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Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.

True aneurysms are dilatations of blood vessels, bounded by the tunica intima, tunica media and tunica adventitia. False aneurysms are dilatations bounded by the tunica adventitia only, and are more common than true aneurysms. The femoral artery is the second most common location for true peripheral artery aneurysms, and the most common site of false aneurysms. If left untreated, devastating complications can occur, such as infection, rupture, ischaemia and limb loss. Femoral artery aneurysms should be identified early and managed by a vascular specialist. This article outlines the evidence for the epidemiology, investigation and management of femoral artery aneurysms.

Background: UK National Institute for Health and Care Excellence (NICE) draft clinical guidelines (CG) (2018) regarding aortic aneurysm repair were disputed internationally. We aim to appraise the academic response to the draft CG in terms of quantity and scientific quality by reviewing published conference abstracts from three major national and international, UK meetings. Methods: Abstracts related to aortic practice from The Vascular Societies Annual Scientific Meeting, British Society for Endovascular Therapy (BSET) & Charing Cross (CX) meetings from 2019 were reviewed for methodology, sample size, data collection period, scientific quality and conclusions that supported or conflicted the draft guideline. Results: A total of 549 abstracts were identified from VSGBI, BSET and CX abstract books of which, 226 (41.2%) were related to aortic practices. Of these, 115 (50.9%) were related to EVAR. Twenty-two of these abstracts (19.1%) were identified as having findings relevant to the draft guidelines. Eighteen (15.7%) were identified as findings that potentially conflict the draft CG and 4 (3.5%) that could support the initial recommendations. Six abstracts (5.2%) made direct reference to or challenged the draft CG. The median data collection period was 4 years. The median sample size was 102 patients. In general, scientific quality was poor, with 82% of selected abstracts were graded at level 2b. Conclusion: We have demonstrated a concerted response to the draft NICE clinical guidelines relating to the treatment of abdominal aortic aneurysms at three large scientific meetings. As a result of which and other factors, significant changes were made to the finalized NG156. There is still paucity in evidence regarding the long-term safety and cost-effectiveness of EVAR.

Ischaemic stroke and transient ischaemic attack are of particular interest to the vascular surgeon as over one-third of all strokes are caused by thromboembolism from a stenotic carotid artery, making carotid artery stenosis the leading cause of stroke. If detected early, stenosis can be managed medically, surgically or endovascularly. However, treatment decisions depend on the timing of the transient ischaemic attack and the degree of stenosis, and must be balanced against procedural risk. This article discusses the evidence outlining the epidemiology, measurement and surgical management of carotid artery stenosis that inform national guidelines. Vascular and non-vascular trainees should understand these guidelines because of the potentially debilitating or fatal consequences of untreated carotid stenosis.

Vascular surgery is a relatively new surgical sub-speciality in the UK, with treatment of abdominal aortic aneurysms forming a substantial proportion of the emergency and elective caseload. This article summarises the guidance from the National Institute of Health and Care Excellence and the European Society for Vascular Surgery that outlines the epidemiology, diagnosis and management of abdominal aortic aneurysms. This is important for both vascular and non-vascular trainees to understand because of the critical nature of the disease, which can cause catastrophic haemorrhage, limb loss and mortality. However, if discovered in time, abdominal aortic aneurysms are a very treatable condition.

Background This is a review of our experience in creating transposed femoral vein (TFV) fistulas and some of the lessons we have learnt while performing this challenging procedure over the last 5 years. Methods This is retrospective review of patients who underwent TFV fistula formation between January 2013 and December 2017. Results Fifteen patients underwent FV fistula formation with 4 cases being excluded from analysis. Median follow-up was 1.17 years (interquartile range 0.19–3.59 years). Primary and primary-assisted patency rates were 75% and 100% at 6 months, respectively, and 66.7% and 100% at 1 year. Conclusions Our patient group showed good fistula patency at 1 year and did not experience any incidence of ischemic steal syndrome. We believe this to be due to careful preoperative patient assessment and meticulous surgical technique. Our experience suggests that such procedures should be performed by surgeons with vascular expertise wherever possible to reduce the incidence of complications.

The management of varicose veins and their sequelae are estimated to cost the NHS approximately £400-600 m annually. Along with interventional procedures, the National Institute for Health and Care Excellence (NICE) also recommends the use of compression therapy. With the vast array of different compression therapies available, prescribing the correct method can be challenging, with patients receiving incorrect compression being a matter of concern. This review summarises the key principles underpinning the management of these patients with particular emphasis on the pathophysiology and different classes of compression.

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

Frailty is a global state that does not relate directly to comorbidities and is prevalent among patients with vascular disease. The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to independently predict mortality and morbidity after elective open abdominal aortic aneurysm (AAA) repair.We retrospectively reviewed our institutional National Vascular Registry (NVR) data to identify all patients who underwent an elective open juxta or infrarenal AAA repair between January 2014 and December 2018. The NVR data set included preoperative risk factors, imaging findings, intraprocedural variables, and postprocedural outcomes.A total of 184 patients were assessed using the CFS before they underwent elective open AAA repair. Among 26 (14%) individuals categorized as vulnerable using the CFS, there was no significant difference in age or preoperative cardiac and respiratory testing compared with nonfrail patients. However, vulnerable patients were significantly more likely to have a longer length of stay (12.2 days vs. 8.8 days, P-value 0.044), suffer from respiratory complications (35% vs. 15%, P-value 0.022) and renal failure (23% vs. 6%, P-value 0.013), or die (23% vs. 2%, P-value 0.0003). The regression analysis identified a vulnerable frailty score to be the only significant predictor of mortality (odds ratio = 36.7, P 0.001), all other factors were not shown to be independent predictors.The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective open AAA repair and can be used to predict mortality and morbidity after surgery.

Introduction: Stenosis of an arteriovenous fistula or arteriovenous graft for dialysis is a common problem. Stenosis may lead to a number of problems including failure of the fistula. Treatment of stenosis is commonly with percutaneous angioplasty or surgical patch angioplasty with autologous vein or synthetic graft or patch. Here we report the use of bovine pericardial patch angioplasty as an alternative mode of patch angioplasty when percutaneous intervention has failed. Methods: Patients with fistulae treated with bovine patch angioplasty between 2013 and 2016 were identified from a prospectively maintained renal access database (Cyberren®). Patient records were reviewed, noting type and location of access, patency, re-interventions and complications post bovine pericardial patch. Results: A total of 40 patients were identified as having undergone bovine pericardial patch angioplasty between January 2013 and April 2016. The median time from fistula formation to bovine pericardial patch was 15 months (interquartile range (IQR): 5–43). Median duration of follow-up was 14 months (IQR: 5–18). Primary patency at 6, 12, 18 and 24 months was 91%, 66%, 61% and 54%, respectively. Secondary patency was 94%, 91%, 80% and 77% at the same time points, respectively. In total, 15 patients required 23 re-interventions post bovine pericardial patch. There has been no report of infection or aneurysm formation. Conclusion: Bovine pericardial patch angioplasty for recurrent stenosis in arteriovenous fistulae for dialysis access provides a robust alternative to other surgical patches with the added advantage of allowing early needling and relative resistance to infection. Rates of restenosis and failure post bovine pericardial patch are low.

Background: N-terminal fragment B-type natriuretic peptide (NT-proBNP) prognostic utility is commonly determined post hoc by identifying a single optimal discrimination threshold tailored to the individual study population. The authors aimed to determine how using these study-specific post hoc thresholds impacts meta-analysis results. Methods: The authors conducted a systematic review of studies reporting the ability of preoperative NT-proBNP measurements to predict the composite outcome of all-cause mortality and nonfatal myocardial infarction at 30 days after noncardiac surgery. Individual patient-level data NT-proBNP thresholds were determined using two different methodologies. First, a single combined NT-proBNP threshold was determined for the entire cohort of patients, and a meta-analysis conducted using this single threshold. Second, study-specific thresholds were determined for each individual study, with meta-analysis being conducted using these study-specific thresholds. Results: The authors obtained individual patient data from 14 studies (n = 2,196). Using a single NT-proBNP cohort threshold, the odds ratio (OR) associated with an increased NT-proBNP measurement was 3.43 (95% CI, 2.08 to 5.64). Using individual study-specific thresholds, the OR associated with an increased NT-proBNP measurement was 6.45 (95% CI, 3.98 to 10.46). In smaller studies ( Conclusions: Post hoc identification of study-specific prognostic biomarker thresholds artificially maximizes biomarker predictive power, resulting in an amplification or overestimation during meta-analysis of these results. This effect is accentuated in small studies.

IntroductionThe NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) uses the maximal anterior to posterior (AP) inner-to-inner (ITI) wall diameter in sizing aortic dimensions when screening with ultrasound. It is recognised that ITI measurements are smaller than outer-to-outer (OTO) measurements, and the primary aim was to calculate the absolute difference in AP ITI and OTO measurements across varying aortic diameters. The secondary aim was to estimate the potential number of patients lost from the screening programme.MethodsSince April 2012, patients outside the screening programme that undergo ultrasound of abdominal aortas have their ITI and OTO measurements recorded. These measurements were compared retrospectively and analysed for variability at threshold sizes of AAAs.ResultsFrom May 2012 to October 2013, 452 abdominal aortic ultransound scans recorded both ITI and OTO measurements. The majority (81%) were performed on men with the mean age of 78 years. The mean difference between ITI and OTO measurements was 4.21 mm (p 5 cm. There was no significant difference between the means at each threshold size for ITI diameter (p = .758). In the first 2 years from April 2012, 15,447 men underwent screening. Of these, 177 (1.14%) had sub-threshold ITI aortic diameters between 2.6 cm and 2.9 cm. This would upscale to 5,316 men nationally.ConclusionWe have demonstrated a consistent and significant 4 mm difference between ITI and OTO diameters in live scanning. Lowering the threshold for entry into a surveillance AAAs to an ITI diameter of 26 mm rather than the current 30 mm is advocated. An alternative cost-effective way is to rescreen this small sub-group at 5 or 7 years.

Objective Recent interest has focused on the role of the methyl-arginines, endogenous inhibitors of nitric oxide, as adverse prognostic indicators. To date, few studies have assessed the role of symmetric dimethyl-arginine (SDMA) in patients with peripheral arterial disease. We aimed to determine the relationship, if any, of SDMA to all-cause mortality and disease severity as assessed by the ankle-brachial index (ABI) in patients with symptomatic peripheral arterial disease (PAD). Methods In 238 patients with symptomatic PAD and an ABI of Results The median follow-up was 6 years 11 months (interquartile range [IQR], 4 years 5 months-7 years 10 months). SDMA and ADMA levels were higher in those who died compared with those who survived (0.51 [IQR, 0.44-0.66] μmol/L vs 0.46 [IQR, 0.39-0.55] μmol/L, P ≤ .001; and 0.48 [IQR, 0.41-0.55] μmol/L vs 0.45 [IQR, 0.39-0.50] μmol/L, P = .007, respectively). l-arginine levels were similar in the two groups. On multivariate analysis, SDMA and ADMA as continuous variable were significantly associated with mortality ( P = .001). For SDMA and ADMA, the highest compared with the lowest quartile levels were significantly associated with mortality (SDMA: hazard ratio, 3.855; 95% confidence interval, 1.625-9.143; P = .002; ADMA: hazard ratio, 2.277; 95% confidence interval, 1.114-4.654; P = .024). ADMA and SDMA showed a negative correlation with severity of PAD as assessed by ABI ( r = −0.236, N = 216, P r = −0.209, N = 208, P = .002, respectively). Conclusions The novel finding of this study is that SDMA levels were predictive of all cause-mortality and correlated with disease severity. Further studies should assess the role of nitric oxide donors in patients with high levels of SDMA.

Objectives The objective of this study was to determine whether measuring post-operative B-type natriuretic peptides (NPs) (i.e., B-type natriuretic peptide [BNP] and N-terminal fragment of proBNP [NT-proBNP]) enhances risk stratification in adult patients undergoing noncardiac surgery, in whom a pre-operative NP has been measured. Background Pre-operative NP concentrations are powerful independent predictors of perioperative cardiovascular complications, but recent studies have reported that elevated post-operative NP concentrations are independently associated with these complications. It is not clear whether there is value in measuring post-operative NP when a pre-operative measurement has been done. Methods We conducted a systematic review and individual patient data meta-analysis to determine whether the addition of post-operative NP levels enhanced the prediction of the composite of death and nonfatal myocardial infarction at 30 and ≥180 days after surgery. Results Eighteen eligible studies provided individual patient data (n = 2,179). Adding post-operative NP to a risk prediction model containing pre-operative NP improved model fit and risk classification at both 30 days (corrected quasi-likelihood under the independence model criterion: 1,280 to 1,204; net reclassification index: 20%; p Conclusions Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.

Background: It is unclear whether postoperative B-type natriuretic peptides (i.e., BNP and N-terminal proBNP) can predict cardiovascular complications in noncardiac surgery. Methods: The authors undertook a systematic review and individual patient data meta-analysis to determine whether postoperative BNPs predict postoperative cardiovascular complications at 30 and 180 days or more. Results: The authors identified 18 eligible studies (n = 2,051). For the primary outcome of 30-day mortality or nonfatal myocardial infarction, BNP of 245 pg/ml had an area under the curve of 0.71 (95% CI, 0.64–0.78), and N-terminal proBNP of 718 pg/ml had an area under the curve of 0.80 (95% CI, 0.77–0.84). These thresholds independently predicted 30-day mortality or nonfatal myocardial infarction (adjusted odds ratio [AOR] 4.5; 95% CI, 2.74–7.4; P < 0.001), mortality (AOR, 4.2; 95% CI, 2.29–7.69; P < 0.001), cardiac mortality (AOR, 9.4; 95% CI, 0.32–254.34; P < 0.001), and cardiac failure (AOR, 18.5; 95% CI, 4.55–75.29; P < 0.001). For greater than or equal to 180-day outcomes, natriuretic peptides independently predicted mortality or nonfatal myocardial infarction (AOR, 3.3; 95% CI, 2.58–4.3; P < 0.001), mortality (AOR, 2.2; 95% CI, 1.67–86; P < 0.001), cardiac mortality (AOR, 2.1; 95% CI, 0.05–1,385.17; P < 0.001), and cardiac failure (AOR, 3.5; 95% CI, 1.0–9.34; P = 0.022). Patients with BNP values of 0–250, greater than 250–400, and greater than 400 pg/ml suffered the primary outcome at a rate of 6.6, 15.7, and 29.5%, respectively. Patients with N-terminal proBNP values of 0–300, greater than 300–900, and greater than 900 pg/ml suffered the primary outcome at a rate of 1.8, 8.7, and 27%, respectively. Conclusions: Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

A 66 year old white woman presented to the emergency department of a district general hospital with shortness of breath and chest pain, which radiated to her back. She had previously received antibiotics from her general practitioner for a presumed chest infection. Comorbidities included drug controlled hypertension. On examination she was tachypnoeic and hypertensive with a blood pressure of 170/90 mm Hg. No disparity in blood pressure was seen between her arms. Because clinical signs and plain chest radiography were suggestive of a left sided basal pneumonia with associated parapneumonic effusion (fig 1⇓), she received intravenous antibiotics. Fig 1 Left pleural effusion on computed tomography (white asterisk) Poor clinical response prompted further imaging to rule out pulmonary embolism. This identified a large distal thoracic penetrating aortic ulcer (PAU) at the level T11-12 with associated intramural haematoma (IMH) and a left sided pleural effusion (fig 2⇓). She was transferred urgently to a regional tertiary vascular centre for further management and later discharged with appropriate follow-up. Fig 2 Axial computed tomography at different levels of the thoracic aorta (A) before and (B) after intravenous administration of iodinated contrast. (C) Sagittal multiplanar reformatted image (MPR) after iodinated contrast administration. Intramural haematoma is seen as a crescent of high attenuation within the wall of the aorta best identified before contrast administration (A; white arrows) but also seen on the MPR (C; white arrows). A large penetrating ulcer is seen in the distal descending thoracic aorta (B and C; black asterisk). A large pleural effusion is seen on the left side (A and B; white asterisk) 1. To what group of conditions do penetrating aortic ulcers and intramural haematomas belong? 2. What are the risk factors for these conditions? 3. What is the most common presenting problem? 4. What is the most appropriate diagnostic investigation? 5. How are …

ObjectiveRecent interest has focussed on the role of biomarkers to predict outcome in patients undergoing major vascular surgery. We wished to determine if pre- and postoperative N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) levels could predict all-cause mortality (ACM; primary aim) and major adverse cardiac event (MACE) (secondary aim) in the medium-term follow-up in patients who have undergone elective major vascular surgery.MethodPatients who underwent major elective vascular surgery (n = 136) were followed up for up to 2 years. ACM and first MACE episode were identified from the case notes and the patient management system database of the hospital intranet.ResultsOne patient was lost to follow-up. In the mean follow-up of 654 days, 27 (20%) died and 23 (17%) patients suffered a MACE. Receiver operator curve (ROC) analysis showed that a pre-operative NT-pro-BNP level with a cut-off of 359 pg ml−1 had a sensitivity and specificity of 73% each (area under the curve (AUC) 80%, p

Background The general medical council stipulate all intimate examinations should be chaperoned, and their identity documented within patients' notes. We decided to audit our surgical unit for compliance to these guidelines. Methods A prospective audit before and after intervention was performed. Patients undergoing an intimate examination on the surgical assessment unit over five working days were recruited. Data was collected for the following: chaperone use, identity or decline by a patient. Statistical significance calculated using the unpaired t-test. Intervention following audit results included design of a chaperone sticker and posters to act as an aide memoir to clinicians. Results 61 patients recruited before intervention. Examination of notes revealed documentation of chaperone use in 10patients(16.4%), identity in 9patients(14.8%) and decline in 3patients(4.9%). Chaperone documentation was found in only 13 medical notes(21.3%). After two-months of intervention, 53patients were recruited. Analysis revealed documentation of chaperone use in 27patients(50.9%), identity in 20patients(37.7%) and decline in 5patients(9.4%). Following intervention chaperone documentation was found in 32 medical notes, an improvement to 60.3%(p = 0.0001). Conclusion A chaperone should be offered to all patients who undergo an intimate examination. The identity of the chaperone or decline by a patient should be documented within their medical notes. Our team have demonstrated how effective an audit tool is to improve compliance to guidelines, patient safety and care. A further audit will be undertaken once our surgical proformas have been redesigned to incorporate an area for the chaperone to sign and we encourage other surgical units to do the same., Highlights • Intimate patient examinations should be chaperoned and their identity documented. • Providing medial legal protection to clinicians and ensuring patient safety. • Using a chaperone sticker we have increased compliance to chaperone documentation. • And urge other surgical units to do the same, protecting both clinician and patient.

Myocardial ischemia is the leading cause of postoperative mortality and morbidity in patients undergoing major vascular surgery. Platelets have been implicated in the pathogenesis of acute thrombotic events. We hypothesized that platelet activity is increased following major vascular surgery and that this may predispose patients to myocardial ischemia.Platelet function in 136 patients undergoing elective surgery for subcritical limb ischemia or infrarenal abdominal aortic aneurysm repair was assessed by P-selectin expression and fibrinogen binding with and without adenosine diphosphate (ADP) stimulation, and aggregation mediated by thrombin receptor-activating peptide and arachidonic acid (AA). Cardiac troponin-I (cTnI) was performed.P-selectin expression increased from days 1 to 3 after surgery [median increase from baseline on day 3: 53% (range: -28% to 212%, P0.01) for unstimulated and 12% (range: -9% to 45%, P0.01) for stimulated]. Fibrinogen binding increased in the immediate postoperative period [median increase from baseline: 34% (range: -46% to 155%, P0.05)] and decreased on postoperative day 3 (P0.05). ADP-stimulated fibrinogen binding increased on day1 (P0.05) and thereafter decreased. Platelet aggregation increased on days 1-5 (P0.05). Twenty-eight (21%) patients had a postoperative elevation (0.1 ng mL(-1)) of cTnI. They had significantly increased AA-stimulated platelet aggregation in the immediate postoperative period and on day 2 (P0.05), and non-response to aspirin (48% vs. 26%, P = 0.036).This study has shown increased platelet activity and the existence of non-response to aspirin following major vascular surgery. Patients with elevated postoperative cTnI had significantly increased AA-mediated platelet aggregation and a higher incidence of non-response to aspirin compared with patients who did not.

This study was conducted to assess the ability of preoperative B-type natriuretic peptide levels to predict medium-term mortality in patients who undergo major noncardiac surgery. During a median of 654 days of follow-up, 33 patients from a total cohort of 204 patients (16%) died, 17 from cardiovascular causes. The optimal cutoff in this cohort, determined using a receiver-operating characteristic curve, was >35 pg · ml −1 . This was associated with a 3.5-fold increase in the hazard of death (p = 0.001) and a 6.9-fold increase in the hazard of cardiovascular mortality (p = 0.003). In conclusion, these findings extend recent work demonstrating that B-type natriuretic peptide levels obtained before major noncardiac surgery can be used to predict perioperative morbidity and indicate that they also forecast medium-term mortality, particularly cardiovascular death.

Background B-type natriuretic peptide (BNP) levels predict cardiovascular risk in several settings. We hypothesized that they would identify individuals at increased risk of early cardiac complications after major non-cardiac surgery. The current study tests this hypothesis. Methods Two hundred and four patients undergoing major non-cardiac surgery were studied. The primary end-point was the development of acute myocardial injury [defined as cardiac troponin I (cTnI) level > 0.32 ng ml−1] or death in the 3 days after surgery. Results Preoperative BNP levels were raised in patients who died or suffered perioperative myocardial injury (median 52.2 vs 22.2 pg ml−1, P = 0.01) and BNP predicted this outcome with an area under the receiver operating characteristic curve of 0.72 [95% confidence interval (CI) 0.59–0.86, P = 0.01]. A preoperative BNP value > 40 pg ml−1 was associated with an increased risk of death or perioperative myocardial injury [odds ratio (OR) 6.8, 95% CI 1.8–25.9, P = 0.003], and remained independently predictive after correction for the Revised Cardiac Risk Index. Preoperative BNP levels were higher in patients who exhibited new onset atrial fibrillation or ST/T-wave changes on their postoperative ECG (median 50.5 vs 22.5 pg litre−1, P = 0.01). They were also higher in patients who had either elevation of cTnI > 0.32 ng ml−1 or postoperative ECG abnormalities (median 50.4 vs 21.5 pg ml−1, P Conclusions In the setting of major non-cardiac surgery, preoperative BNP levels are higher in patients who experience perioperative death and myocardial injury. Larger studies are required to confirm these data and to clarify what BNP levels may add to existing methods of risk stratification.

Recent interest has focused on the role of the methyl-arginines, endogenous inhibitors of nitric oxide, as adverse prognostic indicators. To date, few studies have assessed the role of symmetric dimethyl-arginine (SDMA) in patients with peripheral arterial disease. We aimed to determine the relationship, if any, of SDMA to all-cause mortality and disease severity as assessed by the ankle-brachial index (ABI) in patients with symptomatic peripheral arterial disease (PAD).In 238 patients with symptomatic PAD and an ABI of0.8, l-arginine, asymmetric dimethyl-arginine (ADMA) and SDMA levels were measured by hydrophilic-interaction liquid chromatography-electrospray tandem mass spectrometry.The median follow-up was 6 years 11 months (interquartile range [IQR], 4 years 5 months-7 years 10 months). SDMA and ADMA levels were higher in those who died compared with those who survived (0.51 [IQR, 0.44-0.66] μmol/L vs 0.46 [IQR, 0.39-0.55] μmol/L, P ≤ .001; and 0.48 [IQR, 0.41-0.55] μmol/L vs 0.45 [IQR, 0.39-0.50] μmol/L, P = .007, respectively). l-arginine levels were similar in the two groups. On multivariate analysis, SDMA and ADMA as continuous variable were significantly associated with mortality (P = .001). For SDMA and ADMA, the highest compared with the lowest quartile levels were significantly associated with mortality (SDMA: hazard ratio, 3.855; 95% confidence interval, 1.625-9.143; P = .002; ADMA: hazard ratio, 2.277; 95% confidence interval, 1.114-4.654; P = .024). ADMA and SDMA showed a negative correlation with severity of PAD as assessed by ABI (r = -0.236, N = 216, P.001; r = -0.209, N = 208, P = .002, respectively).The novel finding of this study is that SDMA levels were predictive of all cause-mortality and correlated with disease severity. Further studies should assess the role of nitric oxide donors in patients with high levels of SDMA.

Introduction Percutaneous transluminal angioplasty (PTA) is a common therapeutic option for the treatment of peripheral vascular disease. Pseudoaneurysm at the puncture site is a well-documented complication in patients. Case presentation This case report describes a patient who presented to hospital several days following a left superficial femoral and popliteal artery PTA with lower limb pain and swelling. The working diagnosis included a deep vein thrombosis based on the Wells criteria. However, a combination of a duplex scan and computed tomography angiography confirmed a clinically rare occurrence of pseudoaneurysm of the sural artery, a branch of the popliteal artery. This was managed successfully with a thrombin injection, leading to complete resolution of the patient’s symptoms. Conclusion This case highlights the importance of the technical aspects of performing a PTA. We believe that the guide-wire position was not confirmed to be completely in the popliteal artery upon inflation of the balloon.

Aorto-enteric fistula (AEF) is a rare condition caused by an abnormal connection between the aorta and the intestinal tract. This often results in fatal upper gastrointestinal bleeding (UGIB) with an untreated mortality rate of 100%.1 Of the two types of AEF, primary and secondary, the latter is more common and occurs following aortic surgery. The majority of primary AEF (PAEF) are due to spontaneous erosion of an abdominal aortic aneurysm (AAA) into the distal portion of the duodenum. These are extremely rare with an incidence of 0.07%.2 Other causes of PAEF include: infection, tumour, radiotherapy or foreign body ingestion. A high index of suspicion is required in symptomatic patients with a known AAA or recent abdominal aortic surgery to facilitate prompt diagnosis and intervention. An elderly man known to have a 3.8 cm AAA presented to the surgical team with lower abdominal pain radiating to his back. His vital signs were …

Background We present a case of external iliac vein patch venoplasty to accommodate rescue vascular access via a polytetrafluoroethylene loop arteriovenous fistula graft (AVG) for a patient with multiple central venous stenoses. Methods A 35-year-old female with anti-glomerular basement membrane antibody disease required rescue vascular access for hemodialysis. Repeated occlusion and/or thrombosis of long-term central venous access cannulae, to facilitate dialysis, had caused stenosis of brachiocephalic veins: right external iliac vein and occlusion of the left common iliac vein. A previous right brachiobasilic fistula had occluded within 1 year. No other upper limb options for arteriovenous fistula (AVF) were available. A right external iliac vein bovine patch angioplasty concurrently with a polytetrafluoroethylene AV graft between common femoral artery and common femoral vein was performed to restore venous patency and allow rescue dialysis access. Results At 3-year follow-up, the fistula remains widely patent with 2 L/min flow rates and no recurrent stenosis to the treated iliac vein. She has not required any further surgical or interventional radiological procedures to maintain fistula or central venous patency. Central venous stenosis or occlusion is common for patients requiring dialysis, especially those with multiple previous long-term central venous cannulations. If restriction of outflow is present, AVF may fail. Venous patch angioplasty in these cases is a successful technique, allowing AVF formation and long-term patency. Conclusion Central venous stenosis can be treated successfully with patch venoplasty to accommodate AVF/AVG formation for rescue vascular access; this is a potentially lifesaving intervention for patients requiring dialysis.

A 26-year-old man, who was previously fit and well was referred to the vascular surgical team with a painful right forearm 1 week after an aortic valve replacement for infective endocarditis (IE). He was an in-patient recovering from his cardiac surgery. He was on appropriate antibiotics for the IE. He had no systemic signs but had marked leucocytosis. Physical examination revealed a warm swollen painful right forearm with a more discrete pulsatile painful swelling in the mid-forearm measuring about 3×3 …