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Aims 1) To determine whether ‘nil by mouth’ (NBM) emergency surgery patients are fasted for longer than the recommended 6 hours for food and 2 hours for clear fluids. 2) To establish whether oral medications are being correctly administered/omitted in these patients. Methods Fasting and medication administration data were collected prospectively on patients who received emergency surgery over a 2- week period. Drug administration decisions were categorised as ‘correct’ or ‘incorrect’ by comparison with local guidelines. Results A total of 65 patients were identified with the average preoperative fasting times being 24 hours for food and 14 hours for clear fluids. However, the range of fasting times exceeded 110 hours. Notably, only 16 (25%) patients had a drink while they were NBM and 29 (45%) patients were incorrectly administered medications, including several instances of omission of critical drugs. Conclusions Further work is needed to establish the cause of prolonged fasting periods. However, likely factors include; operation scheduling difficulties, lack of understanding of NBM guidelines, inadequate communication with patients, and patient choice. This is resulting in poor preoperative optimisation of patients (e.g. dehydration of patients), as well as a significant risk to patient safety with critical medications being omitted. In order to rectify the severe lack of adherence to the guidelines, we are introducing further NBM training for medical professionals in our trust, in addition to updating the current trust guideline to reflect a wider range of medications and keep up to date with current national guidance.

The pathophysiology of haemodialysis arteriovenous fistulae (AVF) stenoses is not fully understood. The aim of this study was to perform histology assessment of stenoses in native AVF and compare and correlate the findings between ultrasound and histology. Intimal medial thickness (IMT) was measured on ultrasound where there was measurable neointimal hyperplasia at the site of stenosis and percentage intimal thickening calculated. Ultrasound findings were then compared with histology analysis of AVF stenoses in nine patients. In this small sample, different sonographic appearances and histology were demonstrated. Ultrasound demonstrated stenoses with neointimal hyperplasia and those with no measurable neointimal hyperplasia. Percentage intimal thickening was between 0% and 100%. The histology of the de novo stenoses (where no previous radiological or surgical procedure was performed) demonstrated stenoses with neointimal hyperplasia, no neointimal hyperplasia and neointimal hyperplasia and fibrosis. The histology findings after percutaneous angioplasty (PTA) demonstrated stenoses with neointimal hyperplasia and fibrosis and a stenosis with an acute inflammatory reaction. The findings in this small sample demonstrated that AVF stenoses are not a uniform group as demonstrated by different sonographic and corresponding appearances at histology. Ultrasound appearances of neointimal hyperplasia appear to correlate with neointimal hyperplasia on histology. These findings warrant further investigation and may have implications for treatment strategies.

Purpose: To describe a novel bailout technique to approach below-the-knee chronic total occlusions after a failed bidirectional recanalization attempt using the plantar loop maneuver in patients who are poor candidates for a retrograde puncture. Technique: After a failure of recanalization of the opposite tibial artery using the plantar loop maneuver, an assisted direct retrograde transpedal approach can be performed regardless of poor vessel caliber or even arterial occlusion. After crossing the plantar arch, a low profile angioplasty balloon is used as a landmark for the pedal puncture and to give guidance for the wire advancement from the new access. Conclusion: A balloon-assisted retrograde transpedal approach may be considered for below-the-knee recanalization after standard plantar loop technique failure in patients who are not candidates for conventional retrograde puncture.

Purpose: The purpose of the study is to describe a bailout technical strategy to prevent below-the-knee (BTK) distal embolization during procedures with increased inherent risk using universally-available “off-the-shelf” devices. Technique: A conventional retrograde access is obtained of the BTK target vessel where embolization protection is sought. Before starting any potential proximal maneuver with an associated significant risk of distal embolization (eg, atherectomy and mechanical thrombectomy), a low-profile balloon is inserted and inflated through the distal retrograde access, so that any debris resulting from the recanalization procedure is blocked by the stagnant column of blood generated by the inflated balloon. Once the revascularization procedure has been completed, a 4F curved catheter is antegradely advanced down to the distally-inflated balloon, and in case of distal embolization the debris is aspirated in a standard fashion way. Conclusion: A retrograde balloon-assisted “off-the-shelf” embolic protection approach may be considered for BTK revascularization procedures where there is an inherent increased risk of distal trash, especially in the presence of distal single-vessel runoff. Clinical Impact Distal embolization following endovascular procedures can have devastating consequences and there is a general recommendation for selective use of EPDs in high-risk-scenarios. The increased cost and low availability of the current EPD devices for BTK/BTA arteries have prohibited their widespread use. The retrograde balloon-assisted “off-the-shelf” EPD prevents distal embolization during procedures with increased risk of distal trash using inexpensive, nonspecific equipment available in any basic endovascular suite.

Purpose: To evaluate the efficacy of a new guidewire threading instrument (GTI) in reducing guidewire threading times compared with the traditional freehand method. Materials and Methods: This prospective, controlled, single-center study recruited 100 subjects (mean age 45.2±11.3 years; 43 men) and divided them into 2 groups depending on their professional background: 50 experienced medical personnel (performed or assisted in >50 catheter-based procedures) and 50 medical personnel with no experience in endovascular techniques (inexperienced group). The threading time of both groups was recorded using the conventional freehand method and with the GTI for both 0.035- and 0.014-inch platforms. Users of eyeglasses for presbyopia were tested with and without glasses. Median values are reported with the interquartile range (IQR; Q1, Q3) in parentheses. Results: The mean insertion times with both the 0.035-inch and 0.014-inch guidewires in the overall study group were significantly better with the use of the GTI compared with the traditional freehand method (p

Secondary aorto-enteric fistulas (AEFs) are an uncommon but serious complication of abdominal aortic aneurysm (AAA) repair. Case review of two cases of secondary AEF are as follows: the first case involved a 75-year- old male who presented with AEF 1 year post-emergency open AAA repair, successfully managed with endovascular aortic aneurysm repair (EVAR) without complication. The second case involved a 75-year-old male patient 14 months post open AAA repair for an inflammatory aneurysm who presented with an iliac-enteric fistula. The previous repair was relined with a bifurcated EVAR with subsequent laparotomy and resection of the affected portion of the small bowel. Both patients on lifelong antibiotics without further episodes of sepsis, recurrence of AEF or mortality at 12 months follow up. EVAR can be successful in the management of secondary AEF. Careful patient selection, accurate image interpretation, and expedient management are key factors to successful short- and long-term outcomes.

Introduction Pancreatic adenocarcinoma (PAC) is a devastating disease. Endothelial progenitor cells (EPCs) are important mediators in PAC. Omega 3 fatty acids (ω-3FAs) have been shown to have anti-inflammatory properties. Methods This was a single centre study investigating intravenous ω-3FAs and gemcitabine chemotherapy versus gemcitabine therapy alone in patients with APC. The primary outcome measure was the level of EPCs with the secondary outcome measure being the relationship between the EPC levels, progression free survival and overall survival.Results Over the treatment period CD45-, CD31+, CD133+ EPCs and CD45-, CD31+, CD34+ EPCs significantly increased (P=O.O42 and P=0.0001), whilst no change was observed in control EPCs (P=0.705). There was a non-significant downward trend in control EPCs (P=0.930, 95%). There was a significant difference between the trial and control patients over time on logistic regression analysis (P=0.0001). There was a significant increase in CD45-, CD34+, CD31+ and CD133+ EPCs trial EPCs over treatment (P=0.007). There was no significant increase seen in control EPCs (P=0.358, 95%). There was a significant difference between the trial and control patients over treatment on logistic regression analysis (P=0.0001). There was a significant correlation in the trial patients between progression free survival benefit and an increase in EPCs.Conclusion Intravenous ω-3FAs with gemcitabine chemotherapy in APC results in a significantly increased level of EPCs. There appears to be a survival benefit in patients with an increase in EPCs which may be the result of a reduction in pro-inflammatory mediators.

Purpose: To present a simple method to avoid favored passage of a guidewire into the profunda femoris artery (PFA) after antegrade puncture of the common femoral artery. Technique: A 6-F conventional introducer sheath with a radiopaque distal marker is placed on the nurse’s table with its side port orientated to the 12 o’clock position. A small (2–2.5 mm) oval fenestration is created on the superior aspect of the sheath about 3 cm from its tip with a size 11 surgical blade. The modified introducer is passed over the angled 0.035-inch guidewire into the PFA and gently retrieved until the tip marker is ~3 cm from the femoral bifurcation. The dilator is removed, and the guidewire is withdrawn to the level of the fenestration, manipulated through it, and advanced further into the superficial femoral artery under fluoroscopic guidance. Conclusion: When repeated passage of the guidewire down the PFA persists despite conventional manipulation of the wire or needle, an on-site modification of the sheath is an easy alternative approach for the catheterization of the superficial femoral artery.

Graphical Abstract This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. Graphical Abstract One of the most affected specialties

Purpose: To describe a maneuver to facilitate percutaneous arteriovenous fistula creation during venous arterialization procedures in patients with no-option critical limb ischemia. Technique: Following a failed arterial recanalization attempt, a balloon catheter is passed up to the tip of the guidewire. Venous access is gained distally, a 4-F sheath is antegradely passed, and a 4-mm GooseNeck snare is advanced through it. A fluoroscopic view that overlaps the snare and the inflated balloon is obtained. If the vein remains anterior with respect to the artery, a needle is inserted across the vein, passing through the snare loop and puncturing the intra-arterial balloon. A wire is inserted and placed inside the punctured balloon. The balloon is retrieved and the wire externalized through the femoral access. A catheter is advanced antegradely over this wire from the artery into the vein. If the vein remains posterior to the artery, a needle is inserted, puncturing the balloon and thereafter the vein (crossing through the snare). A wire is inserted, captured by the snare, and externalized through the vein sheath. A catheter is finally advanced over this wire from the vein into the artery. Conclusion: This maneuver is a simple alternative to create an arteriovenous fistula during venous arterialization procedures in patients with no-option critical limb ischemia.

To describe a technical trick to overcome a prior failed retrograde puncture of the tibial vessels secondary to arterial calcification.Following a prior failed retrograde puncture attempt, the needle is left in place next to the artery. The tip of the needle is then moved toward the artery as a lever so that the artery is fixed between the needle, the skin, and the surrounding tissues. With the artery fixed, a standard puncture procedure is performed. Alternatively, if additional support is needed, 2 micropuncture needles are inserted one on either side of the artery, crossing under the target vessel and hence trapping it between them, providing additional support and therefore enhancing the chance of successful arterial access.The buddy needle technique may be considered as an alternative procedure in a retrograde pedal/tibial approach after prior failed standard attempts in patients with heavily calcified vessels.

Purpose: To describe a simple maneuver to facilitate the retrograde puncture of challenging tibial vessels in the lower leg. Technique: Because of the depth of the tibial vessels at the mid to upper calf, especially in obese or muscular patients, a 7- or 9-cm, 21-G micropuncture needle is often needed to reach the artery. However, the low profile of the needle contributes to its flexibility and therefore the tendency to bend as it progresses through the deep tissues, hindering access to the target vessel. To overcome this obstacle, a 4- to 5-cm, 18-G needle is initially placed pointing to the artery. The 21-G needle is advanced through it to the target site. This simple maneuver increases the support to the 21-G needle, preventing its bending and facilitating arterial puncture in the presence of calcified vessels. Conclusion: The telescoping needle technique may be considered as a bailout procedure in the retrograde tibial approach after failed attempts secondary to needle bending or calcified vessels.

Antegrade puncture is a routinely used technique of obtaining access to the common femoral artery to perform infrainguinal interventions. However, antegrade arterial access can be challenging in the presence of hostile, scarred groins, obesity, or a high common femoral artery bifurcation. A simple method of converting a retrograde femoral access to an antegrade catheterization using an inexpensive and universally available monofilament suture is presented.

A case of a femoropopliteal recanalization procedure using a new bailout technical maneuver to aid reentry into the true lumen is described. After a failed standard reentry attempt, at the level of the vessel reconstitution in the subintimal space, the guidewire was exchanged for a GooseNeck Snare Kit. A needle was inserted across the target artery, piercing both arterial walls and passing through the snare loop. Once the needle had exited the artery, a wire was inserted and the needle withdrawn. The snare was closed, withdrawn, and the wire externalized through the femoral access. Finally, a catheter was advanced from the antegrade sheath up to the arterial reconstitution. Selective injection at the site of reentry confirmed the intraluminal position, and the procedure was successfully completed from the antegrade sheath.

Although iliac artery (IA) endarterectomy has largely been replaced by bypass and endovascular options, open endarterectomy continues to play an important role in selected patterns of occlusive disease. The objective of this report is to present a contemporary clinical series of patients having undergone IA endarterectomy. Specifically, we define patterns of disease amenable to open endarterectomy and provide an updated technical note of this procedure. A retrospective study on 23 patients with IA occlusions unsuitable for radiologic intervention (TransAtlantic Inter-Societal Consensus [TASC] C and D lesions) underwent extraperitoneal IA endarterectomy. Twenty-five primary IA endarterectomies were performed. Of these, five required more extensive endarterectomy, three of the distal aorta and two of the contralateral IA. Sixteen of the 25 endarterectomies required common femoral artery endarterectomy and 6 required iliofemoral bypass. The average follow-up was 26 months. Procedure-related mortality occurred in one patient (4.3%). Within 4 months, one patient underwent an aortofemoral bypass and two patients required major amputation. Primary patency rates were 96% at 3 months and 88% at 1, 2, and 3 years. This series shows that in selected patterns of aortoiliac occlusive disease, endarterectomy remains an important alternative to consider.

Highlights • Curcumin + FOLFOX inhibits growth of primary cancer stem cell (CSC) spheroid models. • Curcumin + FOLFOX decreases expression of CSC markers in primary CSC spheroid models. • Curcumin enhances proapoptotic effects of chemotherapy in explant culture. • Curcumin is safe and tolerable in combination with FOLFOX chemotherapy. • Curcumin is perceived by patients as an acceptable daily adjunct to chemotherapy., In vitro and pre-clinical studies have suggested that addition of the diet-derived agent curcumin may provide a suitable adjunct to enhance efficacy of chemotherapy in models of colorectal cancer. However, the majority of evidence for this currently derives from established cell lines. Here, we utilised patient-derived colorectal liver metastases (CRLM) to assess whether curcumin may provide added benefit over 5-fluorouracil (5-FU) and oxaliplatin (FOLFOX) in cancer stem cell (CSC) models. Combination of curcumin with FOLFOX chemotherapy was then assessed clinically in a phase I dose escalation study. Curcumin alone and in combination significantly reduced spheroid number in CRLM CSC models, and decreased the number of cells with high aldehyde dehydrogenase activity (ALDHhigh/CD133−). Addition of curcumin to oxaliplatin/5-FU enhanced anti-proliferative and pro-apoptotic effects in a proportion of patient-derived explants, whilst reducing expression of stem cell-associated markers ALDH and CD133. The phase I dose escalation study revealed curcumin to be a safe and tolerable adjunct to FOLFOX chemotherapy in patients with CRLM (n = 12) at doses up to 2 grams daily. Curcumin may provide added benefit in subsets of patients when administered with FOLFOX, and is a well-tolerated chemotherapy adjunct.

No definitive evidence exists regarding the treatment of acute portal vein thrombosis (PVT). Treatment modalities that have been employed and investigated include conservative management, anticoagulation, thrombolysis and thrombectomy. This observational study examines the impact of anticoagulation on PVT.The electronic radiology database was searched with keywords 'portal vein' and 'thrombosis'. Relevant patient notes and imaging were reviewed to collect data from those with acute PVT. The primary end point was portal vein recanalisation. Secondary outcome measures were morbidity and the development of portal hypertension and its sequelae (including variceal bleeding). Data from patients with PVT in the context of cirrhosis, malignancy or liver transplant were excluded.Partial or complete recanalization of the portal vein occurred in 81.8% of anticoagulated patients and 37.5% of the non-treatment group. Five patients died, 1 following an intracranial haemorrhage whilst anticoagulated and another who was not treated and developed secondary small bowel ischaemia and peritonitis. The remaining 3 died from their underlying pathology. Late complications, such as varices and ascites occurred more frequently in the patients in whom the portal vein failed to recanalize (83.3% vs. 27.3%).Spontaneous resolution of acute portal vein thrombosis is uncommon. Early anticoagulation results in a higher rate of recanalisation with minimal associated morbidity when compared with no treatment.

Introduction The effectiveness of percutaneous access with large vessel closure (pEVR) in non-selective groups of patients undergoing endovascular aneurysm repair (EVR) remains unclear. This study aims to identify factors that predict success in pEVR, performed using percutaneous access and the Prostar XL (Abbott Vascular, Redwood City, Calif) closure device. Method Consecutive patients who underwent pEVR between April 2010 and March 2011 were identified from a prospectively maintained database. Procedural and postoperative outcomes were compared with consecutive patients who underwent endovascular aneurysm repair using standard open femoral access between April 2008 and March 2009. To determine the predictors of technical success of pEVR, the association between clinical, anatomical and procedural variables with technical success, were examined in a multiple logistic regression model. Results pEVR was attempted in 186 common femoral arteries (CFAs) with a technical success rate of 95.2% (177/186). Conventional open femoral access in the historic control group was performed in 208 CFAs. pEVR was associated with a reduced operation length (131 min [105–152] versus 150 min [124–195], p ≤0.001) and length of stay (2 days [2–5] versus 4 days [2–7], p = 0.01) in patients undergoing infrarenal EVR. In secondary analysis of outcomes following percutaneous access in 91 CFAs, pre-operative renal failure, CFA depth (min and max), CFA diameter (min and max) and operator experience predicted success of percutaneous access in univariate analysis. Operator experience was the only independent predictor of technical success ( p = 0.05) after adjustment for all confounding variables. Conclusion pEVR using the Prostar XL device is effective in the majority of patients. In this study there were benefits in terms of reduced postoperative complications, shorter procedures and decreased lengths of stay. Operator experience is a predictor of technical success for pEVR, irrespective of clinical and morphological characteristics at baseline.

Endovascular repair has emerged as a potential alternative to emergency open surgical repair for type A dissection in selected patients, with isolated reports describing the results obtained with a range of devices designed originally for the descending aorta. We believe that we present the first reported repair of an acute ascending aortic dissection using an endovascular stent graft manufactured specifically for the ascending aorta.