical contexts. This review aimed to gather the current evidence for CAG use in Asian CVI patients. Methods: Asian studies for the use of CAG in CVI were included in this review. Successful ablation rates, quality of life improvement and novel complications such as glue hypersensitivity reactions are described, along with anatomical descriptions of superficial venous anatomy in study patients. Use of CAG in Singapore and Asia was addressed. Results: CAG has been gaining traction as an option for CVI treatment in Asians. In Singapore, it has been adopted with comparable low complication rates and significant improvement of quality of life after treatment. As we increase our understanding of the variations in venous anatomy in the Asian population, new techniques such as retrograde deployment of the device and use of CAG ablation for venous leg ulcers have been developed. Conclusion: Further robust evidence in terms of large randomised control trials along with costeffectiveness studies are needed to determine the true value of CAG ablation in the Asian setting.

Objective Patients with venous leg ulcers (VLUs) represent the worse spectrum of chronic venous insufficiency (CVI). The Early Venous Reflux Ablation (EVRA) landmark trial published in 2018 demonstrated that early endovenous intervention results in faster healing of VLUs. We describe our post-EVRA experience using endovenous cyanoacrylate glue ablation (ECGA) to treat superficial venous reflux on an early basis and assess its efficacy and safety in the setting of VLUs. Methods There were 37 patients (39 legs, 43 truncal veins) with 43 discrete venous ulcers who underwent ECGA for CVI symptoms and VLUs. They received compression therapy and regular dressings for the VLUs postoperatively and were reviewed at 1 week, 3 months, 6 months, and 12 months after the procedure. Postoperative healing time for VLUs and complications were recorded along with the patient's satisfaction and postprocedure pain scores. Results The venous ulcers were all Conclusions ECGA together with compression therapy for VLUs is both safe and effective in this population of Asian patients. ECGA for patients with VLUs has excellent patient acceptability, minimal morbidity, and low recanalization rates at 12 months. Larger extensive studies and longer follow-up periods are required to validate the preliminary outcomes of this paper, and if it is proven to significantly improve ulcer healing rates, this will change the way we approach chronic venous ulceration.

Summary: Background: The aim was to evaluate the safety and efficacy of a high pressure, non-compliant balloon in the treatment of infrapopliteal occlusive disease in Asian patients with chronic limb threatening ischaemia (CLTI) from Singapore. Patients and methods: Prospective, multi-centre, single arm, non-randomized study. Immediate technical success, 6-month primary vessel patency (determined by Duplex ultrasonography), limb salvage, one-year clinically driven target lesion re-intervention (TLR) and amputation free survival (AFS) were the efficacy endpoints of interest. Results: 86 patients (63% males, mean age 68.9 ± 9.9 years) were enrolled over a 15-month period. Diabetes mellitus (DM) and end-stage renal failure (ESRF) were present in 94% and 38% of patients respectively. All had some degree of tissue loss at baseline (Rutherford scale 5 and 6 = 91% and 9% respectively). Of the 86 legs, 72% had 3 crural vessel disease and 84% had moderate/severe vessel wall calcification. 90% had > = 1 TASC D tibial lesion. Acute technical success was 89%. One month mortality was 3.5% and one-year freedom from TLR was 91%. 6-month tibial patency was 73%. 54/66 (82%) patients had at least one target treated tibial artery open at 6 months. A lower baseline toe pressure (OR 1.03, 95%CI 1.00–1.05) and elastic recoil post angioplasty (OR 0.20, 95%CI 0.05–0.79) were associated with a worse 6 month tibial patency. One-year AFS was 67%. 47/66 (71%) patients had a clinical improvement of at least one Rutherford class at 6 months and 52/59 (88%) experienced complete wound healing at 12 months. Conclusions: Use of a high pressure non-compliant balloon is safe and efficacious in treating highly complex infra-popliteal atherosclerotic lesions in an otherwise challenging population of CLTI patients with a high incidence of DM and ESRF. It is associated with highly satisfactory acute technical success, 6-month target lesion patency and one-year limb salvage.

Heparin-induced thrombocytopaenia (HIT) is a rare life-threatening complication following exposure to heparin. It is mediated by immune-mediated thrombocytopaenia due to antibody against heparin platelet factor 4 complex. Early identification of the condition and the prompt administration of appropriate treatment are important to prevent morbidity and mortality from HIT. We report a case of HIT associated with open abdominal aortic aneurysm repair causing anterior tibial artery and peroneal artery thrombosis following prophylactic use of unfractionated heparin for prophylaxis of venous thromboembolism. Even though enoxaparin was switched to rivaroxaban after HIT was suspected, our patient unfortunately developed a minor cerebrovascular accident during the hospital stay as a consequence of HIT.

Dissecting splenic artery pseudoaneurysm due to segmental arterial mediolysis (SAM) is a rare condition. We describe a case of direct percutaneous transgastric–transpancreatic thrombin injection into a dissecting splenic artery pseudoaneurysm due to SAM. The direct thrombin injection resulted in successful thrombosis of the pseudoaneurysm. At 1-month follow-up, the patient remained well with persistent thrombosis of the pseudoaneurysm.

Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.govNCT04409912. Registered on 1 June 2020

May-Thurner syndrome (MTS) is rare condition thought to occur due to an anatomical variation. In MTS, there is left iliac vein compression by the right iliac artery and lumbar spine resulting in left lower limb deep venous thrombosis. The authors report a rare cause of MTS postarterial intervention. They describe the unusual case of an Asian man who presented with acute left lower limb deep venous thrombosis 5 days following left common iliac artery angioplasty and stent insertion. Computed tomographic (CT) venogram demonstrated the left iliac vein compression by the left iliac artery stent. Successful recanalization of the thrombosed iliac vein was achieved with a combination of pulse spray thrombolysis and rheolytic mechanical thrombectomy, followed by angioplasty and stent placement in the iliac vein. There was rapid and complete resolution of symptoms. This report illustrates the use of complementary imaging modalities and a multidisciplinary team approach to achieve a successful technical and clinical outcome following an unusual case of MTS postarterial intervention and the subsequent successful endovascular management.

Objectives The VenaSeal™ closure system (Medtronic, Galway, Ireland) is a novel non-thermal, non-tumescent ablative device that induces endovenous closure by inducing fibrosis of the truncal superficial vein. The conventional IFU antegrade technique is straightforward except when the great saphenous vein is small at the planned access site below the knee, deep, or steeply traverses the fascia making passage of the introducer wire to the groin difficult. We describe our technique for retrograde great saphenous vein puncture, which mitigated these access problems and assessed the effectiveness and outcomes. Methods Fourteen patients (14 legs; 14 great saphenous vein) underwent VenaSeal™ ablation via a retrograde puncture, all for great saphenous vein incompetence; 10/14 (71.4%) had C4–C5 disease. Retrograde puncture introduces the VenaSeal™ catheter in a cranial-caudal manner, with the designated puncture site at the most proximal point of the great saphenous vein reflux. Patients were reviewed at 1 week, 3, 6 and 12-months post-procedure. Post-operative outcomes and complications were recorded, along with patient satisfaction. Results The most common reason for a retrograde puncture approach was the small great saphenous vein calibre below the knee, in 9/14 (64.3%) patients. There was 100% technical success, with no major complications from the procedure; 11/14 (78.6%) patients tolerated the procedure under local anaesthesia without any sedation. There was 100% Duplex-occlusion rate at 1 week, 3, 6 and 12-months post-procedure. Conclusion The retrograde puncture technique for the VenaSeal™ Closure system is safe and effective in ablating the great saphenous vein in patients who are not amendable to the conventional antegrade puncture approach. Patients tolerated this procedure without additional mean operative time and minimal complications. More extensive studies with longer follow-up periods are required to validate the long-term outcomes of this technique.

Peripheral artery mycotic aneurysms are rare occurrences. In this case, we review a 52-year-old lady with poorly controlled diabetes who developed a spontaneous left superficial artery mycotic aneurysm. She underwent excision and subsequent extra-anatomic bypass with a great saphenous vein graft. She had full functional recovery after a short period of rehabilitation.

INTRODUCTION Percutaneous transluminal angioplasty (PTA) is commonly used to treat patients with chronic limb-threatening ischaemia (CLTI). This study aimed to examine the mortality and functional outcomes of patients with CLTI who predominantly had diabetes mellitus in a multi-ethnic Asian population in Singapore. METHODS Patients with CLTI who underwent PTA between January 2015 and March 2017 at the Vascular Unit at Singapore General Hospital, Singapore, were studied. Primary outcome measures were 30-day unplanned readmission, two-year major lower extremity amputation (LEA), mortality rates, and ambulation status at one, six and 12 months. RESULTS A total of 221 procedures were performed on 207 patients, of whom 184 (88.9%) were diabetics. The one-, six- and 12-month mortality rate was 7.7%, 16.4% and 21.7%, respectively. The two-year LEA rate was 30.0%. At six and 12 months, only 96 (46.4%) and 93 (44.9%) patients were ambulant, respectively. Multivariate analysis revealed that preoperative ambulatory status, haemoglobin, Wound Ischaemia and foot Infection (WIfI) score, and end-stage renal failure (ESRF) were independent predictors of one-year ambulatory status. Predictors of mortality at one, six and 12 months were ESRF, preoperative albumin level, impaired functional status and employment status. CONCLUSION PTA for CLTI was associated with low one-year mortality and two-year LEA rates but did not significantly improve ambulation status. ESRF and hypoalbuminaemia were independent predictors of mortality. ESRF/CKD and WIfI score were independent predictors of loss of ambulation at six months and one year. We need better risk stratification for patients with CLTI to decide between initial revascularisation and an immediate LEA policy.

May–Thurner syndrome (MTS) is an underdiagnosed cause of lower limb deep vein thrombosis (DVT). The clinical prevalence of MTS-related DVT is likely underestimated, particularly in patients with other more recognisable risk factors. MTS is classically described in females between the age group of 20–50 years. In patients with acute iliofemoral thrombosis, medical treatment with anticoagulation alone has been associated with higher risk of postthrombotic syndrome (PTS) and lower iliofemoral patency rates, as compared to endovascular correction. We describe a case of MTS-related extensive iliofemoral DVT occurring in a middle age male who presented with acute onset of left lower limb swelling and pain, complicated by pulmonary embolism. Doppler compression ultrasonography of the left lower limb showed partial DVT extending from the left external iliac to the popliteal veins, and contrasted computed tomography (CT) of the thorax abdomen and pelvis established features of MTS, together with right pulmonary embolism. He was started on low molecular weight heparin (LMWH) and then underwent left lower limb AngioJet pharmacomechanical thrombolysis/thrombectomy, iliac vein stenting, and temporary inferior vena cava (IVC) filter insertion. After the procedure, the patient recovered and improved symptomatically with rapid resolution of this left lower limb swelling and pain. He was switched to an oral Factor Xa inhibitor and was subsequently discharged. After 1-month follow-up, he remained well with stent patency visualised on repeat ultrasound and underwent an uneventful elective IVC filter retrieval with subsequent plans for a 1-year follow-up.

Background: Aim of Arch V SUPERA-LUX was to evaluate the safety and efficacy of the combination therapy of SUPERA™ ( Abbott Vascular, Santa Clara, CA, USA) helical stent implantation and Passeo-18 Lux™ ( Biotronik Asia Pacific Pte Ltd, Singapore) drug coated balloon (DCB) elution to treat recurrent cephalic arch stenosis (CAS) in the setting of AV access dysfunction. Methods: Investigator-initiated, single-center, single-arm prospective pilot study of 20 end-stage renal failure Asian patients with a dysfunctional brachiocephalic fistula. All had symptomatic recurrent CAS within 6 months of prior intervention. The lesion was pre-dilated with a standard high-pressure balloon (Biotronik Passeo-35 HP balloon). The DCB (Passeo-18 Lux™) is subsequently inflated and the SUPERA™ stent deployed to sit 2 mm distal to the cephalic arch and covering the CAS but within the DCB zone. All patients were prescribed dual antiplatelet therapy for 3 months and followed up with Duplex ultrasound at 6- and 12-months. Results: There were 9 (45%) males and mean age was 67 ± 11.0 years. Mean time from prior procedure was 113 ± 68 days and main indication for reintervention was high venous pressure (9/20, 45%). Technical success was 100% and there were no peri-procedural complications related to either stent or DCB deployment. Target lesion primary patency at 6- and 12-months was 10/18 (55%) and 5/16 (31%), respectively. Mean time to target lesion re-intervention was 170 ± 82 days. Circuit access patency was 8/18 (44%) and 2/16 (13%) at 6- and 12-months respectively and mortality was 3/20 (15%) attributed to the patients’ underlying co-morbidities. Conclusion: Dual prong strategy of using SUPERA™ stenting and Passeo-18 Lux™ drug elution for recurrent CAS, although safe, was no more efficacious than conventional balloon angioplasty or stenting alone. Development of an intense inflammatory reaction within the stent led to reinterventions of a number of cases with suboptimal results.

The Surfacer Inside-Out Access Catheter System (Surfacer) is a novel approach to restore access in total central vein occlusion (TCVO). We report a series of three cases, with mean 18-months follow up, in our institution where this technique was safely and effectively used in tandem with Hemodialysis Reliable Outflow (HeRO) graft for creation of upper limb vascular access in patients with TCVO. Although there have been reports describing the simultaneous combination of Surfacer and HeRO graft, to our knowledge, this is the first time where the outcomes with 18-months mean follow-up are reported. All three patients had failed prior conventional attempts at TCVO crossing and had exhausted most conventional upper limb vascular access methods. The above technique yielded a 100% technical success rate with mean operative time of 140 min. Cannulation rate was 100% with all undergoing successful early cannulation by post-operative day 3. Mean primary patency of 199 days was achieved. Average intervention rate of 1.2 a year was required to maintain patency. The Surfacer device used together with HeRO graft is a feasible technique to avoid femoral catheter in patients where conventional attempts to cross the TCVO have failed.

Introduction: The ability to successfully cannulate the arteriovenous fistula reliably is a critical step in the delivery of hemodialysis therapy. The av-Guardian vascular access system (Advent Access, Singapore) is designed to overcome the technical barrier to establishing reliable blunt needle access in patients with mature arteriovenous fistula. Methods: This was a first-in-man, prospective, non-randomized trial (registered on the Australian New Zealand Clinical Trial Registry (ACTRN12617000501347)) performed to assess the safety and feasibility of achieving repeatable successful cannulation via av-Guardian vascular access system to facilitate blunt needling in patients with mature arteriovenous fistula. The primary endpoints of the study included rate of successful hemodialysis sessions via av-Guardian vascular access system cannulation over 3 months and safety of the implants. Results: A total of six patients (four patients with brachiocephalic and two with radiocephalic arteriovenous fistula) were enrolled in the study. A pair of av-Guardian vascular access system were implanted, one each at the arterial and venous cannulation sites, under local anesthesia. Overall, the rate of successful cannulation through the av-Guardian vascular access system over 3 months in 216 hemodialysis sessions was 98.1% (212/216) at the arterial site and 94.4% (204/216) at the venous site. Significantly, 90% and 85.5% of the cannulations at the arterial and venous site, respectively, were successful at first attempt. Blood flow rates within the arteriovenous fistula were unaffected by the devices. Conclusion: The results demonstrated the safety and feasibility of a subcutaneously implanted, extravascular device in achieving repeatable successful cannulation via a constant site, to facilitate blunt needling in matured arteriovenous fistula in limited number of patients.

Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.

Objective/Background The aim was to investigate the expression of genes associated with carotid plaque instability and their protein products at a local and systemic level. Methods Carotid plaques from 24 patients undergoing carotid endarterectomy (CEA) were classified as stable or unstable using clinical, histological, ultrasound, and transcranial Doppler criteria, and compared using whole genome microarray chips. Initial results of differentially expressed genes were validated by quantitative reverse transcriptase polymerase chain reaction in an independent group of 96 patients undergoing CEA. The protein product of genes significantly differentially expressed between patients with stable and unstable plaques were analysed by plaque immunohistochemistry and serum protein quantification by enzyme-linked immunosorbent assay on a further independent cohort. Results Expression of chemokine (c-c-motif) ligand 19 (CCL19) was significantly upregulated in plaques from patients with clinically unstable disease ( p p = .04). Serum concentration of CCL19 was significantly higher in patients with clinically unstable plaques ( p = .02). Immunohistochemical staining for CCL19 demonstrated positive staining in histologically and clinically unstable plaques ( p = .03). CCL19 also co-localised with CD3 + T-cell lymphocytes in the core region, around where CCL19 was expressed. Conclusions CCL19 is significantly overexpressed in patients with unstable carotid atherosclerotic plaques and may be a possible novel biomarker for identifying high-risk patients in whom more urgent intervention may be indicated.

Internal iliac aneurysms (IIAs) are a rare group of intra-abdominal aneurysms that, if not diagnosed and treated promptly, can lead to significant morbidity and mortality. We present a case of an elderly Chinese male who presented acutely with abdominal pain due to a leaking left IIA. Prompt diagnosis and expedient treatment with a hybrid approach, i.e. with endovascular balloon occlusion followed by surgical excision of the IIA, led to an excellent outcome. Case presentation is followed by a brief discussion of the current literature on the management of this elusive condition.

BackgroundThe aim of this pilot study was to evaluate the safety and efficacy of the MagicTouch™ sirolimus-coated balloon (SCB) catheter (Concept Medical Inc., Tampa, FL, US) on improving the patency of failing arterio-venous fistulas (AVF) with de novo and recurrent stenoses. MATILDA reports early outcomes at 3- and 6 months post intervention.MethodsSingle-centre, single-arm prospective pilot study of 33 (18 males; mean age 64.7±11.6 years) end-stage renal failure Asian patients with a dysfunctional AVF, who underwent SCB angioplasty between May 2019-January 2020. All procedures were performed under local anaesthetic without sedation and as day surgery. All patients were prescribed dual antiplatelet therapy for 3 months and followed up with Duplex ultrasound at 3 and 6 months.Results47 stenotic target lesions treated and 24/33 (72.7%) patients were for restenosis. Main indications for intervention was low/dropping access flow (21/33; 63.6%) and most common target lesion was in the juxta-anastomosis (19/47; 40.4%). There was 100% technical and procedural success. There were no peri-procedural complications related to the SCB. The target lesion primary patency rates at 3 and 6 months were 46/47 (97.9%) and 29/35 (82.9%) respectively. Circuit access patency rates at 3 and 6 months were 31/33 (93.9%) and 17/25 (68%) respectively. There was one (2.9%) death at 6 months and 4/33 (12.1%) overall to date, all from patients' underlying co-morbidities.ConclusionsSCB angioplasty for dysfunctional AVF circuits is a safe and efficacious modality in Asian haemodialysis patients at six months comparable if not better than the paclitaxel data reported to date in the literature.

Objectives The aim of this prospective single-centre study is to assess the effectiveness and patient experience of the VenaSeal™ Closure System, a novel non-thermal, non-tumescent catheter technique, which uses cyanoacrylate glue to occlude the refluxing truncal superficial veins to treat varicose veins and chronic venous insufficiency, in a multi-ethnic Asian population from Singapore. Methods Seventy-seven patients (93 legs; 103 procedures) underwent VenaSeal™ Closure System ablation. Forty-nine (63.6%) for great saphenous vein incompetence, 16 (20.8%) bilateral great saphenous vein, 2 (2.6%) small saphenous vein and 10 (13.0%) combined unilateral great saphenous vein and small saphenous vein/anterior thigh vein reflux. In addition, 65/93 legs (69.9%) had C4–C6 disease. Patients were reviewed at 2 weeks, 3, 6 and 12 months post-procedure. Results There was 100% technical success. 28/77 (36.4%) underwent concomitant phlebectomies. All procedures were well tolerated with a mean post-operative pain score of 3.0 (range: 0–5). After three months, median patient satisfaction was 9.0 (interquartile range: 7.0–10.0). At two-week follow-up, the great saphenous vein was completely occluded in 88/88 (100%) veins and small saphenous vein completely closed in 11/11 (100%) veins. At three-month follow-up, the great saphenous vein was occluded in 51/53 (96.2%) veins and small saphenous vein completely closed in 5/5 (100%) veins. At six-month follow-up, the great saphenous vein was completely occluded in 42/45 (93.3%) veins and small saphenous vein completely closed in 5/7 (71.4%) veins. At one year, great saphenous vein and small saphenous vein occlusion rates were 54/59 (91.5%) and 5/8 (62.5%), respectively. There was one deep vein thrombosis. Transient superficial phlebitis was reported in 10/93 (10.8%) legs, which were all self-limiting. There were 9/103 (8.7%) anatomical recurrences, but no patients required re-intervention as they were asymptomatic. Conclusions Cyanoacrylate glue is a safe and efficacious modality to ablate refluxing saphenous veins in Asian patients in the short term. There is a high satisfaction rate and peri-procedural pain is low. Early results are promising but further evaluation and longer term follow-up are required.

Background Surgical management of aortic arch pathologies is complex, and endovascular developments have now enabled total or hybrid endovascular aortic arch repair. We present our early experience with fenestrated aortic arch repairs in Ishimaru zones 1 and 2 pathologies. Methods In a single tertiary institution, all consecutive endovascular aortic arch repairs were reviewed. A preoperative computed tomography aortogram was performed to assess anatomic suitability, which we defined as having a proximal sealing zone with a maximum diameter of 38 mm and minimum length of 20 mm, absence of significant aortic tortuosity, and suitable sealing zones in target vessels. Results From September 2015 to February 2018, 5 cases of fenestrated aortic arch endovascular repairs were performed. There were 3 male patients. The patients were between 57 and 83 years old, all of whom were American Society of Anesthesiologists (ASA) class II or III. Indications for surgery included aortic arch aneurysms (n = 3), a symptomatic aortic dissection, and a left subclavian artery aneurysm. Three patients had a scallop to the innominate artery, and one patient had a scallop to the left common carotid artery. Fenestrations were made to 3 left common carotid arteries and 3 left subclavian arteries. In 2 patients, a left carotid–subclavian bypass was performed, and the left subclavian artery origin occluded with a vascular plug. Technical success was 100%. One patient developed a right occipital infarct and acute myocardial infarction. The mean duration of surgery was 164 min, and the mean length of stay was 4.2 days. The mean follow-up period was 14.4 months. Conclusions The use of fenestrated grafts in the aortic arch is a feasible treatment option. However, certain limitations still exist, and preoperative planning is important in ensuring clinical success. Although this procedure appears feasible in the short term, long-term results and durability remain to be seen.

Background Screening for abdominal aortic aneurysm (AAA) has reduced the rate of AAA rupture. However, cardiovascular disease is still a major cause of death in men with an AAA. The aim of this study was to assess cardiovascular risk in patients with a small AAA. Methods Standard PRISMA guidelines were followed. Analysis was performed of studies reporting cardiovascular outcomes in patients with a small AAA (30–54 mm). Weighted metaregression was performed for cardiovascular death in patients with a small AAA, and the prevalence of cardiovascular disease was reviewed. Results Twenty-one articles were identified describing patients with an AAA, and the prevalence of, and death from, cardiovascular disease. Ten of these reported cardiovascular death rates in patients with a small AAA. Some 2323 patients with a small AAA were identified; 335 cardiovascular deaths occurred, of which 37 were due to AAA rupture. Metaregression demonstrated that the risk of cardiovascular death was 3·0 (95 per cent c.i. 1·7 to 4·3) per cent per year in patients with a small AAA (R2 = 0·902, P < 0·001). The prevalence of ischaemic heart disease (44·9 per cent), myocardial infarction (26·8 per cent), heart failure (4·4 per cent) and stroke (14·0 per cent) was also high in these patients. Conclusion The risk of cardiovascular death in patients with a small AAA is high and increases by approximately 3 per cent each year after diagnosis. Patients with a small AAA have a high prevalence of cardiovascular disease. Patients a small AAA should be considered for lifestyle modifications and secondary cardiovascular protection.

To review the trends in patient selection and early death rate for patients undergoing elective endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) in 3 countries. For this study, audit data from 4,163 patients who had undergone elective infrarenal EVAR were amalgamated. The data originated from Australia, Canada (Ontario), and England (London, Cambridge, and Leicester).Statistical analyses were undertaken to determine whether patient characteristics and early death rate varied between and within study groups and over time. The study design was retrospective analysis of data collected prospectively between 1999 and 2012.One-year survival improved over time (P = 0.0013). Canadian patients were sicker than those in Australia or England (P0.001). American Society of Anesthesiologists classification (ASA) increased over time across all countries although more significantly in Canada. Age at operation remained constant, although older patients were treated more recently in London (P0.001). English centers treated larger aneurysms compared with Australia and Canada (P0.001). Australian centers treated a much larger proportion of aneurysms that were55 mm than other countries. Preoperative creatinine levels decreased over time for all countries and centers (P0.001). Infrarenal neck angles have significantly decreased over time (P0.001). Recent data from London (UK) showed that operations were performed on longer (P0.001) and wider (P0.001) infrarenal necks than elsewhere.In this international comparison, several trends were noted including improved 1-year survival despite declining patient health (as measured by increasing ASA status). This may reflect greater knowledge regarding EVAR that centers from different countries have gained over the last decade and improved medical management of patients with aneurysmal disease.

Objectives: To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival. Materials and Methods: A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively. Results: Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively. Conclusion: This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.

In the UK, vascular surgery and interventional radiology are both involved in the management of patients with vascular disease. Both have the required skills and proficiencies, with their own distinctive advantages in treating vascular patients in specific situations. Keeping pace with state-of-the-art practice is a basic prerequisite of any modern surgical specialty. The state of the art in vascular surgery is no longer open surgery; it is endovascular techniques. From the patients’ point of view, endovascular procedures have obvious advantages in achieving quicker recovery times with subsequent shorter hospital stays, improving clinical outcomes and reducing rates of infection. From healthcare institutions and commissioners’ point of view, the cost savings from shorter hospital stays and less morbidity are economically appealing. The high expense of imaging equipment, of building and staffing of dedicated hybrid theatres and of the endovascular devices themselves are potential obstacles. However, the combination of strong patient preference with top level evidence-based medicine from randomised controlled trials demonstrating comparable medium term efficacy will continue to drive the trend towards endovascular techniques. The interventional radiologists’ skill sets are dedicated to minimally invasive techniques. Vascular surgeons have been quick to recognise these benefits, and therefore, many have adopted interventional techniques into their skill sets. This encroachment by vascular surgeons into a territory customarily occupied by interventional radiologists needs to be addressed judiciously and delicately. The overall aim is to achieve a delicate balance of relationships to deliver the best possible care to vascular patients. There are obvious values in trying to resolve any ensuing conflicts and find means to flourish in situations where physicians collaborate effectively with each other. This article reviews the drivers for change in vascular surgery, the reasons for the development of the potential ‘territorial conflict’ in vascular medicine and proposes some possible solutions through restructuring of vascular …

Background Many studies have investigated the systemic and local expression of biomarkers in patients with abdominal aortic aneurysm (AAA). The natural history of AAA varies between patients, and predictors of the presence and diameter of AAA have not been determined consistently. The aim of this study was to perform a systematic review, meta-analysis and meta-regression of studies comparing biomarkers in patients with and without AAA, with the aim of summarizing the association of identified markers with both AAA presence and size. Methods and results Literature review identified 106 studies suitable for inclusion. Meta-analysis demonstrated a significant difference between matrix metalloproteinase (MMP) 9, tissue inhibitor of matrix metalloproteinase 1, interleukin (IL) 6, C-reactive protein (CRP), α1-antitrypsin, triglycerides, lipoprotein(a), apolipoprotein A and high-density lipoprotein in patients with and without AAA. Although meta-analysis was not possible for MMP-2 in aortic tissue, tumour necrosis factor α, osteoprotegerin, osteopontin, interferon γ, intercellular cell adhesion molecule 1 and vascular cell adhesion molecule 1, systematic review suggested an increase in these biomarkers in patients with AAA. Meta-regression analysis identified a significant positive linear correlation between aortic diameter and CRP level. Conclusion A wide variety of biomarkers are dysregulated in patients with AAA, but their clinical value is yet to be established. Future research should focus on the most relevant biomarkers of AAA, and how they could be used clinically.

Background The National Vascular Registry Report on Surgical Outcomes (NVSRO) coincided with the update of the National Health Service Standard Contract for Specialized Vascular Services in Adults (NHSSCSVS). The latter promises patients minimum standards for vascular centres. The present study aimed to determine whether current data support the standards proposed in the NHSSCSVS. Methods Numbers of abdominal aortic aneurysm (AAA) repairs and carotid endarterectomies (CEAs) performed by hospital Trust and surgeon, and their outcomes were obtained from the NVRSO. These were assessed against NHSSCSVS recommendations that included: more than 60 AAA repairs per year per Trust, over 50 CEAs per year per Trust and at least six vascular surgeons per Trust. Results Based on NVRSO data, 107 hospital Trusts (92·2 per cent) would fail to meet the minimum standards required to achieve vascular centre status. Outcomes were poorer in these hospitals (overall mortality rate after AAA: 2·7 versus 1·3 per cent; P = 0·007). There were strong associations between number of AAA repairs or CEAs per Trust and better outcomes (AAA repair, P < 0·001; CEA, P = 0·004). These remained significant when analysed by individual surgeon (AAA repair, P < 0·001; CEA, P < 0·001). Trusts undertaking 60 or fewer elective AAA repairs per year had significantly higher elective AAA mortality rates (2·7 versus 1·7 per cent; P = 0·010). Trusts performing a minimum of 50 CEAs per year had significantly lower perioperative mortality/morbidity rates (1·9 versus 3·0 per cent; P = 0·032). Trusts with seven or more surgeons demonstrated lower AAA-related mortality rates (1·7 versus 2·7 per cent; P = 0·018). Conclusion Data from the NVRSO suggest that the majority of hospital Trusts presently fail to meet the standards for vascular centre status. NVRSO data support a standard of more than 60 elective AAA repairs and 50 CEAs per Trust per year. A minimum of seven vascular surgeons per unit was associated with better outcomes. These data support the ongoing remodelling of vascular services in the UK.

Lifelong surveillance is not cost-effective after endovascular aneurysm repair (EVAR), but is required to detect aortic complications which are fatal if untreated (type 1/3 endoleak, sac expansion, device migration). Aneurysm morphology determines the probability of aortic complications and therefore the need for surveillance, but existing analyses have proven incapable of identifying patients at sufficiently low risk to justify abandoning surveillance. This study aimed to improve the prediction of aortic complications, through the application of machine-learning techniques. Patients undergoing EVAR at 2 centres were studied from 2004–2010. Aneurysm morphology had previously been studied to derive the SGVI Score for predicting aortic complications. Bayesian Neural Networks were designed using the same data, to dichotomise patients into groups at low- or high-risk of aortic complications. Network training was performed only on patients treated at centre 1. External validation was performed by assessing network performance independently of network training, on patients treated at centre 2. Discrimination was assessed by Kaplan-Meier analysis to compare aortic complications in predicted low-risk versus predicted high-risk patients. 761 patients aged 75 +/− 7 years underwent EVAR in 2 centres. Mean follow-up was 36+/− 20 months. Neural networks were created incorporating neck angu- lation/length/diameter/volume; AAA diameter/area/volume/length/tortuosity; and common iliac tortuosity/diameter. A 19-feature network predicted aor- tic complications with excellent discrimination and external validation (5-year freedom from aortic complications in predicted low-risk vs predicted high-risk patients: 97.9% vs. 63%; p < 0.0001). A Bayesian Neural-Network algorithm can identify patients in whom it may be safe to abandon surveillance after EVAR. This proposal requires prospective study.

Mortality after lower limb amputation is high, with UK 30-day mortality rates of 9-17%. We performed a retrospective analysis of factors affecting early and late outcome after lower limb amputation for peripheral vascular disease or diabetic complications at a UK tertiary referral vascular centre between 2003 and 2010. Three hundred and thirty-nine patients (233 male), of median (IQR [range]) age 73 (62-79 [26-92]) years underwent amputation. Thirty-day mortality was 12.4%. On regression modelling, the risk of 30-day mortality was increased in patients of ASA grade ≥ 4 (OR 4.23, 95% CI 2.07-8.63), p 79 years (HR 2.78, 95% CI 1.82-4.25), p

Background— Contemporary data from Western populations suggest steep declines in abdominal aortic aneurysm (AAA) mortality; however, international trends are unclear. This study aimed to investigate global AAA mortality trends and to analyze any association with common cardiovascular risk factors. Methods and Results— AAA mortality (1994–2010) using International Classification of Diseases codes were extracted from the World Health Organization mortality database and age standardized. The World Health Organization InfoBase and International Mortality and Smoking Statistics provided risk factor data. Nineteen World Health Organization member states were included (Europe, 14; Australasia, 2; North America, 2; Asia, 1). Regression analysis of temporal trends in cardiovascular risk factors (1946–2010) was done independently for correlations to AAA mortality trends. Global AAA mortality trends show substantial heterogeneity, with the United States and United Kingdom recording the greatest national decline, whereas internationally, male individuals and those P ≤0.03), cholesterol ( P ≤0.03), and smoking prevalence ( P ≤0.02) in males and females. Body mass index demonstrated a negative linear association with AAA mortality ( P ≤0.007), whereas fasting blood glucose showed no association. Conclusions— AAA mortality has not declined globally, and this study reveals that differences between nations can be explained by variations in traditional cardiovascular risk factors. Declines in smoking prevalence correlate most closely with declines in AAA mortality, and a novel obesity paradox has been identified that requires further investigation. Public health measures could therefore further reduce global AAA mortality, with greatest benefits in the younger age group.

Background Endovascular aneurysm sealing (EVAS) was developed with the intention of expanding the anatomical limitations of conventional endovascular aneurysm repair devices and decrease rates of reintervention secondary to migration and type II endoleaks in treatment of abdominal aortic aneurysms. 1 Since its inception, EVAS has gained much popularity especially for patients with concomitant common iliac aneurysms, with good long-term durability suggested by several studies. Currently, the known complications of EVAS, while considered uncommon, include endoleaks, renal artery, and limb thrombosis. 2 This report emphasizes the importance of vigilance in terms of early recognition of unusual complications after EVAS and describes the successful management of type B aortic dissection after EVAS, which is a novel complication of EVAS not previously described. Method We describe a rare case of type B aortic dissection after EVAS and discuss the possible causes. Result After diagnosis of progressive type B aortic dissection after EVAS, patient underwent emergency thoracic endovascular aortic repair with carotid to subclavian bypass for the aortic dissection with good results. He was discharged well with return to his baseline function. Conclusions Aortic dissection is a potentially catastrophic complication of EVAS and with prompt recognition and monitoring, adverse complications may be averted.

Screening for abdominal aortic aneurysm (AAA) has been shown to be effective at reducing AAA-related mortality and is cost-effective. There are, however, significant variations in AAA screening protocols between healthcare systems and numerous challenges to be overcome. Further evidence of cost- and clinical effectiveness is likely to be required before there is widespread international adoption of AAA screening.

To report a systematic review and meta-analysis of outcomes following endovascular aneurysm repair (EVAR) in patients with hostile neck anatomy (HNA) vs. those with favorable neck anatomy (FNA).Systematic review and meta-analysis of data on EVAR in patients with HNA and FNA was performed by 2 reviewers in February 2013. An eligible study was required to have at least 50 participants and to incorporate one or more of the HNA criteria of neck length15 mm, neck diameter28 mm, and/or angulation60°. Of the 24 full-length articles ultimately reviewed, 8 were excluded, resulting in 16 articles that were suitable for inclusion in the meta-analysis. The study size ranged from 55 to 5183 participants, with a total of 8920 patients in the FNA group and 3039 patients in the HNA group. Mean follow-up ranged from 9 to 49 months.Analysis of the pooled data revealed a significant increase in 30-day mortality (2.4% FNA vs. 3.5% HNA; OR 1.60, 95% CI 1.13 to 2.27; p0.01), intraoperative adjuncts (8.8% FNA vs. 15.4% HNA; OR 1.88, 95% CI 1.15 to 3.07; p=0.01), and 30-day migration (0.9% FNA vs. 1.6% HNA; OR 2.08, 95% CI 1.20 to 3.62; p=0.009) in patients with HNA. A decrease in primary technical success (97.5% FNA vs. 93.8% HNA; OR 0.41, 95% CI 0.18 to 0.93; p=0.03) was significant when all 3 criteria were used to define HNA. For outcomes at30 days, the increase in secondary interventions (OR 1.29, 95% CI 1.00 to 1.66; p=0.05) approached significance, but aneurysm-related mortality, all-cause mortality, migration, and aortic rupture did not achieve statistical significance. There was no difference in rates of sac expansion. Analysis of endoleak rates revealed a significant increase in 30-day type I endoleaks (OR 2.92, 95% CI 1.61 to 5.30; p0.001) and late type I endoleaks (OR 1.71, 95% CI 1.31 to 2.23; p0.0001) in patients with HNA.These results suggest that performing EVAR in patients with HNA increases the technical difficulty and results in poorer short-term outcomes. The higher rates of early and late type I endoleaks, along with secondary interventions, suggest that increased monitoring should be performed in this category of patient to ensure rapid treatment.

Background Lifelong surveillance is standard after endovascular repair of abdominal aortic aneurysm (EVAR), but remains costly, heterogeneous and poorly calibrated. This study aimed to develop and validate a scoring system for aortic complications after EVAR, informing rationalized surveillance. Methods Patients undergoing EVAR at two centres were studied from 2004 to 2010. Preoperative morphology was quantified using three-dimensional computed tomography according to a validated protocol, by investigators blinded to outcomes. Proportional hazards modelling was used to identify factors predicting aortic complications at the first centre, and thereby derive a risk score. Sidak tests between risk quartiles dichotomized patients to low- or high-risk groups. Aortic complications were reported by Kaplan–Meier analysis and risk groups were compared by log rank test. External validation was by comparison of aortic complications between risk groups at the second centre. Results Some 761 patients, with a median age of 75 (interquartile range 70–80) years, underwent EVAR. Median follow-up was 36 (range 11–94) months. Physiological variables were not associated with aortic complications. A morphological risk score incorporating maximum aneurysm diameter (P < 0·001) and largest common iliac diameter (measured 10 mm from the internal iliac origin; P = 0·004) allocated 75 per cent of patients to a low-risk group, with excellent discrimination between 5-year rates of aortic complication in low- and high-risk groups at both centres (centre 1: 12 versus 31 per cent, P < 0·001; centre 2: 12 versus 45 per cent, P = 0·002). Conclusion The risk score uses commonly available morphological data to stratify the rate of complications after EVAR. The proposals for rationalized surveillance could provide clinical and economic benefits.

Objective Abdominal aortic aneurysm (AAA) is a condition that mainly affects elderly men. At present, there is no effective medical therapy that can retard aneurysm growth or prevent aneurysm rupture. There is evidence that angiogenesis within the wall of an aortic aneurysm may play key roles in aneurysm progression as well as rupture. The use of anti-angiogenic therapy as potential medical therapy in AAA is a promising strategy but has never been studied in detail. Design This paper discusses the basic mechanisms of angiogenesis, the role played by angiogenesis in aortic aneurysms and the potential therapeutic role of anti-angiogenic drugs against aneurysm expansion or rupture. Results Angiogenesis is a multi-step process which is fundamental for growth and differentiation of various tissues within a multi-cellular organism. Hypoxia and inflammation are key stimuli for activation of neoangiogenesis. Investigations in both human tissues and animal models of AAA have shown that angiogenesis is a pathological hallmark of AAA and appears to play a role in the development and progression of the condition. Pre-clinical studies have shown that anti-angiogenic drugs can potentially be effective in reducing the intensity of aneurysm formation, suggesting that such drugs may potentially be useful as novel drug therapy for AAA in humans. Conclusion Current evidence suggests that angiogenesis contributes to the destructive processes within aneurysmal aortic wall. As novel drug therapy for aortic aneurysms (for use in humans) is still eluding researchers, anti-angiogenic pathway appears to be an attractive approach.