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Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive surgery for repairing thoracic aneurysms and dissections. This study aims to compare postoperative outcomes of TEVAR performed under general versus locoregional anesthesia.Utilizing the 2008-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients older than the age of 18 years who received TEVAR, were identified using the following current procedural terminology codes: 33880, 33881, 33883, 33884, or 33886. Patients who underwent concomitant procedures, those with both thoraco-abdominal and abdominal aortic pathologies, and trauma cases were excluded. Standard descriptive statistics, in addition to χOf the 1,028 patients included in the study, 86.5% received general anesthesia, and 13.5% received locoregional anesthesia, such as local anesthesia with monitored anesthesia care or regional anesthesia. No significant differences were found between patients receiving locoregional vs general anesthesia in mortality (3.6% vs 7.9%, respectively, p=0.071) and morbidity (18.7% and 24.8%, respectively, p=0.121) within 30 days post-TEVAR, including any wound, pulmonary, thromboembolic, renal, septic, and cardiac arrest complications. Patients who received general anesthesia had significantly higher median LOS compared to those who received locoregional anesthesia [5 days (IQR: 3-10) vs 4 days (IQR: 2-7), p=0.002], with 34.3% of the general anesthesia group having a LOS greater than 7 days compared to 21.6% of locoregional anesthesia group, p=0.003. On multivariable logistic regression analysis, general anesthesia was found to be an independent predictor of prolonged LOS greater than 7 days (OR: 1.72, 95% CI: 1.05-2.81, p=0.031).Locoregional anesthesia results in significantly lower postoperative hospital LOS with similar postoperative mortality and morbidity compared to general anesthesia in patients undergoing TEVAR.

Endovascular aortic aneurysm repair (EVAR) has become the most common procedure for treating abdominal aortic aneurysms based on multiple studies conducted in the western world. The implication of such findings in developing countries is not well demonstrated. The objective of this study was to compare medical outcomes and costs of EVAR and open surgical repair (OSR) in a developing country.This is a retrospective study of all patients undergoing elective abdominal aortic aneurysm repair between 2005 and 2020 at a tertiary medical center in a developing country. Medical records were used to retrieve demographics, comorbidities, and perioperative complications. Medical records were also used to provide data on the need of reintervention, date of last follow-up, and mortality.The study included a total of 164 patients. Median follow-up time was 41 months. The mean age was 69.9 +/- 7.84 years and 90.24% (n = 148) of patients were males. Regarding long-term mortality outcomes, no significant difference was detected between both groups; OSR patients had a survival rate of 91.38% and 74.86% at 5 and 10 years, compared to 77.29% and 56.52% in the EVAR group (P value = 0.10). Both groups had comparable long-term reintervention rates (P value = 0.334). The OSR group was charged significantly less than the EVAR group ($27,666.35 vs. $44,528.04, P value = 0.008).OSR and EVAR have comparable survival and reintervention outcomes. Unlike what was reported in developed countries, patients undergoing OSR in countries with low hospital stay costs incur lower treatment costs.

Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients.LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA.In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations.The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.

Objectives The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE). Methods This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis. Results Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01). Conclusion ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Highlights Abstract Background: A postoperative chest x-ray (CXR) remains part of some hospital protocols following tunneled hemodialysis catheter placement despite the use of operative imaging-guided techniques. The aim is to assess the usefulness of this practice and its impact on clinical outcomes and resource use. Methods: A review of medical records and postoperative CXR was done for 78 adult patients who had tunneled hemodialysis catheters placed in the operating room under fluoroscopy guidance. Catheters were inserted by ultrasound-guided puncture (51.3%) or exchanged from an existing catheter over a guide wire (48.7%). The postoperative CXRs were also examined by an independent reviewer to assess the catheter tip position and the need for repositioning to mimic a real-life postoperative setting. Procedural, nursing, and billing records were also reviewed. Results: No patients had a pneumothorax or major complications. On postoperative CXRs, 29 (37.2%) patients had the catheter tips in the right atrium, 23 (29.5%) in the cavoatrial junction, 25 (23.1%) in the superior vena cava, and 1 (1.3%) in the brachiocephalic vein. The independent reviewer found the catheter tips in acceptable anatomical positions in 75 of 78 patients. Only 3 (3.9%) patients had catheter malfunctions during dialysis and exchanged their catheters (2 had high catheters in the superior vena cava and brachiocephalic vein, 1 had a kinked catheter). Postoperative CXRs also caused delays in patient discharge from postanesthesia care units and significant increases in medical expenses (around $199 per patient). Conclusion: Routine CXR after tunneled hemodialysis central venous catheter insertion is unnecessary and does not add to the procedure’s safety or to the patient’s outcome.

Background: A 69-year-old man underwent ligation and evacuation of a popliteal artery aneurysm with a femoral-to-popliteal vein bypass. He had a history of Citrobacter koseri prostatitis two months...

Poor nutritional status is common among patients undergoing lower extremity amputation (LEA). In this study, the association between preoperative hypoalbuminemia, a marker for malnutrition, and postoperative mortality in patients undergoing LEA was explored.Data on patients undergoing LEA between 2005 and 2017 were retrospectively analyzed from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database. Patients were divided into clinically relevant categories based on their serum albumin level (2.5, 2.5-3.39, ≥3.4 g/dl) and were further stratified according to amputation level. Operative death was compared across groups and multivariable logistic regression was performed to estimate risk-adjusted odds ratio (AOR).In 35,383 patients, the rate of 30-day postoperative mortality was 7.6% (n = 2693). Mortality rate was highest in patients with very low albumin levels (11%) as compared to low (6.8%) and normal levels (3.9%). On multivariable analysis, lower albumin levels emerged as a risk-adjusted independent predictor of mortality. After risk-adjustment, patients with very low albumin levels (AOR [95% CI]: 2.25 [1.969-2.56], P0.001) and low albumin levels (AOR [95% CI]: 1.42 [1.239-1.616], P0.001) had higher odds of mortality when compared to patients with normal albumin levels. On sensitivity analysis, a similar trend was seen in patients undergoing above knee amputation but not in patients undergoing minor amputations.In patients undergoing major LEA, hypoalbuminemia is associated with an increased risk of postoperative mortality in a dose response manner, specifically in above knee amputations. Monitoring and optimizing patients' nutritional status before surgery, when possible, may be warranted and should be further explored.

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

Mass casualty incidents can be devastating events associated with a large number of fatalities, morbidities, and long-lasting sequelae. The negative outcomes can be further amplified if the incident occurred during a pandemic surge, such as what occurred in Beirut, Lebanon with the August 4, 2020 Beirut Port explosion. To decrease the mortality and morbidity and avoid inefficiency, management depends on having an established coordinated multidisciplinary approach from transport and triage to emergency department care and in-hospital management. In this article, the mass casualty management and the impact of the coronavirus disease 2019 pandemic will be discussed based on the American University of Beirut Medical Center experience.

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

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

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

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

Objective We sought to perform a systematic, comprehensive, and nationwide cross-sectional analysis of surgical capacity in Lebanon. Background Providing surgical care in refugee areas is increasingly recognized as a global health priority. The surgical capacity of Lebanon where at least 1 in 6 inhabitants is currently a refugee remains unknown. Methods The Surgical Capacity in Areas with Refugees cross-sectional study included 3 steps: (1) geographically mapping all hospitals providing surgical care in Lebanon, (2) systematically assessing each hospital's surgical capacity, and (3) identifying surgical care gaps/disparities. First, a list of hospitals in Lebanon and their locations was generated combining data from the Lebanese Ministry of Health and Syndicate of Hospitals. Specialty, rehabilitation, and maternity facilities were excluded. Second, the validated 5 domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool was administered in each hospital through a face-to-face or phone interview. Hospitals' PIPES indices were computed; data were aggregated and analyzed for geographic and private/public disparities. Results A total of 129 hospitals were geographically mapped; 20% were public. The PIPES tool was administered in all hospitals (100%). The mean PIPES index was 10.98 (Personnel = 14.91, Infrastructure = 15.36, Procedures = 37.47, Equipment = 21.63, Supplies = 24.78). The number of hospital beds, operating rooms, surgeons, and anesthesiologists per 100,000 people were 217, 8, 16, and 9, respectively. Deficiencies in infrastructure were significant, whereby 62%, 36%, 16%, and 5% of hospitals lack incinerators, pretested blood, intensive care units, and computed tomography, respectively. Continuous external electricity was lacking in 16 hospitals (12%). Compared to private hospitals, public hospitals had a lower PIPES index (10.48 vs 11.1, P = 0.022), including lower Personnel and Infrastructure scores (12.31 vs 15.57, P = 0.03; 14.04 vs 15.7, P = 0.003, respectively). Geographically, the administrative governorates with highest refugee concentrations had the lowest PIPES indices. Conclusions Evaluating surgical capacity in Lebanon reveals significant deficiencies, most pronounced in public hospitals in which refugee care is provided and in areas with the highest refugee concentration.

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

An end-to-end anastomosis is usually performed in trauma or for aneurysmal disease to replace an injured or aneurysmal vessel. An end-to-end anastomosis is also used when constructing a composite bypass or when replacing a diseased segment of a bypass. Furthermore, an end-to-end configuration may be chosen when preservation of retrograde flow is not essential, such as in a renal or celiac artery bypass.

When exposing a blood vessel, the approach that provides a simple and direct access to the vessel of interest is usually the most desirable. In general, the skin incision is placed along the longitudinal axis of the vessel to be exposed. This will facilitate proximal and distal extensions of the exposure. Anatomical landmarks or palpation of the pulse are used to select the site of the skin incision. In patients with scarring due to previous procedures (redo operations), or in the presence of infection, an alternate approach may be possible. This may provide access to the blood vessels through non-scarred planes. The common and alternate arterial exposures are listed in Table 4.1. The anatomy and various exposures of these vessels are reviewed in Chap. 3.

When the aortic aneurysm is entered, the orifice of the inferior mesenteric artery should be inspected. If pulsatile backbleeding is noted, it is usually safe to oversew the origin of the inferior mesenteric artery. The orifice is suture ligated from within the aneurysmal lumen to avoid injury to its branches, especially at the junction of the left colic to the sigmoidal and superior rectal branches.

The conditions in which a side-to-side anastomosis is used include the creation of a side-to-side portocaval shunt in portal hypertension, the creation of a side-to-side radiocephalic arteriovenous fistula for chronic hemodialysis, and the creation of a side-to-side arteriovenous fistula distal to an infrainguinal prosthetic bypass as an adjunctive procedure to decrease the outflow resistance. The side-to-side configuration is also used in the construction of the second anastomosis of a sequential bypass when multiple segments of a limb require revascularization.

Neointimal hyperplasia is a leading cause of bypass failure in the intermediate postoperative period (2–24 months). In prosthetic bypasses, neointimal hyperplasia is most likely to develop at the level of the distal anastomosis. Several techniques have been developed in an attempt to improve the patency of infrainguinal prosthetic bypasses. These techniques involve incorporating a segment of vein between the prosthetic bypass and the recipient artery. The theory behind these techniques is that the interposition of the vein segment may ameliorate the future development of neointimal hyperplasia at the level of the distal anastomosis. In addition, incorporating the vein segment could facilitate the construction of the distal anastomosis and improve bypass patency in the immediate postoperative period. Although these techniques were often used, there are very few prospective randomized trials to date that show their efficacy. Furthermore, there are no prospective randomized trials that compare these various techniques in an attempt to identify which technique is best. With the advancement of endovascular technology and the availability of aggressive infrainguinal and infrapopliteal revascularization options, including retrograde pedal and popliteal access, tibial prosthetic bypasses are rarely performed nowadays. Nevertheless, when used as a last resort prior to an amputation, adjunctive techniques may be useful.

During the replacement of an infrarenal abdominal aortic aneurysm, the proximal anastomosis between the graft and the neck of the aneurysm is constructed in an end-to-end fashion. The basic techniques for preparing the neck of the aneurysm for the creation of the proximal anastomosis are illustrated in section “General Principles.” The aneurysm wall is incised longitudinally on its anterior aspect keeping to the right of the origin of the inferior mesenteric artery. The incision in the aorta is carried to the level of the neck of the aneurysm. The incision is then teed off on each side of the neck, leaving the posterior wall intact.

The anatomy and various exposures of the major arteries and veins are outlined in this chapter.

In most bypasses performed for occlusive disease, the proximal and distal anastomoses are constructed in an end-to-side fashion. Such a configuration allows for constructing the proximal anastomosis in the least diseased area of the inflow vessel while maintaining the original circulation. The distal anastomosis is constructed distal to any occlusive pathology and provides both antegrade and retrograde blood flow. The revascularization provided by the end-to-side configuration protects the limb from ischemia between the proximal and distal anastomoses. This condition, often referred to as “interval ischemia,” is more likely to occur when both anastomoses are constructed using an end-to-end configuration. This chapters covers the various techniques for constructing an end to side anastomosis.

Modern vascular surgery became possible with the development of acceptable arterial substitutes. The usefulness of an arterial substitute is determined by several essential qualities. These qualities include porosity, durability, tissue reactivity, and flexibility. The ideal conduit should be impermeable to blood and capable of lasting the duration of the recipient’s life. Graft durability is dependent on its ability to maintain its characteristics and strength over time, resisting dilatation and degeneration. Graft durability is also related to its short- and long-term patency rates. The ideal conduit should be able to resist thrombosis even in low flow states. In addition, its compliance, which measures its volume change with variations in pressure, should match that of the replaced arterial segment. Compliance mismatch has been identified as a possible cause of neointimal hyperplasia, which is a leading cause of graft failure. The graft should also stimulate minimal antigenicity and should not induce significant tissue reaction. The conduit should be flexible with good handling characteristics. It should be resistant to infection and easily available for elective or emergency use. Finally, the graft should be affordable. Vascular grafts can be classified according to their source of origin into autogenous, homologous, bovine, and synthetic (prosthetic) grafts. It is hard to find, in the currently available vascular grafts, one conduit that possesses all the characteristics of the ideal arterial substitute; this explains why the ultimate arterial substitute is still to be developed. In general, in high-flow situations, such as aortic reconstructive surgery, large-caliber prosthetic grafts perform well and are the conduits of choice. In infrainguinal reconstructions, the best performance has been achieved with autogenous conduits.

An incision in an artery (arteriotomy) can be closed either primarily or with a patch. In a primary closure, the edges of the arterial walls are approximated and sutured directly to each other. In a patch closure, also known as patch angioplasty, a patch is used to bridge the defect between the edges of the incision. The choice of the closure method depends on various factors. These factors include the size of the artery, the direction and the shape of the arteriotomy, and the presence of atherosclerotic plaque at the arteriotomy site.

The main principles of constructing a bypass for infrainguinal occlusive disease include: 1. Identifying a soft arterial segment proximal to the occlusive disease to serve as an inflow source 2. Identifying a soft arterial segment distal to the occlusive disease to serve as a suitable outflow vessel 3. Connecting these two arterial segments with a conduit, preferably a single segment of autogenous great saphenous vein

This chapter discusses some techniques and tricks that are helpful for all vascular surgeons and interventionalists.

The technique used for the construction of the proximal aortic anastomosis in a patient with a thoracoabdominal aortic aneurysm depends on the extent of the aneurysmal pathology and the relationship of the aneurysm to the orifices of the celiac, superior mesenteric, and the right and left renal arteries.

Preservation of pelvic perfusion should be an integral part of any aortic reconstructive procedure. Pelvic ischemia is an important complication that may, on occasion, be fatal. The clinical manifestations of pelvic ischemia include buttock claudication, buttock necrosis, rectosigmoidal ischemia, cord ischemia resulting in urinary and fecal incontinence, and sexual dysfunction. A knowledge of the pelvic blood supply is essential to understanding and planning the preservation of pelvic perfusion during aortic reconstruction.

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

Background: Vascular infections are rare and challenging conditions with significant deaths and morbidity. Their management necessitates a multi-disciplinary approach and substantial human and financial resources. The management selected may be influenced by the available resources in low- and middle-income countries (LMICs), where such resources may be variable. Methods: We reviewed the published literature and reviewed the management options for various vascular infections with a focus on carotid, aortic, infrainguinal, and dialysis access infections. Results: Recommendations related to prevention and treatment will be offered from the perspective of LMICs. The general principles for prevention are in compliance with established surgical site infection guidelines and minimize the use of prosthetic material. Early detection and intervention by removing all infected prosthetic material, debridement, drainage, and coverage of the infected field with vascularized tissue are essential steps in the management of the infection. Revascularization using an extra-anatomic or in situ approach is individualized based on the resources and expertise available. Conclusions: The prevention and management of vascular infections in LMICs are effective by adhering to time-proven principles even with limited resources.

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

Transcatheter treatment is becoming the mainstay treatment for structural heart diseases (SHD) in prohibitive surgical risk patients. Recently with the encouraging results, it is being offered to regular risk patients. Peripheral vascular complications (VCs) are still inherent to these procedures due to the nature of this atherosclerotic high-risk group and the profile of the devices. This is a single-center early first year experience with such events occurring after initiating a SHD program treating severe aortic stenosis, aortic regurgitation, mitral valve prolapse and regurgitation, as well as paravalvular leaks. Out of 33 patients in this time period, 5 developed PV complications which are detailed in this article with their associated risk factors and management. These include access-related complications, closure device issues, arterial rupture post device embolization, and vessel dissection. Vascular complications of those procedures take special interest since they are associated with a worse long-term prognosis. Thus, prevention with proper planning remains of essence along with multidisciplinary management.

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

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Background Shifting from a short-term catheter to a long-term one is done either by removing the old catheter and placing a new long-term one via fresh new puncture site, or by replacing the old catheter with a long-term one over a guidewire. Aim We aimed to describe our technique in changing a temporary line to a long-term catheter (LTC) over a guidewire and to determine the incidence of line-related infections following this procedure. Materials and methods A retrospective pilot study was conducted between 2005 and 2010 at the American University of Beirut Hospital. We compared the first group (A), which consisted of 20 patients who underwent exchange of a short-term dialysis catheter with a tunneled one over a guidewire using our technique, to a second group (B) of 60 patients who underwent de-novo LTC placement. The two groups were matched by age, with a follow-up of at least 1 month. Results The technical success rate of the catheter-conversion procedure was 100%. Our results revealed no significant difference of catheter duration between the two groups, with median duration of 6.5 vs. 4.0 days for group A and group B, respectively (p = 0.21). Moreover, there was also no significant mean time difference between any infection and long term catheter (LTC) insertion among the two groups (p = 0.31). Furthermore, there was no difference of catheter infection between the two groups (p = 0.1). Conclusion We concluded that there was no difference in terms of side effects or risk of infection in the guidewire group when compared to standard technique. .