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Deep venous thrombosis (DVT) is considered the most common cause of preventable death among hospitalized patients. A few studies have investigated the risk of venous thromboembolic events (VTE) in patients undergoing elective spine surgery and reported varying incidences. We aim to assess the incidence of preoperative lower limb DVT in lumbar degenerative disease patients undergoing elective surgery.This is a retrospective review of prospectively collected data on adult patients with lumbar degenerative spine diseases (lumbar stenosis; LST, lumbar spondylolisthesis; SPL, or lumbar disc herniation; LDH) who were scheduled for operative management. Each patient underwent a preoperative lower limb venous Duplex (LLVD). Incidence of DVT, risk factors, and clinical course of patients were reported.Forty-nine patients (32 females; 65%) were included. All patients were diagnosed clinically and radiologically with lumbar degenerative diseases; LST (44.9%), SPL (36.7%), and LDH (18.4%), requiring surgical management. Three patients (6.1%) were found to have positive DVT studies, leading to the cancellation or rescheduling of their procedures (p0.01). These included one patient with LST (p = 0.045) and two patients with SPL (p = 0.006). Among patients with LST and SPL, higher disability (modified Rankin scale; mRS ≥3) was significantly associated with positive LLVD (p = 0.035).Patients with LST or SPL with higher preoperative disability scores were at higher risk to have preoperative DVT. Further research is needed to evaluate the feasibility and value of preoperative LLVD to detect DVT in patients planned for lumbar degenerative surgery.

Objectives: To determine the prevalence of vasculopathic diabetic foot and the associated factors in a Saudi tertiary center. Methods: This retrospective chart review included adult patients (≥18 years) diagnosed with diabetic foot between May 2015 and July 2019 in King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia. Based on clinical presentation and laboratory results, the patients were categorized into 2 groups namely, “vascular induced diabetic foot group” and “non-vascular induced diabetic foot group”. Results: A total of 404 diabetic patients were enrolled in the study. The mean age of the patients was 62.03±12.30 years; 61.9% were males. Most of the diabetic foot cases had a non-vascular etiology (n=327, 80.9%), while 77 cases (19.1%) were due to vasculopathy. Patient in the vascular group had a significantly higher incidence of coronary artery disease (32.5% versus 14.4%; p greater than 0.001), and a higher incidence of peripheral artery disease (PAD) in the unaffected limb (22.1% versus 2.1%; p less than 0.001). Conclusion: Most cases of diabetic foot were due to non-vascular causes. Old age, history of coronary artery disease, or PAD in the unaffected limb were factors that were significantly associated with diabetic foot due to arterial disease. Saudi Med J 2021; Vol. 42 (1): 49-55 doi: 10.15537/smj.2021.1.25640 How to cite this article: Altoijry A, AlGhofili H, Alanazi SN, AlHindawi DA, AlAkeel NS, Julaidan BS, AlHamzah M, Altuwaijri T. Diabetic foot and peripheral arterial disease. Single centre experience. Saudi Med J. 2021 Jan;42(1):49-55. doi: 10.15537/smj.2021.1.25640. PMID: 33399171.

To outline our experience with both arterial vascular thoracic outlet syndrome (ATOS) and venous TOS (VTOS).This was a retrospective review carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from 1992-2022. All patients were diagnosed based on clinical presentation, imaging, and underwent surgical decompression solely via the supraclavicular approach. The median follow-up period was 18 months (range: 4-36 months).A total of 90 limbs were diagnosed with vascular TOS in 69 patients. Females accounted for 69.6% of the patients and approximately 86.7% had ATOS. All patients were symptomatic and underwent plain thoracic inlet and cervical spine radiography, along with duplex scans in both rest and provocative positions. Total cervical rib resection was carried out in 60% of cases, while 2% had partial resection. First rib resection was carried out in 13.3% of cases and combined cervical and first rib resections were carried out in 23.3%. Vascular procedures were needed for arterial repair in 20% of cases, while venous repair were carried out in 2.2%. No recurrence or post-operative mortality had been reported. Post-operative complications were observed in 18.9% of cases.Careful patient selection and diagnosis using advanced, but less invasive radiological imaging coupled with adequate surgical treatment can improve the patient's outcome.

Objectives To determine the effect of therapeutic anticoagulation, with low molecular weight heparin (LMWH) or unfractionated heparin (UFH, high dose nomogram), compared to standard care in hospitalized patients admitted for COVID-19 with an elevated D-dimer on the composite outcome of intensive care unit (ICU) admission, non-invasive positive pressure ventilation, invasive mechanical ventilation or death up to 28 days. Trial design Open-label, parallel, 1:1, phase 3, 2-arm randomized controlled trial Participants The study population includes hospitalized adults admitted for COVID-19 prior to the development of critical illness. Excluded individuals are those where the bleeding risk or risk of transfusion would generally be considered unacceptable, those already therapeutically anticoagulated and those who have already have any component of the primary composite outcome. Participants are recruited from hospital sites in Brazil, Canada, Ireland, Saudi Arabia, United Arab Emirates, and the United States of America. The inclusion criteria are: Laboratory confirmed COVID-19 (diagnosis of SARS-CoV-2 via reverse transcriptase polymerase chain reaction as per the World Health Organization protocol or by nucleic acid based isothermal amplification) prior to hospital admission OR within first 5 days (i.e. 120 hours) after hospital admission; Admitted to hospital for COVID-19; One D-dimer value above the upper limit of normal (ULN) (within 5 days (i.e. 120 hours) of hospital admission) AND EITHER: D-Dimer ≥2 times ULN OR D-Dimer above ULN and Oxygen saturation ≤ 93% on room air; > 18 years of age; Informed consent from the patient (or legally authorized substitute decision maker). The exclusion criteria are: pregnancy; hemoglobin platelet count 9/L in the last 72 hours; known fibrinogen known INR >1.8 (if testing deemed clinically indicated by the treating physician prior to the initiation of anticoagulation); patient already prescribed intermediate dosing of LMWH that cannot be changed (determination of what constitutes an intermediate dose is to be at the discretion of the treating clinician taking the local institutional thromboprophylaxis protocol for high risk patients into consideration); patient already prescribed therapeutic anticoagulation at the time of screening [low or high dose nomogram UFH, LMWH, warfarin, direct oral anticoagulant (any dose of dabigatran, apixaban, rivaroxaban, edoxaban)]; patient prescribed dual antiplatelet therapy, when one of the agents cannot be stopped safely; known bleeding within the last 30 days requiring emergency room presentation or hospitalization; known history of a bleeding disorder of an inherited or active acquired bleeding disorder; known history of heparin-induced thrombocytopenia; known allergy to UFH or LMWH; admitted to the intensive care unit at the time of screening; treated with non-invasive positive pressure ventilation or invasive mechanical ventilation at the time of screening; Imminent death according to the judgement of the most responsible physician; enrollment in another clinical trial of antithrombotic therapy involving hospitalized patients. Intervention and comparator Intervention: Therapeutic dose of LMWH (dalteparin, enoxaparin, tinzaparin) or high dose nomogram of UFH. The choice of LMWH versus UFH will be at the clinician’s discretion and dependent on local institutional supply. Comparator: Standard care [thromboprophylactic doses of LMWH (dalteparin, enoxaparin, tinzaparin, fondaparinux)] or UFH. Administration of LMWH, UFH or fondaparinux at thromboprophylactic doses for acutely ill hospitalized medical patients, in the absence of contraindication, is generally considered standard care. Main outcomes The primary composite outcome of ICU admission, non-invasive positive pressure ventilation, invasive mechanical ventilation or death at 28 days. Secondary outcomes include (evaluated up to day 28): All-cause death Composite of ICU admission or all-cause death Composite of mechanical ventilation or all-cause death Major bleeding as defined by the ISTH Scientific and Standardization Committee (ISTH-SSC) recommendation; Red blood cell transfusion (>1 unit); Transfusion of platelets, frozen plasma, prothrombin complex concentrate, cryoprecipitate and/or fibrinogen concentrate; Renal replacement therapy; Hospital-free days alive; ICU-free days alive; Ventilator-free days alive; Organ support-free days alive; Venous thromboembolism (defined as symptomatic or incidental, suspected or confirmed via diagnostic imaging and/or electrocardiogram where appropriate); Arterial thromboembolism (defined as suspected or confirmed via diagnostic imaging and/or electrocardiogram where appropriate); Heparin induced thrombocytopenia; Trajectories of COVID-19 disease-related coagulation and inflammatory biomarkers. Randomisation Randomisation will be stratified by site and age (>65 versus ≤65 years) using a 1:1 computer-generated random allocation sequence with variable block sizes. Randomization will occur within the first 5 days (i.e. 120 hours) of participant hospital admission. However, it is recommended that randomization occurs as early as possible after hospital admission. Central randomization using an interactive web response system will ensure allocation concealment. Blinding (masking) No blinding involved. This is an open-label trial. Numbers to be randomised (sample size) 462 patients (231 per group) are needed to detect a 15% risk difference, from 50% in the control group to 35% in the experimental group, with power of 90% at a two-sided alpha of 0.05. Trial Status Protocol Version Number 1.4. Recruitment began on May 11th, 2020. Recruitment is expected to be completed March 2022. Recruitment is ongoing. Trial registration ClinicalTrials.gov Identifier: NCT04362085 Date of Trial Registration: April 24, 2020 Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

BackgroundHeparin, in addition to its anticoagulant properties, has anti-inflammatory and potential anti-viral effects, and may improve endothelial function in patients with Covid-19. Early initiation of therapeutic heparin could decrease the thrombo-inflammatory process, and reduce the risk of critical illness or death.MethodsWe randomly assigned moderately ill hospitalized ward patients admitted for Covid-19 with elevated D-dimer level to therapeutic or prophylactic heparin. The primary outcome was a composite of death, invasive mechanical ventilation, non-invasive mechanical ventilation or ICU admission. Safety outcomes included major bleeding. Analysis was by intention-to-treat.ResultsAt 28 days, the primary composite outcome occurred in 37 of 228 patients (16.2%) assigned to therapeutic heparin, and 52 of 237 patients (21.9%) assigned to prophylactic heparin (odds ratio, 0.69; 95% confidence interval [CI], 0.43 to 1.10; p=0.12). Four patients (1.8%) assigned to therapeutic heparin died compared with 18 patients (7.6%) assigned to prophylactic heparin (odds ratio, 0.22; 95%-CI, 0.07 to 0.65). The composite of all-cause mortality or any mechanical ventilation occurred in 23 (10.1%) in the therapeutic heparin group and 38 (16.0%) in the prophylactic heparin group (odds ratio, 0.59; 95%-CI, 0.34 to 1.02). Major bleeding occurred in 2 patients (0.9%) with therapeutic heparin and 4 patients (1.7%) with prophylactic heparin (odds ratio, 0.52; 95%-CI, 0.09 to 2.85).ConclusionsIn moderately ill ward patients with Covid-19 and elevated D-dimer level, therapeutic heparin did not significantly reduce the primary outcome but decreased the odds of death at 28 days.Trial registration numbers: NCT04362085; NCT04444700

Objective Vascular surgery has evolved with increasing use of endovascular therapies and a decline in open surgery. The influence of these changes, in addition to a new vascular surgery training program introduced in 2012, on case volumes of vascular trainees is not known. We sought to evaluate trends in operative case volumes of Canadian vascular surgery trainees. Methods A survey was administered to graduates of the Canadian Royal College-accredited Vascular Fellowships (VFs) and Integrated Vascular Surgery Residency (IVSR) programs (2007-2019) to record cases performed during their final 2 years of training. Procedures of interest were open abdominal aortic aneurysm (oAAA) repair, open thoracic/thoracoabdominal aortic (oTAA/TAAA) repair, lower extremity bypass (LEB), carotid endarterectomy (CEA), lower extremity endovascular intervention (LEEI), and endovascular abdominal, advanced, and thoracic aortic repair (EVAR, aEVAR, and TEVAR). Case volumes were analyzed overall, and by graduation year, type of training program, and resident demographics. Results A total of 60 participants (10% female) from all the 10 Canadian training institutions responded (response rate, 63%). There was a declining trend in overall procedures performed since the introduction of IVSR in 2012 (median, 427 [interquartile range (IQR), 304-496] in 2007-2012 vs median, 342 [IQR, 279-405] in 2013-2019; P = .055), driven by a significant decline in open vascular surgery cases (median, 273 [IQR, 221-339] in 2007-2012 vs median, 156 [IQR, 128-181] in 2013-2019; P = .001). Case volumes of oAAA, LEB, and CEA declined by 44%, 40%, and 45%, respectively. Compared with vascular fellows, IVSR residents logged ∼2.5 times more aEVARs (median, 8; IQR, 2-11 vs median, 19; IQR, 8-27; P = .001) and ∼1.5 times more LEEIs (median, 60; IQR, 40-99 vs median, 93; IQR, 69-120; P = .018). Trainees were most confident (range, 90%-100%) in performing oAAA, EVAR, LEB, LEEI, and CEA after training, and least confident in performing oTAA/TAAA and aEVAR (20% and 49% confidence, respectively). Conclusions Operative case volumes of Canadian vascular surgery trainees since the introduction of IVSR program in 2012 have decreased, driven by declining exposure to open cases. However, trainees continue to receive adequate operative exposure to perform most standard vascular procedures confidently upon graduation.

ObjectivesPhysicians have poor knowledge of peripheral arterial disease (PAD). Inadequate exposure to PAD in medical school curricula may by a contributing factor. The objective of this study was to explore the awareness and knowledge of PAD among medical students.MethodsWe conducted a descriptive cross-sectional study using an interview-based survey of the medical students in the college of medicine of King Saud University Riyadh, KSA.ResultsOf 350 students, 244 students agreed that they had some knowledge about PAD. More students in their clinical years (3–5) had heard about PAD compared to students in their basic science years (1–2; 76.5% versus 65.4%, respectively); however, the overall scores were low for both groups for recognition of PAD symptoms (mean scores, 2.83 out of 7 for students in years 3–5 versus 1.81 for students in years 1–2; p

Previous data suggest that physicians have suboptimal knowledge about peripheral artery disease (PAD). Our aim was to evaluate Canadian medical students' knowledge of PAD to determine if this knowledge gap exists early in medical training.We conducted a descriptive, cross-sectional, interview-based study of graduating medical students at the University of Toronto. We used a standardized questionnaire to evaluate students' knowledge of PAD and coronary artery disease (CAD) in the following domains: clinical presentation, risk factors, preventative measures, treatment, and complications. We calculated mean (standard deviation [SD]) scores for each CAD and PAD knowledge domain and examined for differences in PAD vs CAD scores.Seventy-two graduating medical students participated in this study, of which females accounted for 58%. Nearly all participants reported being exposed to PAD (89%) and CAD (92%) through their medical school curriculum. Overall, medical students scored better in identifying CAD characteristics (mean [SD] score, 16.4 [2.7]) compared with PAD (mean [SD] score, 14.6 [3.2]) (P .0001). This difference was driven by the inferior performance of students in identifying risk factors (P .0001), preventative measures (P = .049), and complications (P .0001) of PAD compared with CAD. Out-of-class exposure (eg, clinical rotation, research experience) had a positive impact on students knowledge of both PAD and CAD.Our results demonstrate suboptimal knowledge of medical graduates of both CAD and PAD. Although they share common atherosclerotic risk factors and cardiovascular complications, medical students were less likely to associate these with PAD than CAD. We recommend a comprehensive module that incorporates all presentations of atherosclerotic disorders to enhance students' understanding of these pathologies in medical schools.

Background Prevalence of peripheral arterial disease (PAD) has dramatically increased in both developing, as well as developed countries. However, significant knowledge and practice gaps persist. In Canada, efforts to improve this knowledge level are lacking. In this study, we examine PAD knowledge in Toronto, and evaluate a pilot intervention to address the knowledge gaps. Objectives Measure PAD awareness in Toronto, and evaluate an intervention to improve PAD knowledge among the public. Methods In the context of a community-based awareness campaign, an interview-based survey was used to assess the PAD awareness among general public. A sample of participants was split into two arms: control (survey only) and intervention (survey and education pamphlet), the choice between assigning the site as case or control was random. A follow-up telephone and email-based survey was conducted after 6 weeks to assess the attained knowledge level of PAD. Results Two hundred thirty-seven participants completed the baseline survey. One hundred eighty-eight participants (78.7%) had never heard of PAD. The remaining “PAD-aware” cohort had low overall knowledge of the disease characteristics. Participants from each arm completed the follow-up survey. The level of education, age, and gender were not predictors of knowledge scores; however, age was a predictor of PAD awareness, while gender and level of education were not. Participants in the intervention group showed significant knowledge scores improvement in five PAD domains, while those from control group showed significant improvement in their preventative measures, treatment modalities, and total scores. The impact of the study intervention on average scores was borderline not significant ( p = 0.05). Conclusion PAD knowledge gap in the Canadian public is larger than what was previously reported. Educational campaigns are necessary to address this gap and improve the outcome of PAD patients through patients' activation. Our results are encouraging and warrant a next intervention to explore an educational program impact on PAD knowledge.

Peripheral arterial disease is a marker of severe atherosclerosis with a significantly higher risk of cardiovascular morbidity and mortality. It is often underdiagnosed and undertreated. Public and patients’ perception of peripheral arterial disease is influenced by their knowledge of the condition. In this study, we aimed to evaluate the Saudi public’s knowledge of peripheral arterial disease and its specific characteristics. We conducted an interview-based cross-sectional survey, and collected data on basic demographics, self-reported peripheral arterial disease awareness, and knowledge of clinical features, risk factors, preventative measures, management strategies, and potential complications of peripheral arterial disease. A total of 866 participants completed the survey (response rate, 94%); two-thirds were females. Only 295 (34%) of the surveyed participants indicated awareness of peripheral arterial disease. Overall peripheral arterial disease knowledge was low among the “peripheral arterial disease aware” group, particularly in the clinical features domain. Age > 40 years, female gender, and higher education were predictors of self-reported awareness of peripheral arterial disease. In conclusion, the Saudi public is largely unaware of peripheral arterial disease. Educational programs are important to address this critical knowledge gap.