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We demonstrate a simple, intraoperative modification to a 65 cm Beacon Tip Kumpe catheter (Cook Medical) using readily-available components in order to increase its functionality during endovascular procedures. The steerable endovascular catheter has near-spherical range, improving accessibility to challenging anatomy over conventional catheters as demonstrated by our qualitative modeling. In addition, the modification provides structural reinforcement at the catheter tip leading to precise wire advancement. Use of the steerable catheter was demonstrated in vivo during contralateral gate cannulation of an endovascular aneurysm repair, however it holds broad applications in visceral, branched and fenestrated cannulations. Physician-modified devices offer the potential to improve endovascular techniques and reduce additional procedure costs while avoiding regulatory board approval required of novel steerable endovascular devices.

Presented is a patient with carotid artery stenosis resulting in crescendo anterior and posterior circulation transient ischemic attacks. Treatment was complicated by a rare persistent hypoglossal artery (HGA) arising from the left internal carotid artery in addition to severe contralateral carotid disease, hypoplastic vertebral arteries, and incomplete circle of Willis. A carotid endarterectomy with shunting was performed, maintaining perfusion of both the proper left internal carotid artery and HGA. This is a rare case of carotid stenosis in the setting of a persistent HGA with contralateral carotid disease and highlights the importance of planning intracranial perfusion before carotid surgery.

Objective Angioplasty is a fundamental treatment for atherosclerotic disease and may be performed as the sole therapy in small vessel disease. However, the ideal duration of balloon inflation has not yet been identified. Our study investigated whether prolonged inflation of at least 1-min duration, when compared with brief inflation, affects residual stenosis after arterial angioplasty. Data sources and methods Two independent reviewers conducted a systematic review of EMBASE, MEDLINE, CENTRAL, trial registries and grey literature, using pre-specified search syntax. Data abstraction and quantitative analysis was performed independently, according to pre-specified criteria. The primary outcome was residual stenosis after initial angioplasty, in addition to other pre-specific clinical and radiographic outcomes. All analyses were stratified by coronary, cerebrovascular, and peripheral territory. The study protocol is published and registered on PROSPERO (CRD42018092702). Results Six relevant articles were identified, of which one investigated peripheral vascular angioplasty and five investigated coronary artery angioplasty, encompassing 1496 procedures. The studies were at moderate risk of bias. Minimal heterogeneity within coronary studies allowed for subgroup meta-analysis. Prolonged inflation was significantly associated with lower risk of residual stenosis post-inflation in the pooled coronary trials (RR 1.76 [95% CI 1.46–2.12], I2 = 0%, p

Atherosclerosis remains a leading cause of morbidity and mortality, with revascularization remaining a cornerstone of management. Conventional revascularization modalities remain challenged by target vessel reocclusion-an event driven by mechanical, thrombotic, and proliferative processes. Despite considerable advancements, restenosis remains the focus of ongoing research. Adjunctive agents, including dipyridamole, offer a multitude of effects that may improve vascular homeostasis. We sought to quantify the potential therapeutic impact of dipyridamole on vascular occlusion. We performed a literature search (EMBASE and MEDLINE) examining studies that encompassed 3 areas: (1) one of the designated medical therapies applied in (2) the setting of a vascular intervention with (3) an outcome including vascular occlusion rates and/or quantification of neointimal proliferation/restenosis. The primary outcome was vascular occlusion rates. The secondary outcome was the degree of restenosis by neointimal quantification. Both human and animal studies were included in this translational analysis. There were 6,839 articles screened, from which 73 studies were included, encompassing 16,146 vessels followed up for a mean of 327.3 days (range 7-3650 days). Preclinical studies demonstrate that dipyridamole results in reduced vascular occlusion rates {24.9% vs. 48.8%, risk ratio 0.53 [95% confidence interval (CI) 0.40-0.70], I2 = 39%, P < 0.00001}, owing to diminished neointimal proliferation [standardized mean differences -1.13 (95% CI -1.74 to -0.53), I2 = 91%, P = 0.0002]. Clinical studies similarly demonstrated reduced occlusion rates with dipyridamole therapy [23.5% vs. 31.0%, risk ratio 0.77 (95% CI 0.67-0.88), I2 = 84%, P < 0.0001]. Dipyridamole may improve post-intervention vascular patency and mitigate restenosis. Dedicated studies are warranted to delineate its role as an adjunctive agent after revascularization.

Background Endovascular therapy is a fundamental treatment for peripheral arterial disease. However, the success rate of endovascular therapy remains poor, as a third of patients with critical limb ischemia ultimately require a major amputation for gangrene despite endovascular treatment. This failure rate has prompted investigation into methods of determining physiologic procedural success before and after treatment, before clinically apparent outcomes occur such as gangrene. The aim of this systematic review is to evaluate if in patients undergoing endovascular surgery for lower extremity atherosclerotic peripheral arterial disease, do changes in physiologic measures of perfusion during surgery correlate with clinical outcomes. Methods We registered and designed a study protocol for a systematic review. Literature searches will be conducted in MEDLINE, EMBASE, and CENTRAL (from January 1977 onwards). Grey literature will be identified through OpenGrey and clinical trial registries, and supplemented by citation searches. We will include randomized controlled trials, quasi-experimental trials, and observational (cohort, case-control) studies conducted in human adults (age 18 or older) who received elective arterial angioplasty for atherosclerotic peripheral vascular disease. The primary outcome of interest will be major adverse limb events. Two investigators will independently screen all citation, full-text articles, and abstract data. The study quality (risk of bias) will be appraised appropriate tools. Data analysis and synthesis will be qualitative; no meta-analysis is planned, as the anticipated homogeneity of measurement and outcome reporting standardization is low. Discussion The treatment of peripheral arterial disease is unique in that the tissue of the ischemic leg is easily accessible for direct monitoring during procedures. This is contrasted with cardiac and neurologic monitoring during cardiac and cerebral procedures, where indirect or invasive measures are required to monitor organ perfusion. Currently synthesized evidence describing limb perfusion focuses on static states of ischemia, and does not evaluate the value of change in perfusion measurement as an indicator of endovascular treatment success. These methods could potentially be applied to optimize procedural outcomes by guiding perfusion-based decision-making during surgery. Systematic review registration PROSPERO CRD42019138192

We investigated the yield of ultrasound surveillance for small abdominal aortic aneurysms (AAAs) in patients older than 80 years compared with a younger population for detecting AAA growth reaching the threshold size for repair. Secondary objectives included analysis of the incidence of AAA repair and the cost-benefit of surveillance.A retrospective cohort study was performed of all patients undergoing AAA surveillance in Ottawa between 2007 and 2015. Patients were dichotomized by enrollment age (80 years vs ≥80 years) and stratified by enrollment AAA size. Cohorts were cross-referenced with the Ottawa surgical database, leveraging the common health region to ensure complete data capture. The threshold size for repair was sex specific (female, 5.0 cm; male, 5.5 cm). Factors influencing AAA growth rate were assessed with a general linear multiple mixed model. Analyses with Cox proportional hazards models with competing risk for mortality assessed aorta-related events, and cost-benefit was analyzed by referencing Ontario billing codes.A total of 1231 patients underwent serial ultrasound surveillance, of whom 500 were older than 80 years at some point during the study period. The mean AAA growth rate was 1.63 mm/y (95% confidence interval [CI], 1.54-1.71). Old age and small enrollment aneurysm size were significantly protective against AAA growth. Overall, 357 (29%) patients reached the AAA size threshold for repair, and 272 (22%) underwent AAA repair. Patients older than 80 years were less likely to reach the AAA threshold size for repair compared with their younger counterparts (adjusted hazard ratio, 0.77; 95% CI, 0.61-0.97). Of the 357 patients whose AAA reached the threshold size for repair, octogenarians were substantially less likely to undergo elective AAA repair (adjusted hazard ratio, 0.34; 95% CI, 0.24-0.47). Repair of ruptured AAA was rare (0.8%), and age differences were insignificant. For every octogenarian with an enrollment AAA size between 3.0 and 3.9 cm who ultimately received elective AAA repair, 51 patients were enrolled in surveillance without elective repair. This corresponded to an estimated $33,139 in ultrasound fees.Surveillance of most patients with small AAA is appropriate. However, patients older than 80 years were significantly less likely than their younger counterparts to experience aortic growth reaching the threshold size for repair. Furthermore, in the unlikely event of AAA growth, patients older than 80 years were substantially less likely to undergo repair. These results suggest that in the context of patient-specific health and wishes, surveillance of AAAs 4 cm in octogenarians is costly and unlikely to be beneficial.

Inpatient treatment of peripheral artery disease (PAD) is more than six times as costly as that of the general inpatient population. Our objective was to describe factors associated with hospital cost for patients admitted for PAD, the characteristics of high-cost patients, and their outcomes including amputations and death.We performed a retrospective cohort study of admitted patients receiving a procedure for PAD at The Ottawa Hospital between 2007 and 2016. Demographics, comorbidity, inpatient events, and hospital cost data during the index admission were collected. We defined high-cost patients as those whose total costs of index admission were in the tenth percentile and above. Features associated with high-cost status were examined using logistic regression with elastic net regularization. We used generalized linear models to examine overall drivers of cost.We identified 3084 eligible patients, incurring $72.2 million in hospital costs. The mean cost of the most expensive 10% of patients was $88,076 (standard deviation, $54,720), more than five times the mean cost of $16,217 (standard deviation, $10,322) for nonhigh-cost patients. High-cost patients were more likely to present urgently (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.16-2.25; P .01). After adjustment for preadmission factors, high-cost patients were more likely to have experienced an adverse patient safety incident (OR, 13.49; 95% CI, 6.97-24.8; P .01), amputation (OR, 2.79; 95% CI, 1.68-4.49; P .01), intensive care unit admission (OR, 6.42; 95% CI, 3.62-10.2; P .01), and disposition barriers requiring alternate level of care status (OR, 10.44; 95% CI, 6.42-15.2; P .01). The high-cost group was more likely to have received hybrid revascularization (OR, 7.07; 95% CI, 3.34-13.6; P .01). High-cost patients had higher than predicted in-hospital mortality (18% vs 9.2% predicted) compared with the low-cost group (3.0% vs 2.7%; P .001), and fewer than half of high-cost patients were discharged home.Providing hospital care for the top 10% most expensive patients in our cohort was more than five times as costly per patient than providing care for the nonhigh-cost patients. Whereas pre-existing factors may predispose a patient to require expensive care, there are potentially modifiable factors during the admission that could reduce costs of these patients.

Objective Infrarenal aortic neck angulation is one of the most powerful predictors of endovascular aneurysm repair failure. Whereas the “gold standard” to measure this angle is three-dimensional (3D) reconstruction and centerline measurement, many surgeons rely on estimations of angulation based on two-dimensional (2D) views of computed tomography imaging. Unfortunately, these views do not accurately represent the true angle, particularly if aortic angulation is oblique to the standard views. In response to this issue, our group has developed a novel trigonometric formula that uses coronal and sagittal measured angles to calculate the true angle. The purpose of this study was to compare the paired angle formula with 3D centerline measurements for estimating true aortic neck angulation. Methods Fifty randomly selected patients treated by endovascular aneurysm repair at The Ottawa Hospital between 2010 and 2015 were studied. The 3D centerline aortic neck angle measurements were made by a radiology staff physician. The paired angle formula was applied by a vascular surgeon, resident, and student using 2D coronal and sagittal angles from computed tomography imaging to estimate the true angle. Results The average age was 78 years; 74% of patients were male, and average preoperative aneurysm diameter was 5.7 cm. The mean neck length was 1.9 cm (1.1-3.2 cm), and mean neck angulation calculated by the gold standard measurements was 39 degrees (2-84 degrees). Linear regression demonstrated strong association between 3D measurements and the paired angle formula, with correlations comparable to the intraobserver variability (intraclass correlation coefficient values range, 0.74-0.87). The average user estimates deviated minimally from the gold standard (absolute difference, 6 degrees; 95% confidence interval, 4-8 degrees) without systemic bias. The paired angle formula accurately ruled out severe angulation >60 degrees with an overall negative predictive value of >99%. Compared with isolated 2D measurements, application of the paired angle formula significantly decreased the false-negative rate of unappreciated severe angulation >60 degrees from 4.8% to 0.7% (P = .032). Conclusions The paired angle formula detects significantly more severe angles than isolated 2D measurements and can accurately rule out severe angulation >60 degrees compared with the 3D measurements. The implementation of this angle estimation method is a useful adjunct in the measurement of aortic neck angulation, especially if 3D reconstruction software is not readily available. Furthermore, the importance of accurate angle measurement is not limited to vascular surgery and has direct relevance to any procedural specialty that relies on preoperative angle measurements.

The Enhanced Recovery After Surgery (ERAS) Society has set out to improve patient recovery by developing evidence-based perioperative practices. Many institutions and other specialties have begun to apply their principles with great success; however, ERAS principles focus mostly on general surgery, and their applicability to other specialties, such as vascular surgery, is less clear. We sought to investigate the current standard of perioperative care in Canadian vascular surgery by assessing surgeons' perceptions of evidence supporting ERAS practices, identifying barriers to aligning them and identifying aspects of perioperative care that require research specific to vascular surgery before they could be broadly applied.We administered an online survey with 26 questions to all Canadian Society for Vascular Surgery members.Respondents varied largely in perioperative practice, most notably in the use of nasogastric tubes, Foley catheters and neck drains. Familiarity with supporting evidence was poor. Approximately half (44%) of respondents were not familiar with contrary evidence, while those who were often perceived institutional barriers to change. Finally, one-third (30%) of respondents felt that relevant evidence did not exist to support changing their practice.The variability of perioperative practice in Canadian vascular surgery is likely due to multiple factors, including a lack of specific evidence. Further research in areas of perioperative vascular care where the current standard of practice varies most greatly may help improve recovery after vascular surgery in Canada over simply adopting existing ERAS principles.L’Enhanced Recovery After Surgery Society (ERAS) cherche à améliorer la convalescence des patients en mettant au point des pratiques périopératoires basées sur des données probantes. Beaucoup d’établissements et d’autres spécialités ont commencé à appliquer les principes de l’ERAS avec beaucoup de succès, mais ceux-ci visent principalement la chirurgie générale, et leur applicabilité à d’autres spécialités, comme la chirurgie vasculaire, est moins claire. Nous avons cherché à étudier la norme actuelle de soins périopératoires en chirurgie vasculaire au Canada en évaluant les perceptions qu’ont les chirurgiens des données probantes à l’appui des pratiques de l’ERAS et en cernant les obstacles à leur harmonisation et les aspects des soins périopératoires devant faire l’objet d’une recherche particulière à la chirurgie vasculaire avant qu’on puisse les généraliser.Nous avons mené un sondage en ligne de 26 questions auprès de tous les membres de la Société canadienne de chirurgie vasculaire.La pratique périopératoire des répondants variait considérablement, surtout en ce qui concerne l’usage des sondes naso-gastriques, des cathéters de Foley et des drains de cou. La connaissance des données probantes à l’appui était faible. Environ la moitié (44 %) des répondants ne connaissaient pas bien les données probantes allant à l’encontre de ces pratiques, et ceux qui les connaissaient percevaient souvent des obstacles institutionnels au changement. Enfin, le tiers (30 %) des répondants étaient d’avis qu’aucune donnée probante pertinente ne justifiait un changement de pratique.La variabilité de la pratique périopératoire en chirurgie vasculaire au Canada est probablement attribuable à de multiples facteurs, y compris le manque de données probantes précises. Des recherches plus poussées dans les domaines des soins vasculaires périopératoires où la norme actuelle de pratique varie le plus pourraient aider à améliorer la convalescence après une chirurgie vasculaire au Canada par rapport à la simple application des principes de l’ERAS.

To the Editor, Continuous peripheral nerve blocks are susceptible to various complications, including leakage from the catheter insertion site which increases the risk of leakage of the bolus of injectate. This has the potential to disrupt the adhesive dressing and may further compromise the sterility of the surgical field if leakage occurs during the operation. Continuous interscalene brachial plexus blocks are commonly administered for pain control following shoulder and upper arm surgery. A prior study of complications of continuous interscalene analgesia showed a 9.3% incidence of leakage at the catheter site. We conducted a prospective randomized study to test the hypothesis that interscalene catheter-over-needle (CON) assemblies are clinically less prone to leakage at the insertion site compared with conventional catheterthrough-needle (CTN) counterparts. The primary outcome of the study was leakage from the catheter insertion site. Secondary outcomes were block performance time (the time from the initial skin puncture to first application of Tegaderm dressing) and pain scores in recovery and at 24 and 48 hr post-surgery. An 11-point visual analogue scale in which 0 indicated ‘‘no pain’’ and 10 indicated ‘‘worst pain imaginable’’ was used to record pain scores. The study was conducted from May 2012 to September 2012 at the University of Alberta Hospital. Following approval from the University of Alberta Health Research Ethics Board (January 2012) and informed written consent, adult patients admitted for shoulder surgery or surgery of the proximal humerus were randomly assigned using sealed envelopes to the CON (catheter-over-needle: study) or CTN (catheter-through-needle: control) group. Patients were blinded to the allocation, as was a member of the research team who collected follow-up data. Ultrasound-guided interscalene brachial plexus blocks using the CTN and CON methods were performed as previously described. All blocks were performed by staff regional anesthesiologists or by supervised regional anesthesia trainees. After insertion of the catheter, general anesthetic was administered to patients in both groups. A nerve block catheter remained in each of the patients in both groups throughout the operation and in the postoperative period with local anesthetic infusion with bolus dose for two to three days. Ten patients, six in the CON group and four in the CTN group, were approached and consented to participate in the trial. After the fourth CTN patient, the study was terminated at the request of our surgical colleagues (see below). None (0/6) of the CON patients experienced leakage around the catheter, and none required catheter remanipulation or fortification during the perioperative period (Table). Based on the ‘‘rule of three’’, the 95% confidence interval for the occurrence of leakage in CON patients was 0 to 0.5. In contrast, all CTN patients (4/4) experienced leakage around the perineural catheter during the perioperative period. One CTN catheter migrated out on postoperative day one, and two CTN catheters required fortification with gauze to address leakage. One CTN catheter was removed just before surgery due to excessive leakage; this case has been described previously. Following this case, the study had to be terminated earlier than anticipated at the surgeon’s request due to ClinicalTrials.gov Identifier: NCT01522053.

Cases of isolated spontaneous celiac trunk dissections have been appearing in the literature more recently with the increased availability of high-resolution computerized tomography angiograms. We report a unique case of this entity. A 48-year-old woman presented with acute abdominal pain that radiated to the back and worsened with breathing. This was diagnosed as a celiac trunk dissection by computerized tomography angiogram. She was treated conservatively with antihypertensive medications, anticoagulants, and opioid medication for pain control.