Search

Advances in endovascular technologies have allowed the treatment of common femoral artery (CFA) steno-occlusive disease by minimally invasive means; however, the proportion of lesions treated with common femoral artery endarterectomy (CFAE) which would be amenable to endovascular treatment is unknown. This observational study aimed to describe the morphology and composition of CFA lesions treated with CFAE and report the proportion that would be amenable to endovascular treatment with modern technologies.Patients presenting with symptomatic peripheral artery disease who underwent CFAE from January 2014 to December 2018 in two tertiary NHS hospitals were included. Extensive data relating to patient demographics, risk factors, clinical outcomes, as well as anatomical and morphological characteristics of the CFA atherosclerotic lesions, were collected which included detailed plaque analysis using 3D reconstruction of pre-operative computed tomography angiograms. CFA lesions were considered suitable for endovascular treatment if presented with patent iliac inflow, at least one patent outflow vessel (superficial femoral artery [SFA] or profunda femoral artery [PFA]), and stenotic rather than occluded CFA.A total of 829 CFAs in 737 consecutive patients who underwent CFAE were included (mean age 71 ± 10 years; 526 males, 71%); 451 (62%) presented with chronic limb threatening ischaemia. Overall, 35% of CFAs had a localised lesion (no bifurcation disease) that could possibly be treated endovascularly. In total, 376 (45%) target vessels did not feature severe calcium load, with a patent CFA, PFA, and proximal SFA and therefore would have been amenable to endovascular treatment; while 271 CFAs (33%) featured a significant calcium load which would have potentially required stenting.A significant proportion of patients with atherosclerotic CFA lesions who undergo surgery could potentially be candidates for endovascular treatment. A randomised trial comparing CFAE and new endovascular techniques in this clinical context is required.

Introduction Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). Materials and Methods Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. Results A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97–495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2–41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3–26 months). Conclusion LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

The aims of the present study were to assess the relative proportion of collagen and elastin in the arterial wall and to evaluate the collagen microstructure from the aortic root to the external iliac artery.Arterial wall tissue samples sampled during post-mortem examination from 16 sites in 14 individuals without aneurysm disease were fixed and stained for collagen and elastin. Stained sections were imaged and analysed to calculate collagen and elastin content as a percentage of overall tissue area. Scanning electron microscopy was used to quantify the collagen microstructure at six specific arterial regions.From the aortic root to the level of the suprarenal aorta, the percentages (area fractions) of collagen (ascending, descending, and suprarenal aorta respectively with 95% confidence interval [CI] 37.5%, 31.7 - 43.2; 38.9%, 33.1 - 44.7; 44.8%, 37.4 - 52.1) and elastin (43.0%, 37.3 - 48.8; 40.3%, 34.8 - 46.1; 32.4%, 25.2 - 39.6) in the aortic wall were similar. From the suprarenal aorta to the internal iliac arteries, the percentage of collagen increased (abdominal aorta, common and internal iliac arteries and external iliac artery respectively with 95% CI 50.6%, 42.7 - 58.7; 51.2%, 45.5 - 56.9; 49.2%, 42.0 - 56.4) reaching a double percentage for elastin (23.6%, 15.7 - 31.6; 20.8%, 15.1 - 26.5; 22.2%, 14.9 - 29.5). Mean collagen fibre diameter (MFD) and average segment length (ASL) were significantly larger in the external iliac artery (MFD 6.03, 95% CI 5.95 - 6.11; ASL 22.21, 95% CI 20.80 - 23.61) than in the ascending aorta (MFD 5.81, 5.72 - 5.89; ASL 19.47, 18.07 - 20.88) and the abdominal aorta (MFD 5.92, 5.84 - 6.00; ASL 21.10, 19.69 - 22.50).In subjects lacking aneurysmal disease, the aorta and iliac arteries are not structurally uniform along their length. There is an increase in collagen percentage and decrease in elastin percentage progressing distally along the aorta. Mean collagen fibre diameter and average segment length are larger in the external iliac artery, compared with the ascending and the abdominal aorta.

Although appreciated for its long-term benefits, open repair of abdominal aortic aneurysms (AAA) is associated with a significant perioperative burden. Enhanced recovery and fast track protocols have improved surgical outcomes in many specialties, but remain scarcely applied in the vascular field.Based on the applied perioperative protocol in a single-center experience, three consecutive study groups were identified among 394 consecutive patients undergoing elective AAA open repair in the last 12 years. Group A included 66 patients who underwent traditional surgery, group B comprised 225 patients treated according to a partially adopted perioperative protocol, and group C consisted of 103 patients, operated in line with a complete perioperative protocol. The aim of this study was to evaluate the impact of the perioperative protocol on recovery time by measuring complication rates, analgesic and antiemetic control, and return of bowel function and ambulation, as well as the length of hospitalization.The study groups had similar baseline characteristics. A significant improvement was noted in the complication rates (P = .019) and hospitalization time (P .001) following a complete implementation of the perioperative protocol, where the median hospitalization time was 3 days. No mortality and no readmissions within 30 postoperative days were recorded in this group. There was an improvement in pain levels, as well as postoperative nausea and vomiting control (P .001).Perioperative protocol implementation in AAA open repair is feasible; the clinical outcomes may be improved when strictly adhering to the protocol. All the applied perioperative management interventions seem to have a synergic effect on shortening the recovery time.

Virtual reality (VR) simulation is a vital component of surgical training with demonstrated improvements in surgical quality and clinical outcome. To validate the LAP Mentor (Simbionix™) laparoscopic appendicectomy (LA) VR simulator with inclusion of a novel tool, Cognitive Task Analysis (CTA). Thirty-two novices and nine experienced surgeons performed two simulated LAs. An expert-consensus questionnaire guided face validity assessment. Content validity was assessed using CTA-derived questions encompassing eight operative steps and four decision points. Construct validity was evaluated using dexterity metrics, masked assessment of surgical quality using the OSATS global rating scale, and mental workload from two validated tools: the NASA-TLX and SMEQ. Ten novices performed eight further LAs for learning curve assessment. Face validity was demonstrated across all domains. Considering content validity, the essential technical and non-technical steps were evident. The experienced group performed the procedure quicker (median time 361 vs. 538 s, P = 0.0039) with fewer total movements (426 vs. 641, P

OBJECTIVE Self-assessment is fundamental in surgical training to enhance learning in the absence of trainer feedback. The primary objective of this review was to assess the factors that influence accuracy of self-assessment at technical skills across all surgical specialties. The secondary objective was to assess whether there are any innate factors or attributes to predict those that will carry out effective self-assessment. DESIGN A systematic review was carried out in accordance with PRISMA guidelines. A search strategy encompassing MEDLINE, EMBASE, ERIC, WHO, and the Cochrane database was conducted to identify studies investigating self-assessment at any surgical task. Quality was assessed using the Newcastle-Ottawa scale. A summary table was created to describe specialty, participants, task, setting, assessment tool, and correlation coefficient between self and expert assessment. The review protocol was registered in PROSPERO. RESULTS Of 24,638 citations, 40 met inclusion criteria. In total 1753 participants performed 68 procedures. Twenty-six studies investigated skills in general surgery with the remaining 14 in various other surgical specialties. Accuracy of self-assessment is superior in those with greater experience and age, and with use of retrospective video playback. Accuracy tends to be reflected by overestimation of performance. Stressful environments reduce accuracy. There is limited evidence in the literature regarding predicting traits for those who will carry out accurate self-assessment. CONCLUSIONS The ability to perform accurate self-assessment is an important skill in surgical training, with accuracy being influenced by a multitude of factors. The use of self-assessment from retrospective video playback may be of benefit in surgical training curricula to enhance learning of technical skills. Further studies are required to define predictors of good self-assessment, which will strengthen recruitment and mentoring to assist trainee learning.

Background Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA). Materials and methods Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures. Results Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031). Conclusions Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

An innovative hybrid approach to the supraaortic vessels in a porcelain aorta and severe fibrotic tissue reaction at the neck is described. The technique is demonstrated in an 80-year-old woman with previous several carotid operations but still experiencing recurrent transient ischemic attacks. Clinical success was achieved at midterm follow-up, demonstrating the efficacy of hybrid treatment for this high-risk patient. Novel prosthetic vascular grafts that can be applied without cross-clamping may also provide a solution to approaching a porcelain aorta and difficult anatomies.