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Peripheral arterial disease (PAD) is a growing public health burden. The development and progression of PAD is influenced by vascular risk factor management and lifestyle changes. However, public awareness of PAD is low compared with other conditions such as heart disease and stroke, which have been the subject of widespread public health campaigns. This study aimed to determine current levels of PAD awareness among hospital patients.This cross-sectional, tertiary hospital-based, descriptive study was conducted over 6 months in 2019. Two investigators administered the survey in face-to-face interviews to patients attending 3 different hospital-based settings including vascular clinics (VC), cardiology clinics (CVC), and Emergency Department (ED).A total of 150 patients were interviewed. Participants demonstrated low overall awareness of vascular disease (32% PAD and 21% AAA) compared to cardiovascular disease including stroke (71%) and myocardial infarction (63%). Awareness of PAD was higher in vascular patients (51%) compared to CVC and ED patients (p=0.01). Of the total population, 77% and 71% identified the contributory role of smoking and limited exercise to the development of PAD respectively. VC patients were more informed of intermittent claudication (78%) and amputation (80%) (p 0.01) compared to CVC and ED patients.In the global drive to reduce vascular morbidity, this study highlights the poor knowledge of PAD among the public. In addition, there is poor awareness about the incidence, risk factors and complications of PAD. These results highlight the need for accessible and easily understood information regarding PAD in both the clinic setting and public health campaigns.

Abstract. Background: Supervised exercise therapy (SET) is an effective option in the management of peripheral arterial disease (PAD). Unfortunately, poor compliance remains prevalent. This study aimed to assess patient exercise compliance and to identify factors influencing symptomatic improvement and SET participation. Patients and methods: Data regarding attendance at SET for this cohort study were extracted from a prospectively maintained database of patients with claudication attending SET at Dublin City University. All patients had ankle brachial index confirmed PAD with associated intermittent claudication. Exercise performance and symptomatic data were gathered retrospectively using patient charts and interviews. Results: Ninety-eight patients were referred for SET during the study period. The mean age was 69.2 (± 10.1) with 18 % being female. Median follow-up was 25.1 months (IQ range 17.0–31.6). Overall, the mean number of sessions attended per patient was 19.5. Exercise compliance was associated with a significant improvement in symptoms (p = 0.001). Other factors including anatomical level of claudication (P = 0.042) and educational level (p = 0.007) were found to affect the outcome of SET. Multivariate analysis revealed hypertension as a predictor of symptomatic outcome after SET (p = 0.045). Furthermore, ex-smokers (p = 0.021) and those previously diagnosed with hypercholesterolaemia (p = 0.020) or ischaemic heart disease (p = 0.029) had superior exercise compliance. Using linear regression, smoking history (p = 0.024) was identified as a predictor of compliance to SET. Conclusions: Establishing exercise compliance remains challenging in the PAD cohort. Pre-exercise patient education and personalised exercise prescriptions may result in improvements in function and compliance.

Introduction Negative pressure wound therapy (NPWT) dressings reduce wound complications in a variety of settings but it is unclear whether they reduce groin wound complications in closed incisions after vascular surgery. Therefore, we performed a systematic review and meta-analysis. Methods Randomised controlled trials on the use of negative pressure wound dressings on closed groin incisions following vascular surgery were identified from an electronic search of abstract databases, conference proceedings and article reference lists. The primary outcome was surgical site infection (SSI) and secondary outcomes were seromas, readmissions within 30 days postoperatively, reoperations and length of stay. Results 7 exploratory trials involving 935 incisions and an unclear number of patients were identified. 4 trials yielded primary outcome results that favoured NPWT. Meta-analysis found that NPWT dressings reduced SSIs (RR 0.47; 95%CI 0.31–0.70; 3 studies, 422 patients). No other meta-analyses could be performed. Conclusion NPWT dressings are a promising intervention that may reduce the incidence of groin wound complications following vascular surgery. However, further large-scale well-designed studies are needed before NPWT dressings can become the standard of care.

Background This study evaluated the readability and quality of information regarding arteriovenous (AV) fistula for dialysis on the Internet in the English language. Study design Using Google© search, the keywords “AV Fistula for dialysis” were searched. The top 75 ranking sites were analyzed. One website was excluded due to repetition. Each landing page was assessed independently by two authors (RB, LR) for readability using the Flesch Reading Ease Score (FRES) and Gunning Fog Index (GFI). Web site quality was assessed using the DISCERN instrument. The individual position of the top 15 websites in the search engine ranking order list was noted. The country of origin, organization type and issuance of Health on the Net (HoN) Certification was recorded. Statistical analyses were performed using unpaired t-tests and ANOVA variance. Results The mean GFI score was 9.2 and the mean FRES score was 50.6, indicating poor readability. The mean DISCERN score was 48.4, indicating weak quality of websites. Website quality was influenced by the academic/healthcare organization type (p = 0.012). Organization type was not found to impact GFI and FRES scores. Presence of a HoN Certification was not found to impact the quality of information. The majority of sites originated from the United States (61%). Conclusion Our study demonstrates that internet information pertaining to AV fistula for dialysis is of poor quality necessitating improvements to readability and overall website quality to improve the patient experience. Further research into how to improve healthcare web information is needed.

Introduction. Gallstone ileus (GSI) of the colon is an extremely rare entity with potentially serious complications including perforation.Case Presentation. An 88-year-old man presented to the emergency department with abdominal pain and distension. Clinical exam revealed signs of peritonism. Computed tomography (CT) revealed GSI of the transverse colon with a closed-loop large bowel obstruction (LBO) and caecal perforation. The patient underwent emergency laparotomy. A right hemicolectomy was performed, the gallstone was removed, and a primary bowel anastomosis was undertaken. A Foley catheter was sutured into the residual gallbladder bed to create a controlled biliary fistula. The patient recovered well postoperatively with no complications. He was discharged home with the Foley catheter in situ.Discussion. Gallstone ileus is a difficult diagnosis both clinically and radiologically with only 50% of cases being diagnosed preoperatively. Most commonly it is associated with impaction at the ileocaecal valve and small bowel obstruction. Gallstone ileus should also be considered as a rare but potential cause of LBO. This is the first reported case of caecal perforation secondary to gallstone ileus of the transverse colon. Successful operative management consisted of a one-stage procedure with right hemicolectomy and formation of a controlled biliary fistula.

Introduction Les patients cancereux ont un risque augmente d'evenements thromboemboliques veineux. Certaines substances utilisees lors de chimiotherapies ont egalement ete associees au developpement de thromboses. Les cas rapportes d'episodes ischemiques arteriels aigus chez des patients cancereux sont rares. Methodes Les patients operes chirurgicalement pour une ischemie aigue associee a une tumeur maligne dans un centre hospitalo-universitaire etaient identifies sur une periode de 10 ans. Les caracteristiques demographiques des patients, les types de cancer, l'utilisation de chimiotherapies, le site de la thrombose, les traitements et les resultats etaient notes. Resultats Quatre cents dix-neuf patients etaient operes pour une ischemie aigue arterielle. Parmi eux, 16 patients (3,8%) avaient un cancer associe. Les sites les plus frequents de cancer etaient le tractus urogenital (n = 5) et les poumons (n = 5). Huit patients (50%) avaient ete diagnostiques de leur cancer recemment, et quatre (25%) de ces cancers etaient decouverts fortuitement apres l'episode d'ischemie aigue. Quatre patients (25%) developpaient une ischemie aigue lors d'une chimiotherapie. L'artere femorale superficielle etait le site le plus frequent d'occlusion (50%), suivie par les arteres brachiales (18%) et poplitees (12%). Tous les patients avaient une thrombo-embolectomie, mais deux (12%) patients necessitaient un pontage secondaire. Six patients (37%) perdaient leur membre, et la mortalite intra-hospitaliere etait de 12%. L'histologie revelait que toutes les occlusions etaient dues a une maladie thromboembolique, sans cellule tumorale identifiee. Lors du suivi, 44% de patients etaient vivants a 1 an. Conclusion Le cancer et la chimiotherapie peuvent predisposer les patients a l'ischemie aigue arterielle. Au contraire d'autres rapports qui retrouvaient que cet evenement etait preterminal et mieux traite par des mesures palliatives, dans cette serie, un diagnostic et une intervention precoces permettaient un sauvetage de membre et la survie du patient.

BackgroundAdoption of residents' working time restrictions potentially undermines surgical training by reduction of operating room exposure. Simulation has been proposed as a way to acquire necessary skills in a laboratory environment but remains difficult to incorporate into training schedules. This study assessed whether residents working successive nights could acquire endovascular skills similar to colleagues working day shifts.MethodsThis prospective observational cohort study recruited 20 junior residents, divided into day shift and night shift groups by their respective call schedule. After initial cognitive skills training, a validated renal artery stent module on an endovascular simulator was completed over a series of seven sequential shifts during 1 week. The primary outcome measure was serial technical skill assessments. Secondary measures comprised assessments of activity, cognitive performance, introspective fatigue, quality, and quantity of preceding sleep.ResultsBoth groups demonstrated significant learning curves for total time at the first session median vs seventh session median (181 vs 564 seconds [P < .001]; night, 1399 vs 572 [P < .001]), fluoroscopy time (day, 702 vs 308 seconds, [P < .001]; night, 669 vs 313 [P < .001]), and contrast volume (day, 29 vs 13 mL [P < .001]; night, 40 vs 16 [P < .001]). Residents working day shifts reached plateau 1 day earlier in the above measures vs those on night duty. The night shift group walked more steps (P < .001), reviewed more patients (P < .001), performed worse on all cognitive assessments (P < .05), slept less (P < .05), had poorer quality of sleep (P = .001), and was more fatigued (P < .001) than the day shift group. Acquired skill was retained a week after completion of shifts.ConclusionTechnical skills training after night shift work enables acquisition of endovascular technical skills, although it takes longer than after day shift training. This study provides evidence for program directors to organize simulation-based training schedules for residents on night shift rotations.

Intimal angiosarcomas are rare and difficult to diagnose preoperatively. Complete surgical resection is essential, but long-term survival is unlikely. We report a patient who presented with a contained ruptured infrarenal aorta with clinical and radiologic findings suggestive of infectious aortitis. Surgical resection, regional debridement, and reconstruction were completed using a cadaveric arterial homograft. However, pathologic evaluation revealed a high-grade intimal sarcoma.

Training in endovascular intervention ultimately aims to produce interventionalists who demonstrate competence in technical skills. Herein, the authors investigate the rationale for simulation-based training by providing an overview of the psychological theories underpinning acquisition of technical skills, training and assessment history, recent advances in simulation technology, and a critical appraisal of their role in training and assessment in endovascular intervention. Simulators have potential for training and assessment and promise solution to many shortcomings of traditional 'apprenticeship' training models. Before inclusion into the curriculum, further work is needed regarding fidelity, validity, reliability, and design of simulators to ensure accurate transfer of acquired endovascular skills from simulator to patient.

The purpose of this study is to evaluate the use of endovascular stent grafts in the treatment of para-anastomotic aneurysms (PAAs) as an alternative to high-risk open surgical repair. We identified all patients with previous open aortic aneurysm repair who underwent infrarenal endovascular aneurysm repair (EVAR) at our institution from June 1998 to April 2007. Patient demographics, previous surgery, and operative complications were recorded. One hundred forty-eight patients underwent EVAR during the study period and 11 patients had previous aortic surgery. Of these 11 redo patients, the mean age was 62 years at initial surgery and 71 years at EVAR. All patients were male. Initial open repair was for rupture in five (45%) patients. The average time between initial and subsequent reintervention was 9 years. All patients were ASA Grade III or IV. Fifty-five percent of the PAAs involved the iliac arteries, 36% the abdominal aorta, and 9% were aortoiliac. Ten patients had endovascular stent-grafts inserted electively, and one patient presented with a contained leak. Aorto-uni-iliac stent-grafts were deployed in seven patients, and bifurcated stent-grafts in four patients. A 100% successful deployment rate was achieved. Perioperative mortality was not seen and one patient needed surgical reintervention to correct an endoleak. Endovascular repair of PAAs is safe and feasible. It is a suitable alternative and has probably now become the treatment of choice in the management of PAAs.

Vascular access for hemodialysis remains a challenge for nephrologists, vascular surgeons, and interventional radiologists alike. Arteriovenous fistula and synthetic grafts remain the access of choice for long-term hemodialysis; however, they are subject to complications from infection and repeated needle cannulation. Pseudoaneurysms are an increasingly recognized adverse event. At present, there are many minimally invasive methods to repair these wall defects. We present a graft pseudoaneurysm, which required a combination of endovascular stent graft placement and percutaneous thrombin injection for successful occlusion.

To prospectively assess the impact of peripheral percutaneous transluminal angioplasty (PTA) on quality of life (QOL) in patients with intermittent claudication or critical limb ischemia (CLI). The secondary purpose was to determine if periprocedural medication altered patient QOL.A total of 72 patients underwent lower-limb PTA (86 lesions) over a period of 12 months. QOL data were obtained before PTA and at 1 and 6 months after PTA with use of the Short Form-36 (SF-36) questionnaire.The SF-36 questionnaire was completed in 100% of cases before PTA, in 89% at 1 month after PTA, and in 78% at 6 months after PTA. Baseline QOL was worse than the QOL quoted for the normal population. Overall, there was an improvement in QOL in seven of the nine health domains at 1 month after PTA, and the improvements were significant (P.01) in five. Improvement was demonstrated at 6 months in all nine QOL domains measured, which was significant (P.01) in five. Patients with intermittent claudication (n = 40) exhibited an improvement in all nine health domains at 6 months, which was significant (P.05) in seven. The CLI group (n = 32) showed an improvement in five domains at 6 months, which was significant (P.05) in two. Subjects with intermittent claudication experienced a more significant improvement than those with CLI. SF-36 pain scores at 1 month after PTA were significantly better in patients taking aspirin than in those who were not (P.001).PTA results in improved QOL in patients with intermittent claudication and CLI as early as 1 month, which was shown to be maintained at 6 months in our small series. Aspirin significantly improves pain after PTA. QOL assessment is useful after peripheral angioplasty.

Background Peripheral arterial bypass is an effective procedure for the management of patients with critical limb ischaemia. However, it is commonly associated with high rates of graft occlusion and subsequent limb loss. This is particularly apparent when the distal anastomosis is to the below-knee arterial segment. A number of studies have suggested that an arteriovenous fistula (AVF) sited at the distal anastomosis may reduce afterload, improve graft patency, and boost subsequent limb salvage. The aim of this study was to assess the effects of adjuvant AVF on the outcomes of peripheral arterial bypass. Methods The following databases were searched up to May 2015: Medline through Pubmed; the Cochrane Library; EMBASE; and reference lists of articles. Study eligibility All randomised controlled and observational studies that assessed the role of AVF as an adjunct to peripheral arterial bypass were included. Studies were required to include at least one pre-defined outcome. Data were extracted and assessed by two reviewers with any disagreements adjudicated on by the senior author. Pooled risk ratios were calculated using a random effects model. Additional subgroup analyses were performed. Results Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73–2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80–1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30–0.98). Conclusion Although adjuvant AVF is not associated with additional operative complication there is little evidence to support its use. The evidence assessing its merits is weakened by small, retrospective studies with heterogeneous cohorts.

Peripheral arterial disease (PAD) is associated with considerable morbidity and mortality. Consensus rightly demands the incorporation of supervised exercise training (SET) into PAD treatment protocols. However, the exact role of SET particularly its relationship with intervention requires further clarification. While supervised exercise is undoubtedly an excellent tool in the conservative management of mild PAD its use in more advanced disease as an adjunct to open or endovascular intervention is not clearly defined. Indeed its use in isolation in this cohort is incompletely reported. The aim of this review is to clarify the exact role of SET in the management of symptomatic PAD and in particular to assess its role in comparison with or as an adjunct to invasive intervention. A systematic literature search revealed a total 11 randomised studies inclusive of 969 patients. All studies compared SET and intervention with monotherapy. Study results suggest that exercise is a complication-free treatment. Furthermore, it appears to offer significant improvements in patients walk distances with a combination of both SET and intervention offering a superior walking outcome to monotherapy in those requiring invasive measures.

Background Venous leg ulcers affect 1–3% of adults with a significant economic impact, utilizing 1% of annual healthcare budgets in some western European countries. Objectives To determine the effects of intervention for incompetent superficial veins on ulcer healing and recurrence in patients with active or healed venous ulcers. Search methods In October 2014, we searched Medline, CINAHL, EMBASE, Scopus, the Cochrane library and Web of Science without date or language restriction for relevant randomized or observational studies. Bibliographies of included studies were also searched for additional studies. Selection criteria Observational studies or randomized controlled trials comparing intervention for varicose veins with compression therapy alone for venous leg ulcers were eligible. In addition, studies compared open to endovenous therapy for varicose veins in patients with leg ulcers and those compared treating saphenous and perforating veins to treating saphenous veins only were also included. Studies had to report at least one ulcer-related outcome (healing rate, recurrence or time to healing). Data collection and analysis Details of potentially eligible studies were extracted and summarized using a data extraction table. Data extraction and quality assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third author. Results Intervention for superficial venous reflux improved ulcer healing (risk ratio = 1.11 [1.00, 1.22], 95% CI, p = 0.04) and reduced recurrence (risk ratio = 0.48 [0.32, 0.67], 95% CI, p Conclusion This review confirmed that the evidence for a beneficial effect of endovenous and open surgery for varicose vein in venous leg ulcer is at beast weak. A well-structured RCT is required to investigate the role of endovenous ablation of incompetent superficial veins in improving venous leg ulcer outcomes.

Introduction Endovascular aneurysm repair (EVAR) is a comparatively less invasive technique than open repair (OR). Debate remains with regard to the benefit of EVAR for patients with ruptured abdominal aortic aneurysm (RAAA). We sought to evaluate and report outcomes of EVAR for RAAA in an Irish tertiary vascular referral centre. Methods Patients undergoing emergency surgery for ruptured or symptomatic AAA were identified from theatre logbooks and HIPE database. Retrospective chart review was undertaken. Data were exported to IBM SPSS version 21 for statistical analysis with p Results A total of 41 patients underwent surgery for RAAA. The mean age was 74 years old with a range from 55 to 89 years. The majority (n = 25, 61%) were baseline American Society of Anaesthesiology (ASA) grade 3–4. Of these 56% underwent EVAR with the remaining 44% repaired open. Mortality rate in those undergoing emergency EVAR was 34.8%, compared with 38.9% in those undergoing open surgery. This difference was not statistically significant. The mean overall length of stay was 13 days. With regard to prognostic indicators of patient outcome, increasing patient age was noted to be significantly associated with increased mortality (p = 0.013), as was increased ASA score at time of surgery (p = 0.029). Conclusions Mortality rates in those undergoing EVAR for RAAA are comparable with those undergoing open repair. Increasing age and ASA score are significant predictors of mortality in patients with RAAA undergoing intervention.

Varicose veins are common and frequently cause patient distress. In recent years, Radiofrequency ablation (RFA) has emerged as a minimally invasive alternative to traditional open venous ligation surgery. The aim of this study was to directly compare RFA and open saphenofemoral ligation. This was a single-centre retrospective cohort study. Consecutive patients undergoing surgical management over a 2-year period commencing from January 2011 were studied. Radiological success, peri-operative serological testing and hospital length of stay were documented. Procedural cost was calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. During the study period, 296 patients underwent surgical intervention. A total of 204 patients underwent RFA. Sixty-six percent of all patients were female. RFA was associated with a reduction in overnight hospital stay (18 vs. 78 %, P =

Background Extracranial vertebral artery aneurysms are uncommon and are usually associated with trauma or dissection. Primary cervical vertebral aneurysms are even rarer and are not well described. The presentation and natural history are unknown and operative management can be difficult. Accessing aneurysms at the skull base can be difficult and, because the frail arteries are often afflicted with connective tissue abnormalities, direct repair can be particularly challenging. We describe the presentation and surgical management of patients with primary extracranial vertebral artery aneurysms. Methods In this study we performed a retrospective, multi-institutional review of patients with primary aneurysms within the extracranial vertebral artery. Results Between January 2000 and January 2011, 7 patients, aged 12–56 years, were noted to have 9 primary extracranial vertebral artery aneurysms. All had underlying connective tissue or another hereditary disorder, including Ehler-Danlos syndrome ( n = 3), Marfan’s disease ( n = 2), neurofibromatosis ( n = 1), and an unspecified connective tissue abnormality ( n = 1). Eight of 9 aneurysms were managed operatively, including an attempted bypass that ultimately required vertebral ligation; the contralateral aneurysm on this patient has not been treated. Open interventions included vertebral bypass with vein, external carotid autograft, and vertebral transposition to the internal carotid artery. Special techniques were used for handling the anastomoses in patients with Ehler-Danlos syndrome. Although endovascular exclusion was not performed in isolation, 2 hybrid procedures were performed. There were no instances of perioperative stroke or death. Conclusions Primary extracranial vertebral artery aneurysms are rare and occur in patients with hereditary disorders. Operative intervention is warranted in symptomatic patients. Exclusion and reconstruction may be performed with open and hybrid techniques with low morbidity and mortality.

Purpose: Morbidity and mortality of acute type B thoracic aortic dissections remain alarmingly high. Endoluminal options are promising. Methods: A single-center 5-year review of 17 acute type B aortic dissections complicated by visceral malperfusion (11) or pseudoaneurysm formation (6) treated with endovascular intervention. Interventional techniques included endografting (15) and/or percutaneous fenestration (4). Median follow-up is 28 months (range 0-76 months). Results: Median age was 55 years; 30-day death, stroke, and paraplegia rates were 0%, 17.6%, and 5.9%. Success reversing visceral ischemia or sealing a pseudoaneurysm was 100%. Cross-sectional imaging demonstrated that the false lumen was thrombosed in 9 patients, partially thrombosed in 6 patients. Late events include 1 delayed proximal type I endoleak, 1 delayed rupture of the thoracic aorta requiring successful emergent open surgical repair, and 2 unrelated late deaths. Conclusion: Endovascular approaches to type B dissections presenting with visceral malperfusion and/or pseudoaneurysm can achieve acceptable early results.

Down syndrome, or trisomy 21, has a characteristic constellation of clinical findings, including various congenital heart defects. We report a case of an adult male with Down syndrome who presented with a 3-week history of lower limb pain and swelling, attributed to cellulitis. Clinical and angiographic evaluation identified a below-knee mycotic pseudoaneurysm secondary to infective endocarditis. Surgical aneurysmal repair and revascularization were performed. Various management options are outlined in this report.

Endovascular aortic aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysms. Type I and III endoleaks require prompt, definitive repair or explantation. We review a single center experience of endovascular treatment of type I and III endoleaks. Retrospective review of 22 patients who underwent endovascular intervention for remediation of proximal or distal seal zone endoleaks. Median age was 77 years. Median time interval from EVAR to reintervention was 4 years (range, 1 month–11 years). Sixteen patients (73%) had radiological evidence of endoleak and/or expanding sac size and 6 (27%) had contained rupture. Nine patients underwent a total of 12 endovascular reinterventions before this salvage procedure. Stent grafts used at the original procedure were: AneuRx (n = 10), Excluder (n = 7), Ancure (n = 3), Zenith (n = 1), and custom made (n = 1). Endoleaks treated were type Ia (n = 11), Ib (n = 12), and type III (n = 3). Interventions included: proximal cuff insertion with or without Palmaz stent insertion (n = 8), distal limb extension (n = 2), stent graft relining (n = 6), embolization of hypogastric artery and iliac limb extension (ILE) (n = 5), and aorto-uni-iliac stent graft (AUI) with femoral–femoral crossover (n = 1). One patient who had a rupture died of multiorgan failure. Two patients needed additional reinterventions for endoleaks. Median length of hospital stay was 1 day. Lifelong surveillance after EVAR is advocated because of the potential of delayed type I or III endoleaks, which mandate definitive treatment. Fortunately, most delayed type I and III endoleaks can be successfully corrected with endoluminal interventions rather than resorting to explantation of the endograft.

Background Cancer patients have an increased risk of venous thromboembolic events. Certain chemotherapeutic agents have also been associated with the development of thrombosis. Reported cases of acute arterial ischemic episodes in cancer patients are rare. Methods Patients who underwent surgery for acute limb ischemia associated with malignancy in a university teaching hospital over a 10-year period were identified. Patient demographics, cancer type, chemotherapy use, site of thromboembolism, treatment and outcome were recorded. Results Four hundred nineteen patients underwent surgical intervention for acute arterial ischemia, 16 of these patients (3.8%) had associated cancer. Commonest cancer sites were the urogenital tract ( n = 5) and the lungs ( n = 5). Eight patients (50%) had been recently diagnosed with cancer, and four (25%) of these cancers were incidental findings after presentation with acute limb ischemia. Four patients (25%) developed acute ischemia during chemotherapy. The superficial femoral artery was the most frequent site of occlusion (50%), followed by the brachial (18%) and popliteal (12%) arteries. All patients underwent thromboembolectomy, but two (12%) patients subsequently required a bypass procedure. Six patients (37%) had limb loss, and in-patient mortality was 12%. Histology revealed that all occlusions were due to thromboembolism, with no tumor cells identified. At follow-up, 44% of patients were found to be alive after 1 year. Conclusion Cancer and chemotherapy can predispose patients to acute arterial ischemia. Unlike other reports that view this finding as a preterminal event most appropriately treated by palliative measures, in this series, early diagnosis and surgical intervention enabled limb salvage and patient survival.

Purpose The clinical importance of angiographically detected asymptomatic lower-limb stenoses and occlusions is unknown. This study aims to (i) assess the clinical outcome of asymptomatic lesions in the lower limb, (ii) identify predictors of clinical deterioration, and (iii) determine which asymptomatic lower-limb lesions should be treated at presentation. Materials and Methods All 918 patients undergoing peripheral angiography with or without angioplasty over a period of 7.5 years (January 1999 through June 2006) at a single institution were retrospectively evaluated. One hundred twenty-two patients (54% men; mean age, 70.3 years; age range, 41–91 y) with angiographic stenoses (≥50%) or occlusions on the asymptomatic leg were included. The composite endpoint of interest was major adverse clinical outcome (MACO) of the asymptomatic limb at clinical follow-up, which was defined as the development of intermittent claudication (IC), critical limb ischemia (CLI), or need for subsequent endovascular or surgical revascularization. Actuarial freedom from MACO was assessed with Kaplan-Meier curves and multivariable Cox proportional-hazards regression. Results During a 4.2-year mean follow-up in 122 patients with significant concomitant asymptomatic disease, 32.8% of patients developed symptoms (13.9% with IC, 18.9% with CLI); 42.5% of these cases required revascularization. Cox regression revealed two independent predictors of MACO on the asymptomatic side: contralateral below-knee amputation (BKA; hazard ratio, 2.93; 95% CI, 1.21–7.10; P = .01) and statin treatment (hazard ratio, 3.56; 95% CI, 1.56–8.13; P = .003). Conclusions Asymptomatic peripheral angiographic stenoses and occlusions become symptomatic in one third of patients, necessitating treatment in 13.9% overall. Previous contralateral BKA and statin use were independent predictors of adverse outcome in this population. Close clinical follow-up and appropriate risk factor modification are recommended.

Summary Objectives There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR). Design, materials and methods An observational study of the experience of two centres and a systematic review of the published literature. Results Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair ( n =3) or EVAR ( n =7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection. Conclusions In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Vascular access for hemodialysis remains a challenge for nephrologists, vascular surgeons, and interventional radiologists alike. Arteriovenous fistula and synthetic grafts remain the access of choice for long-term hemodialysis; however, they are subject to complications from infection and repeated needle cannulation. Pseudoaneurysms are an increasingly recognized adverse event. At present, there are many minimally invasive methods to repair these wall defects. We present a graft pseudoaneurysm, which required a combination of endovascular stent graft placement and percutaneous thrombin injection for successful occlusion.

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Results: Initial audit showed that 82% of our theatre sessions did not start in time with a mean delay of 51.9 ( 53.1) minutes. In addition, 47% of the lists overran the finishing time with mean delay of 34.5 ( 47.9) minutes. Implementation of “Fistula first” significantly improved the number of late starting sessions to 56% with a mean delay of 22.6 ( 26.7) minutes (p 1⁄4 0.001). It also reduced overrunning lists to 35% with a mean delay in finishing time of 28.2 ( 48.9) minutes (p>0.05). Looking at dialysis access fistula, intervention reduced late starting sessions from 87.5% to 60% with mean delay reduction from 52.7 ( 41.8) to 20.13 ( 26.2) minutes (p 1⁄4 0.028). Conclusion: Fistula first proved its efficiency in reducing the delay is session starting and this experience could be adopted by other similar institutions.

Type-3 endoleaks. Renal complications were seen in 3/11 patients, 2 acute kidney injuries resolved spontaneously. 1 patient re-admitted Day-19 with acute renal failure and bilateral renal artery occlusion, underwent endovascular recanalization and stenting of the left renal artery, remains dialysis dependent. 2/11 have died at 21 and 60 months, both from non-aneurysm related disease. One iliac limb has been extended for 1b endoleak and sac expansion. 2/11 endoleaks are under surveillance. Conclusions: Complex Endovascular Aneurysm Repair is feasible in patients considered unsuitable for standard endovascular. Mid-term results suggest this procedure is durable, but long-term follow-up is essential and awaited.

Blunt traumatic transection of the aorta (BTTA) is associated with a very high mortality rate. Most victims die at the time of the injury. A review of surgically treated BTTA in Ireland between 1989 and 2002 was performed. The accident files of all road traffic deaths during 2001 and incidence data on national road traffic deaths for the study period were also reviewed. There were 30 acute and 9 chronic BTTA. Of the 30 acute transections, 29 were due to road traffic accidents (RTA) and one a crush injury. Major associated injuries included head injuries (7), fractures (13) with paraplegia in 2 and abdominal injuries requiring surgery in 4. There were 3 (10%) hospital deaths (2 arrested on induction) and no cases of postoperative paraplegia. In 2001, 18.4% of RTA victims had a BTTA on post-mortem and 8.7% of these survived to hospitalisation. 60% of BTTA victims surviving to hospitalisation have undergone successful repair. BTTA must be considered following blunt trauma and should be out-ruled by present scanning techniques.

Introduction Clinical manifestations of hypertrophic bifurcated distal biceps tendons are rarely described. We report the first known case of brachial arterial entrapment resulting from this unusual anatomical variable. Report A 24-year-old gentleman presented with positional upper limb ischaemic symptoms. Initial investigation was unremarkable. Operative exposure of the ante-cubital fossa revealed compression of the brachial artery by a hypertrophic bifurcated distal biceps tendon. Partial division of the tendon led to resolution of symptoms. Discussion In challenging cases of upper limb ischaemia surgical, intervention may be justified for both diagnostic and therapeutic purposes.

To provide a contemporary institutional comparative analysis of expedient correction of acute catastrophes of the descending thoracic aorta (ACDTA) by traditional direct thoracic aortic repair (DTAR) or thoracic endovascular aortic repair (TEVAR).Single-center retrospective review (April 2001-January 2010).Academic medical center.One hundred patients with ACDTA treated with either TEVAR (n = 76) or DTAR (n = 24). Indications for repair included ruptured degenerative aneurysm (n = 41), traumatic transection (n = 27), complicated acute type B dissection (n = 20), penetrating ulcer (n = 4), intramural hematoma (n = 3), penetrating injury (n = 3), and embolizing lesion (n = 2).Demographics and 30-day and late outcomes were analyzed using multivariate analysis over a mean follow-up of 33.8 months.Among the 100 patients, mean (SD) age was 58.5 (17.3) years (range, 18-87 years). Demographics and comorbid conditions were similar between the 2 groups, except more patients in the DTAR group had prior aortic surgery (P = .02) and were older (P = .01). Overall 30-day mortality was significantly better among the TEVAR group (8% vs 29%; P = .007). Incidence of postoperative myocardial infarction, acute renal failure, stroke, and paraplegia/paresis was similar between the 2 treatment groups (TEVAR, 5%, 12%, 8%, and 8% vs DTAR, 13%, 13%, 9%, and 13%, respectively). Major respiratory complications were lower in the TEVAR group (16% vs 48%; P .05). Mean length of hospital stay was also shorter after TEVAR (13.5 vs 16.3 days; P = .30). Independent predictors of patient mortality included age (P = .004) and DTAR (P = .001).Patients presenting with ACDTA are best treated with TEVAR whenever feasible.

Hypothesis Thoracic endovascular aortic repair (TEVAR) for acute blunt thoracic aortic injury has good early and mid-term results. Design Single-center retrospective 7-year review from January 2001 to December 2008. Setting Urban tertiary care hospital. Patients Twenty-four consecutive patients with acute blunt thoracic aortic injury treated with TEVAR. Main Outcome Measures Procedure-related mortality, stroke, or paraplegia; injury severity score; and complications. Results Among the 24 treated patients (mean age, 41 years; range, 20-71 years), the mean injury severity score was 43 (range, 25-66). Thoracic endovascular aortic repair was successful in treating the aortic injury in all patients and there were no instances of procedure-related death, stroke, or paraplegia. Access to the aorta was obtained through an open femoral/iliac approach (n = 7) or an entirely percutaneous groin approach (n = 17). Systemic heparin was not used in 84% of cases. Two access complications (8%) occurred, requiring an iliofemoral bypass in one patient and a thrombectomy in another. One patient required secondary intervention for device collapse, which was treated successfully with repeat endografting. There have been no delayed device failures or complications among the entire cohort at mid-term follow-up. Conclusion Thoracic endovascular aortic repair, via a percutaneous groin approach and without systemic anticoagulation, for blunt thoracic aortic injury can be performed safely with low periprocedural mortality and morbidity.

Introduction.Evidence continues to grow that the bone marrow is a reservoir for mesenchymal stem cells that may be mobilized and differentiated into numerous tissues and participate in a reparative response to injury. We previously reported that the amino acid taurine increases the mobilization of bone marrow stem cells. We hypothesize that tissue injury in Barrett’s esophagitis increases the mobilization of epithelial stem cells which can be further augmented with supplemental taurine. Methods. Bone marrow derived epithelial progenitor cells (EPPCs, CD45−, CD34+, Pancytokeratin+) and endothelial progenitor cells (EPCs, CD45−, CD133+, CD146+) were identified in peripheral blood samples from 16 patients with Barrett’s esophagus and 12 age- and sex-matched controls. Samples were analyzed by flow cytometry before and after 7 days of oral taurine supplementation (500 mg tds). Statistical comparison utilized ANOVA with LSD post-hoc correction. Results are expressed as mean ± standard error of the mean (SEM). Data were taken as statistically significant where P < 0.05. Results. Patients with Barrett’s esophagus were found to have significantly increased levels of baseline EPPCs and this was further significantly increased by the period of taurine supplementation. No significant difference in the levels of EPCs was found between any group before or after treatment. Conclusion. Oral taurine supplementation significantly increases the number of circulating epithelial progenitor cells without inducing a pro-angiogenic state in patients with Barrett’s esophagus. Studies to demonstrate engrafting of peripheral epithelial stem cells are now warranted. TABLE—ABSTRACT P12. Controls (mean no./100,000 cells ± SEM) Barrett’s patients (mean no./100,000 cells ± SEM) EPPC EPC EPPC EPC Pre-treatment 3.67 ± 0.74 2.60 ± 0.54 10.08 ± 2.33χ 2.27 ± 0.67 Post-treatment 5.33 ± 1.73 1.89 ± 0.54 18.21 ± 3.21ϕ 3.86 ± 0.78 χ : statistically significant—v-Controls pre-treatment (P = 0.026) ϕ : statistically significant—v-Barrett’s pre-treatment (P = 0.018)

Objectives Infected carotid prosthetic patches (ICPP) are a rare but catastrophic complication of carotid endarterectomy (CEA). Prevention and appropriate surgical management is essential. We report our experience of carotid artery reconstruction for ICPP. Design Single-center retrospective study. Methods 10-year review of the surgical treatment of ICPP. Results Twelve patients presented with patch infection following CEA. Three patients presented acutely with an expanding hematoma, eight with chronic complications (abscess/discharging sinus n = 5, carotid pseudoaneurysm n = 3). Mean age was 75 years. Replacement conduits included superficial femoral artery ( n = 6), cadaveric homograft ( n = 3), long saphenous vein ( n = 2) and one patient had primary closure. Five patients had muscle flaps fashioned for carotid artery protection. Operative complications included hypoglossal nerve injury (1 patient), superficial skin infection (2 patients) and one patient was returned to the operating room for a neck haematoma. Five surgical specimens were culture positive for: Staphylococcus aureus ( n = 3), Corynebacterium propionibacterium ( n = 1) and Streptococcus anginous ( n = 1). There were no 30-day mortalities. Mean hospital stay was 6 days. Median follow-up was 16 months (range 3–108 months). Conclusion Carotid artery reconstruction in a contaminated wound represents a significant surgical challenge. Unlike previous reports that used venous conduits, this is the first series where cadaveric or autologous arterial conduits were preferred. Arterial conduits achieved durable short term follow-up.

Background Patients undergoing vascular surgery procedures constitute a ‘high-risk’ group. Fatal and disabling perioperative complications are common. Complications arise via multiple aetiological pathways. This mechanistic redundancy limits techniques to reduce complications that target individual mechanisms, for example, anti-platelet agents. Remote ischaemic preconditioning (RIPC) induces a protective phenotype in at-risk tissue, conferring protection against ischaemia-reperfusion injury regardless of the trigger. RIPC is induced by repeated periods of upper limb ischaemia-reperfusion produced using a blood pressure cuff. RIPC confers some protection against cardiac and renal injury during major vascular surgery in proof-of-concept trials. Similar trials suggest benefit during cardiac surgery. Several uncertainties remain in advance of a full-scale trial to evaluate clinical efficacy. We propose a feasibility trial to fully evaluate arm-induced RIPC’s ability to confer protection in major vascular surgery, assess the incidence of a proposed composite primary efficacy endpoint and evaluate the intervention’s acceptability to patients and staff. Methods/Design Four hundred major vascular surgery patients in five Irish vascular centres will be randomised (stratified for centre and procedure) to undergo RIPC or not immediately before surgery. RIPC will be induced using a blood pressure cuff with four cycles of 5 minutes of ischaemia followed by 5 minutes of reperfusion immediately before the start of operations. There is no sham intervention. Participants will undergo serum troponin measurements pre-operatively and 1, 2, and 3 days post-operatively. Participants will undergo 12-lead electrocardiograms pre-operatively and on the second post-operative day. Predefined complications within one year of surgery will be recorded. Patient and staff experiences will be explored using qualitative techniques. The primary outcome measure is the proportion of patients who develop elevated serum troponin levels in the first 3 days post-operatively. Secondary outcome measures include length of hospital and critical care stay, unplanned critical care admissions, death, myocardial infarction, stroke, mesenteric ischaemia and need for renal replacement therapy (within 30 days of surgery). Discussion RIPC is novel intervention with the potential to significantly improve perioperative outcomes. This trial will provide the first evaluation of RIPC’s ability to reduce adverse clinical events following major vascular surgery. Trial Registration www.clinicaltrials.gov NCT02097186 Date Registered: 24 March 2014