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Introduction Varicose veins (VV) negatively impact quality of life (QoL) and have risks of major complications including bleeding, ulceration and phlebitis. During the COVID-19 pandemic, the VSGBI (Vascular Society of Great Britain and Ireland) and GIRFT (Get It Right First Time) classified VVs as lowest priority for intervention. Objective This study aims to determine harm caused and the impact on the QoL on patients waiting for their VVs procedures for more than 1 year. Methods This was a prospective study conducted at the Norfolk and Norwich University Hospital (NNUH). Patients with VVs awaiting intervention for >1 year were included in the study. Patients with CEAP C6 disease were considered to be too high risk to be invited for treatment during the Covid-19 pandemic. Patients were sent QoL questionnaires and underwent a telephone consultation to assess harm. Both generic (EQ-VAS and EQ-5D) and disease-specific (AVVQ and CIVIQ-14) instruments were utilised. There were no control groups available for comparison. Results 275 patients were identified (37.1% male) with median time on waiting list of 60 weeks (IQR 56–65). 19 patients (6.9%) came to major harm, including phlebitis (3.6%), bleeding (1.8%) and ulceration (1.8%). Fifty-two patients (18.9%) had minor harm, including worsening pain (12.7%) and swelling (6.2%). 6.9% reported psychological harm. Rising CEAP stage was also associated with worsening level of harm in patients with C5-6 disease ( p < 0.0001). Only 8.7% stated they would decline surgery during the pandemic. 104 QoL questionnaires were returned. Median EQ-VAS and EQ-5D was 75 (IQR: 60–85) and 0.685 (0.566–0.761), respectively. Median AVVQ score was 23.2 (14.9–31.0) and CIVIQ-14 score was 33 (21–44). ConclusionsThis study highlights the impact of delaying VVs surgery during a pandemic. A significant rate of both major and minor as well as psychological harm was reported. In addition, VVs had a significant detriment to quality of life.

This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient's clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.

Purpose: Visceral stents in fenestrated endovascular aortic repair (FEVAR) have a significant risk of complications and carry a considerable burden of reinterventions. The aim of this study is to identify preoperative and intraoperative predictors of visceral stent failure. Materials: A retrospective review of 75 consecutive FEVARs in a single center from 2013 to 2021 was undertaken. Data on mortality, stent failure, and reintervention pertaining to 226 visceral stents were collected. Methods: Anatomical features including aortic neck angulation, aneurysm diameter, and angulation of target viscerals were obtained from preoperative computed tomography (CT) scans. Stent oversizing and intraprocedural complications were recorded. Postoperative CT scans were analyzed to determine the length of cover of target vessels. Results: Only bridging stents through fenestrations to visceral vessels were considered; 28 (37%) cases had 4 visceral stents, 24 (32%) had 3, 19 (25%) had 2, 4 (5%) had 1. Thirty day mortality was 8%, a third of which was related to visceral stent complications. Intraprocedural complexity was documented during the cannulation of 8 (3.5%) target vessels, with a technical success rate of 98.7%. A significant endoleak or visceral stent failure was identified in 22 stents (9.8%) postoperatively, of which 7 (3%) had in-patient reintervention within 30 days. Further reinterventions at 1, 2, and 3 years were 12 (5.4%), 2 (1%), and 1 (0.4%), respectively. Most reinterventions were for renal stents (n=19, 86%). A smaller stent diameter and a shorter length of visceral stent were significant predictors of failure. No other anatomical feature or stent choice was found to be a significant predictor of failure. Conclusions: The modality of visceral stent failures varies, but renal stents with a smaller diameter and/or shorter length are more likely to fail over time. Their complications and reinterventions are common and carry a significant burden; therefore, close surveillance must be continued long term. Clinical impact With this work we share the methodology adopted at our centre to treat juxtarenal aneurysm with FEVAR. Thanks to this detailed review of anatomical and technical features we provide guidance for endovascular surgeons to face hostile aneurysm with peculiar visceral vessels anatomy. With our findings will also motivate industries in their attempt to produce improved technologies able to overcome issues identified in this paper.

Coronavirus disease 2019 (COVID-19) generates a cytokine storm that predisposes patients to systemic complications including arterial thrombosis (AT) and acute limb ischaemia (ALI). This study reviews our understanding of the incidence and outcomes of patients with COVID-19 who develop AT. The case notes of all emergency patients with COVID-19 referred to the vascular services between March 2020 and March 2021 were reviewed. The study was undertaken to measure 30-day outcomes. Additionally, a literature search was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following search terms: acute limb ischaemia OR arterial thrombosis OR thrombectomy OR embolectomy AND COVID-19.During March 2020 and March 2021, 60,000 people tested positive for COVID-19 in Norfolk. A total of 33 patients were referred to the vascular services, of which 15 had AT (estimated incidence of 0.03%). Of AT patients, 93% had ALI. Fourteen locations of AT were identified. Of ATs, 36% were infrainguinal. The 30-day mortality was 60%. Three patients underwent surgery: two embolectomies (one requiring subsequent below-knee amputation (BKA) and the other died) and one primary BKA requiring subsequent above-knee amputation. The 30-day amputation-free survival (AFS) rate was 29%. The literature search identified 361 studies prior to a thorough full-text review. Nine case series were included with more than 10 participants each. The incidence of AT was reported as high as 15%. In-hospital mortality was 40%, with a significant proportion undergoing amputation or palliative care. Approximately a third of patients undergoing revascularisation subsequently re-occluded. AFS remained as low as 25%. The incidence of AT within the vascular surgery territory in COVID-19 patients is low; however, it is associated with poor 30-day AFS. A computed tomography angiography protocol including the entire major vessels may be indicated in COVID-19 patients.

Objectives The incidence of acute kidney injury (AKI) after open (OAR) or endovascular (EVAR) aortic repair is unknown. This research assessed the proportion of patients who develop AKI after aortic intervention using validated criteria, and explored AKI risk factors. Methods This was a multicentre national prospective cohort study. Eleven centres recruited patients undergoing EVAR or OAR (September 2017–December 2018). Serum creatinine (SCr) and urine outputs were measured over a minimum of 48 h or throughout the index inpatient stay to define post-operative AKI using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Renal decline at 30 days was calculated using estimated glomerular filtration rate (eGFR) and the Major Adverse Kidney Events (MAKE) 30 day composite endpoint (consisting of: death, new dialysis, > 25% eGFR decline). Results 300 patients (mean age: 71 years, standard deviation [SD] 4 years; 9% females) were included, who underwent: infrarenal endovascular aneurysm repair (EVAR) 139 patients, fenestrated EVAR (fEVAR) 30, branched EVAR (bEVAR) seven, infrarenal open aneurysm repair (OAR) 98, juxtarenal OAR 26. Overall, 24% of patients developed stage 1 AKI (defined at 48 h as per KDIGO), 2.7% stage 2 AKI and 1% needed renal replacement therapy before discharge. AKI proportions per intervention were: infrarenal EVAR 18%; fEVAR 27%; bEVAR 71%; infrarenal OAR 41%; juxtarenal OAR 63%. Older age (odds ratio [OR] 1.44 for EVAR, 1.58 for OAR), lower baseline eGFR (OR 0.88 EVAR, 0.74 OAR), and ischaemic heart disease (OR 4.42 EVAR, 5.80 OAR) were the main predictors of AKI for infrarenal EVAR and OAR. Overall, 24% developed the MAKE30 endpoint. All patients who died (0.6%) or developed a major cardiac event (5.6%) at one year had developed AKI. Conclusion AKI and short term renal decline after aortic intervention are common. Age, renal function, and cardiovascular disease are the main risk factors. Research should now focus on AKI prevention in this high risk group.

BACKGROUND: Management of juxta-renal abdominal aortic aneurysms (JRAAA) remains challenging. Both open surgical and endovascular options are feasible, however, there is lack of level 1 evidence to support one modality over the other. Operative interventions frequently necessitate either open repair with a suprarenal clamp positioning (ORSRC) or complex endovascular repair (EVAR) with fenestrated (fEVAR) or parallel stent grafts (chEVAR). AIM: The aim of this study was to compare the renal function deterioration and mortality between ORSRC and fEVAR in patients who were operated on for unruptured JRAAA at a tertiary centre. DESIGN: This was a retrospective observational study of patients. SETTING: Tertiary vascular unit in the United Kingdom. POPULATION: Patients with unruptured juxta-renal AAA. METHODS: A retrospective review of prospectively collected data was performed on patients who underwent repair for unruptured JRAAA between March 2008 and October 2019. Analysis of short and mid-term outcomes after ORSRC (occlusion of the aorta above at least one of the main renal arteries) and fEVAR was conducted. Patients who underwent open repair of JRAAA with an infrarenal clamp were excluded. Procedural data as well as data regarding complications was noted. Acute kidney injury (AKI) and chronic kidney disease were defined using the KDIGO criteria (Kidney Disease: Improving Global Outcomes). Renal impairment data up to 1 year and mortality up to 5 years was recorded. RESULTS: During the study period, 162 patients who underwent JRAAA repair met the inclusion criteria (60.5% of them having ORSRC). Approximately, 85.8% of the population were males (80.6% in the open group compared to 93.7% in the endovascular group; p=0.019). The mean age for patients in the open group was 74.0 (SD=±5.5) years compared to 76.1 (SD=±7.2) years in the fEVAR group (p=0.035). More patients in the ORSRC group were symptomatic (18.4% versus 6.3% in the fEVAR group; p=0.028) and they also had larger aneurysms compared to the fEVAR group (66.9 (±12.7) mm versus 62.6 (±8.6) mm, respectively; p=0.021). In the ORSRC group, all patients required suprarenal clamping, with clamping above only one of the main renal arteries carried out in 43 patients (44.3%) of cases. At baseline, 37.0% and 44.5% of patients had CKD stage 3 or worse in ORSRC and fEVAR groups, respectively (p=0.759). Approximately 47.6% of patients having ORSRC had evidence of acute renal impairment on post-operative day 3 compared to 12.7% of those in the endovascular group (p

Despite an increasing elderly population there is limited evidence regarding the surveillance and management of small abdominal aortic aneurysms (AAAs) in octogenarians. This study investigated outcomes of patients aged ≥85 years undergoing AAA surveillance to identify whether discontinuation of surveillance might be safe.This was a retrospective cohort study of all patients aged 85 years undergoing surveillance with a small (30-54 mm) AAA between January 2007 and November 2017. Patients were stratified depending on aneurysm diameter at index (40 mm, 40-50 mm,50 mm). A threshold of 55 mm was used to decide intervention in all patients. Subsequent management of threshold aneurysms, aneurysm related and all cause mortality were also collected.One hundred and one patients were included (88 male, mean diameter at index 45 mm, median follow up 56.0 months). The majority of patients (72.3%) undergoing surveillance had not reached threshold at the end of follow up. Only one patient in the40 mm group developed a threshold aneurysm, compared with five (11.6%) and 22 (75.9%) in the 40-50 mm and50 mm groups, respectively (p .0001). Of the 28 patients reaching threshold, eight (28.6%) underwent surgical repair (5 standard endovascular, one complex endovascular, and two open). Twenty-six (25.7%) patients died during follow up, with cardiorespiratory pathologies being the leading cause of death. Only three aneurysm related deaths were observed, including two fatal ruptures and one death following repair from an infected stent graft (all in the50 mm index group).The present data suggests that discontinuation of aneurysm surveillance in patients aged 85 years with aneurysms 40 mm might be safe. In patients with a larger aneurysm or those approaching threshold, early assessment of fitness for surgery may prevent unnecessary surveillance. The decision to treat aneurysms reaching threshold is complex but is appropriate in selected patients.

Objectives Patients presenting with digital upper limb ischaemia are occasionally referred to rheumatology services to rule out vasculitis. We aimed to present two cases of delayed diagnosis of arterial thoracic outlet syndrome (aTOS) in middle-aged patients presenting with digital ischaemia in order to raise awareness of this important pathology that requires timely surgical intervention. Methods Two cases of progressive ischaemia of the right upper extremity caused by primarily undiagnosed compression of the subclavian artery by an accessory cervical rib are presented. The case notes, radiological images, intra-operative and postoperative findings for both patients were reviewed. Patients were followed up after ≥6 months to assess prognosis. Results Both patients had a working diagnosis of Buerger’s disease and had been treated with prostaglandin infusions before establishment of the diagnosis of arterial thoracic outlet syndrome. Both patients were heavy smokers, and one patient had bilateral symptoms and a history of axial SpA and positive HLA-B27. Late presentation in one patient led to the loss of three fingers and the need for plastic reconstructive surgery after cervical rib resection and revascularization. In the other patient, surgical thrombectomy of the upper limb arteries along with resection of a cervical rib and repair of the subclavian artery with an interposition graft were necessitated to heal digital ulcers successfully. Conclusion A high index of suspicion of aTOS should be maintained in middle-aged patients presenting with digital or upper limb ischaemia even in the presence bilateral symptoms or relevant risk factors of other diagnoses, such as smoking or a positive rheumatological history.

ObjectiveThe aim of this paper is to describe the stages undertaken to generate the items and conceptual framework of a new electronic personal assessment questionnaire for vascular conditions.DesignA mixed methods study: First a survey of vascular clinicians was completed to identify the most common conditions treated in vascular clinics and wards. Quantitative systematic reviews were done to identify validated patient-reported outcome measures (PROMs) for direct inclsuion in the new instrument. However, due to scarcity of validated PROMs, the items of the new instrument were mainly based on a large qualitative study of patients and systematic reviews of the qualitative evidence . This was followed by a quantitative clinicians’ consensus study and, finally, a qualitative face validity study with patients.ParticipantsVascular patients participated in the primary qualitative study and the face validity study. In the qualitative study, 55 patients were interviewed, and for the face validity, 19 patients gave feedback. Twelve clinicians completed the survey and 13 completed two cycles of the clinicians’ consensus study.ResultsThe items and scales in the electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) were generated based on the results of five systematic reviews evaluating existing PROMs for possible inclusion in ePAQ-VAS, five systematic reviews of qualitative evidence, a primary qualitative study involving 55 patients and clinicians’ input. One hundred and sixty-eight items were initially generated, of which 59 were eliminated by the expert panel due to repetition. The instrument was divided into one generic and three disease-specific sections (abdominal aortic aneurysm, carotid artery disease and lower limb vascular conditions). In each section, items were grouped together into putative scales. Fifty-five items were grouped across eight scales; the remaining items were kept as individual items, because of relevance to service users.ConclusionsThis multidimensional electronic questionnaire covers the most common vascular conditions. This is particularly important for patients presenting with mixed symptoms or multiple conditions. This tool captures symptomatology, health related quality of life (HRQoL) and other clinically relevant data, such as experience with services and comorbidities.

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

Background M-learning is education using personal mobile electronic devices. Given the prevalence of these in society and amongst healthcare professionals, we aimed to assess their use and feasibility in improving the educational programme of a single vascular institution. Methods A weekly vascular departmental teaching programme was initiated with registrars giving 30-min presentations on a defined book chapter. Two multiple-choice questions (MCQ) per session were devised by a supervising consultant utilising the smartphone response system application, Polltogo. A separate investigator disseminated one pre-teaching and one post-teaching MCQ to the attending trainees via a WhatsApp group. Instant feedback of the correct answer was provided by the application. Participants’ satisfaction was judged through a survey after 13 sessions. Results 11 junior doctors of varying seniority participated in the trial. The median number of session attendees was 5. 129 MCQ responses were received. The mobile engagement score (number of answers received divided by total possible answers) was 97.7%. The average correct score for pre-teaching MCQs was 39.4% and post-teaching MCQs 73.0% (p

Objectives Smartphones have become the most important personal technological device. M-learning is learning through mobile device educational technology. We aim to assess the acceptability of a smartphone learning experience among the vascular trainees and determine if results could inform formal teaching efforts. Methods A survey of the vascular trainees at a single center was conducted following a trial of smartphone learning experience. A vascular fellow used a smartphone response system application (Polltogo, Inspirapps Inc.) to send a daily multiple-choice question to the vascular residents for 20 consecutive working days. The application allows for only one attempt from each user, and the answers are registered anonymously. However, each participant receives instant feedback on his/her response by viewing the correct answer after answering each question along with a distribution of answers among other users. Results A total of 9 trainees participated in the trial, and all of them filled a posttrial survey. All the trainees possessed smartphones. The majority (78%) were not aware of the concept of m-learning. The mobile engagement score (number of answers received divided by total possible answers) was 145/180 (81%). All the trainees were “satisfied” or “very satisfied” with the experience, and the same number stated that they were “likely” or “very likely” to use this technology in the future. The majority (89%) agreed that such an application could assist them in preparing for their board examination. On 3 occasions, 75% or more of the participating trainees answered the multiple-choice question incorrectly, which resulted in addressing the relevant topics in the unit’s weekly teaching conference. Conclusion Using smartphones for education is acceptable among the vascular trainees, and the trial of a response system application with instant written feedback represents a novel method for using smartphones for collaborative learning. Such an application can also inform program directors and surgical trainers of their trainees’ learning needs.

Background Stents are placed in the femoropopliteal arteries for numerous reasons, such as atherosclerotic disease, the need for dissection, and perforation of the arteries, and can become stenosed with the passage of time. When a stent develops a flow-limiting stenosis, this process is known as "in-stent stenosis." It is thought that in-stent restenosis is caused by a process known as "intimal hyperplasia" rather than by the progression of atherosclerotic disease. Management of in-stent restenosis may include performing balloon angioplasty, deploying another stent within the stenosed stent to force it open, and creating a bypass to deliver blood around the stent. The role of drug-eluting technologies, such as drug-eluting balloons (DEBs), in the management of in-stent restenosis is unclear. Drug-eluting balloons might function by coating the inside of stenosed stents with cytotoxic chemicals such as paclitaxel and by inhibiting the hyperplastic processes responsible for in-stent restenosis. It is important to perform this systematic review to evaluate the efficacy of DEB because of the potential for increased expenses associated with DEBs over uncoated balloon angioplasty, also known as plain old balloon angioplasty (POBA). Objectives To assess the safety and efficacy of DEBs compared with uncoated balloon angioplasty in people with in-stent restenosis of the femoropopliteal arteries as assessed by criteria such as amputation-free survival, vessel patency, target lesion revascularization, binary restenosis rate, and death. We define "in-stent restenosis" as 50% or greater narrowing of a previously stented vessel by duplex ultrasound or angiography. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to November 28, 2017. Review authors also undertook reference checking to identify additional studies. Selection criteria We included all randomized controlled trials that compared DEBs versus uncoated balloon angioplasty for treatment of in-stent restenosis in the femoropopliteal arteries. Data collection and analysis Two review authors (AK, WA) independently selected appropriate trials and performed data extraction, assessment of trial quality, and data analysis. The senior review author (AD) adjudicated any disagreements. Main results Three trials that randomized a combined total of 263 participants met the review inclusion criteria. All three trials examined the treatment of symptomatic in-stent restenosis within the femoropopliteal arteries. These trials were carried out in Germany and Austria and used paclitaxel as the agent in the drug-eluting balloons. Two of the three trials were industry sponsored. Two companies manufactured the drug-eluting balloons (Eurocor, Bonn, Germany; Medtronic, Fridley, Minnesota, USA). The trials examined both anatomical and clinical endpoints. We noted heterogeneity in the frequency of bailout stenting deployment between studies as well as in the dosage of paclitaxel applied by the DEBs. Using GRADE assessment criteria, we determined that the certainty of evidence presented was very low for the outcomes of amputation, target lesion revascularization, binary restenosis, death, and improvement of one or more Rutherford categories. Most participants were followed up to 12 months, but one trial followed participants for up to 24 months.Trial results show no difference in the incidence of amputation between DEBs and uncoated balloon angioplasty. DEBs showed better outcomes for up to 24 months for target lesion revascularization (odds ratio (OR) 0.05, 95% confidence Interval (CI) 0.00 to 0.92 at six months; OR 0.24, 95% CI 0.08 to 0.70 at 24 months) and at six and 12 months for binary restenosis (OR 0.28, 95% CI 0.14 to 0.56 at six months; OR 0.34, 95% CI 0.15 to 0.76 at 12 months). Participants treated with DEBs also showed improvement of one or more Rutherford categories at six and 12 months (OR 1.81, 95% CI 1.02 to 3.21 at six months; OR 2.08, 95% CI 1.13 to 3.83 at 12 months). Data show no clear differences in death between DEBs and uncoated balloon angioplasty. Data were insufficient for subgroup or sensitivity analyses to be conducted. Authors' conclusions Based on a meta-analysis of three trials with 263 participants, evidence suggests an advantage for DEBs compared with uncoated balloon angioplasty for anatomical endpoints such as target lesion revascularization (TLR) and binary restenosis, and for one clinical endpoint - improvement in Rutherford category post intervention for up to 24 months. However, the certainty of evidence for all these outcomes is very low due to the small number of included studies and participants and the high risk of bias in study design. Adequately powered and carefully constructed randomized controlled trials are needed to adequately investigate the role of drug-eluting technologies in the management of in-stent restenosis.

The aim of this study was to develop and pilot a group education programme for promoting walking in people with intermittent claudication. Patient focus groups ( n=24) and literature reviews were conducted to inform the development of the education programme, which involves a three-hour group-based education workshop and follow-up telephone support. A pilot study was subsequently conducted in which 23 new patients (Rutherford category 1–3) were randomly assigned to usual care (control) or usual care plus the education programme. Outcomes were assessed at baseline and six weeks including daily steps (tri-axial accelerometer), walking capacity (six-minute walk test and Gardner treadmill test), and quality of life (Intermittent Claudication Questionnaire [ICQ]). Exit interviews were conducted to assess the acceptability and usefulness of the programme. Compared with controls, the intervention group had superior walking capacity and quality of life at six weeks. Mean differences in six-minute walk distance, treadmill maximum walking distance and ICQ score were 44.9 m (95% confidence interval [CI], 6.9 to 82.9), 173 m (95% CI, 23 to 322), and −10.6 (95% CI, −18.9 to −2.3), respectively. The daily step count did not differ between groups. The exit interviews indicated that participants valued attending the programme, that it gave them a greater understanding of their condition, and that they had been walking more for exercise since attending. The results suggest that the education programme is feasible, acceptable, and potentially useful for improving walking capacity and quality of life. A fully-powered trial exploring clinical and cost effectiveness is needed. TRIAL REGISTRATION NUMBER: ISRCTN06733130 ( http://www.controlled-trials.com ).

The treatment of chronic mesenteric ischemia remains challenging and controversy exists over the best interventional option. Endovascular treatment has emerged as first-line management due to its associated lower morbidity and mortality than surgical reconstruction. However, open mesenteric reconstructions continue to play an important role in patients with lesions that are unsuitable for an endovascular option. Mesenteric operations utilize the aorta or iliac artery as the inflow source for a vein or prosthetic bypass to the celiac artery or superior mesenteric artery. We describe an exceptional case of chronic mesenteric ischemia due to atherosclerosis that was treated successfully with a novel ileocolic to right iliac arterial transposition.

Background Constructive feedback plays an important role in learning during surgical training. Standard feedback is usually given verbally following direct observation of the procedure by a trained assessor. However, such feedback requires the physical presence of expert faculty members who are usually busy and time-constrained by clinical commitments. We aim to evaluate electronic feedback (e-feedback) after video observation of surgical suturing in comparison with standard face-to-face verbal feedback. Methods A prospective, blinded, randomized controlled trial comparing e-feedback with standard verbal feedback was carried out in February 2015 using a validated pro formas for assessment. The study participants were 38 undergraduate medical students from the University of Sheffield, UK. They were recorded on video performing the procedural skill, completed a self-evaluation form, and received e-feedback on the same day (group 1); observed directly by an assessor, invited to provide verbal self-reflection, and then received standard verbal feedback (group 2). In both groups, the feedback was provided after performing the procedure. The participants returned 2 days later and performed the same skill again. Poststudy questionnaire was used to assess the acceptability of each feedback among the participants. Results Overall, 19 students in group 1 and 18 students in group 2 completed the study. Although there was a significant improvement in the overall mean score on the second performance of the task for all participants (first performance mean 11.59, second performance mean 15.95; p ≤ 0.0001), there was no difference in the overall mean improvement score between group 1 and group 2 (4.74 and 3.94, respectively; p=0.49). The mean overall scores for the e-feedback group at baseline recorded by 2 independent investigators showed good agreement (mean overall scores of 12.84 and 11.89; Cronbach α = 0.86). Poststudy questionnaire demonstrated that both e-feedback and standard verbal feedback achieved high mean Likert grades as recorded by the participants (4.42 [range: 2-5] and 4.71 [range: 4-5], respectively; p=0.274). Conclusion e-Feedback after watching a video recording appears to be acceptable and is not quantitatively different than standard feedback in improving suturing skills among novice trainees. Video assessment of procedural skills is reliable.

We describe the case of a 36-year-old man with bilateral axillary artery aneurysms and a threatened upper limb. We postulate that his aneurysms and diffuse vasculopathy resulted from a missense mutation identified in his ACTA2 gene known to be highly pathogenic. The risk factors and sequelae of axillary aneurysms are reviewed, with a focus on their surgical management and the effect of ACTA2 mutations on the cardiorespiratory system.

Treatment of juxtarenal abdominal aortic aneurysms (AAAs) remains challenging. A 79-year-old male who had infrarenal endovascular repair of abdominal aortic aneurysm (EVAR) 13 years previously presented with leaking juxtarenal AAA. Emergency fenestrated EVAR (FEVAR) was performed utilizing a stent graft designed and built for a different patient. Despite the need to embolize the celiac artery prior to covering it with the stent graft in order to achieve adequate proximal seal, the patient had uneventful recovery.

Mycotic aneurysms constitute a small proportion of aortic aneurysms. Endovascular repair of mycotic aneurysms has been applied with good short-term and midterm results. However, the uncommon aortoenteric fistula formation remains a potentially fatal complication when repairing such infective aneurysms. We present the case of an 80-year-old woman with thoracic and abdominal aortic mycotic aneurysms, which were successfully treated with endografting. However, the patient presented 3 months later with upper gastrointestinal bleeding secondary to erosion of the thoracic graft into the oesophagus. The patient was treated conservatively due to the high risk of surgical repair. There is currently little exposure to the management of mycotic aortic aneurysms. If suspected, imaging of the entire vasculature will aid initial diagnosis and highlight the extent of the disease process, allowing for efficient management. Aortic endografting for mycotic thoracic aneurysms is a high-risk procedure yet is still an appropriate intervention. Aortoenteric fistulae pose a rare but severe complication of aortic endografting in this setting.

Background: Self-expanding metal stents (SEMS) have been used in the management of malignant colorectal obstruction for palliation or as a bridging tool to single-stage surgery. We present the clinical results of a series of patients with colonic cancer in whom SEMS were inserted endoscopically under radiological guidance. Methods: Between September 2007 and January 2010, prospectively collected data from 21 patients who underwent SEMS insertion was analysed. This data includes demographics, indication for stenting, stent size, technical success, clinical success, complications, survival and duration of hospitalisation. Results: 14 male and 7 female patients with malignant colonic obstruction underwent SEMS insertion: 19 requiring palliation and 2 bridging to surgery. The rate of technical success was 100% and of initial clinical success was 100%. In 16/19 (84.2%) of the palliation group, clinical success was maintained at mean follow up of 3.4 months (1-6 months), while 3/19 (15.8%) died, two with functioning stents and one with stent occlusion. The two patients with operable tumours were successfully bridged to one-stage elective surgery at 1 month and 4 months following stenting. Post-procedure complications occurred in 5 patients: 1 perforation, 2 pain, 1 migration and 1 stent occlusion. All patients were discharged alive and the median hospital stay was 1 day (range: 1 to 13 days). Conclusion: SEMS provides an effective and safe option in the palliation of malignant colorectal obstruction. In operable patients, it provides a useful option to avoid colostomy, by facilitating safer single-stage surgery. In this prospective study of SEMS insertion, high rates of technical and initial clinical success were achieved. This could be attributed to performing the procedure under combined endoscopic and radiological guidance.

Objective This study aims to explore the views of members of theater teams regarding the proposed introduction of a workplace-based assessment of nontechnical skills of surgeons (NOTSS) into the Intercollegiate Surgical Curriculum Programme in the United Kingdom. In addition, the previous training and familiarity of the members of the surgical theater team with the concept and assessment of NOTSS would be evaluated. Design A regional survey of members of theater teams (consultant surgeons, anesthetists, scrub nurses, and trainees) was performed at 1 teaching and 2 district general hospitals in South Yorkshire. Results There were 160 respondents corresponding to a response rate of 81%. The majority (77%) were not aware of the NOTSS assessment tool with only 9% of respondents reporting to have previously used the NOTSS tool and just 3% having received training in NOTSS assessment. Overall, 81% stated that assessing NOTSS was as important as assessing technical skills. Trainees attributed less importance to nontechnical skills than the other groups (p ≤ 0.016). Although opinion appears divided as to whether the presence of a consultant surgeon in theater could potentially make it difficult to assess a trainee's leadership skills and decision-making capabilities, overall 60% agree that the routine use of NOTSS assessment would enhance safety in the operating theater and 80% agree that the NOTSS tool should be introduced to assess the nontechnical skills of trainees in theater. However, a significantly lower proportion of trainees (45%) agreed on the latter compared with the other groups (p = 0.001). Conclusions Our survey demonstrates acceptability among the theater team for the introduction of the NOTSS tool into the surgical curriculum. However, lack of familiarity highlights the importance of faculty training for assessors before such an introduction.

Carotid pseudoaneurysms are rare but may present a lifethreatening condition, particularly when associated with rupture, occlusion, or thromboembolism [1]. The etiology of carotid pseudoaneurysms includes blunt or penetrating trauma and vasculitis, as well as iatrogenic and unknown causes [1]. Historically, carotid pseudoaneurysms have been managed operatively by repair or ligation with percutaneous stenting and coil embolization emerging during the past two decades [2]. The surgery often is complicated due to the presence of associated scarring; therefore, the endovascular option has become attractive alternative with minimal morbidity and high success rate. However, introduction of a sheath or guiding catheter into the common carotid artery (CCA) can be difficult in patients with adverse aortic arch anatomy or concomitant atherosclerotic disease in the peripheral vessels or aorta. In addition, selectively catheterizing the external carotid artery (ECA) can be challenging due to the distorted anatomy by the pseudoaneurysm. We submit an exceptional case of superficial temporal artery cut down to facilitate ECA coil embolization after failed conventional approach from the common carotid artery route. To the best of our knowledge, this is the first case in the literature that describes this technique to treat ECA false aneurysm.

INTRODUCTIONInfected abdominal aortic aneurysms (AAAs) can present insidiously with non-specific symptoms or they may present as ruptured AAA in the classical manner.PRESENTATION OF CASEWe report two cases of mycotic AAA with Listeria monocytogenes. One patient presented with a ruptured aneurysm, while the other patient had a symptomatic non-ruptured presentation with computer tomography (CT) angiogram demonstrating peri-aortic inflammatory change of a rapidly expanding aneurysm. Both patients were treated with excision of the infected tissue and inlay prosthetic surgical repair as well as long term antibiotics.DISCUSSIONArterial aneurysms caused by L. monocytogenes are rare. Risk factors include immunosuppression, infective endocarditis, intravenous drug use and septicaemia. Listeria infections should be discussed with the Health Protection Agency and local microbiologists due to their ubiquity.CONCLUSIONAbdominal aortic aneurysm due to L. monocytogenes is best managed via surgical resection in combination with long term antimicrobial therapy. The role of endovascular exclusion is unclear.

Summary There has been recent concern that the number of patients at risk of femoral artery false aneurysms may be increasing, due to an increase in the number of cardiac and vascular radiological interventional procedures performed each year. Rarely, such pseudoaneurysms can develop around the anastomotic site of a femoral bypass graft. The present report describes the unusual presentation of a huge femoral pseudoaneurysm in a 70-year-old male patient who had an aorto-bifemoral bypass in the past. A surveillance CT angiogram of a previously diagnosed right femoral pseudoaneurysm revealed that it had reached a size of 10◊7◊cm - a considerable growth when compared to his previous scan. An urgent referral was then made to the vascular surgery team. He subsequently underwent a successful surgical repair of his right femoral pseudoaneurysm. Postoperatively, he had an uneventful recovery except for a mild wound infection, which was treated with intravenous antibiotics.

Excessive anticoagulation with warfarin may contribute to certain complications, including bleeding into body cavities. Haemopericardiac tamponade secondary to warfarin is rare outside cardiac surgery. The present report describes an unusual presentation of spontaneous cardiac tamponade in a patient on warfarin and recently treated for chest infection with erythromycin. The patient was referred to the surgeons with acute abdominal pain and hypotension. Blood tests revealed an international normalised ratio (INR) of 16.9. An emergency abdominal computed tomography (CT) scan revealed pericardial effusion. Intravenous vitamin K and prothrombin complex concentrate were administered and urgent referral to a cardiologist was made for pericardiocentesis. Monitoring INR in patients on warfarin is paramount in avoiding the potential detrimental complications of excessive anticoagulation. Clinicians should be aware of drug interactions of warfarin and risk factors associated with its prolonged half-life. Internal bleeding, including haemorrhagic cardiac tamponade, should be ruled out in patients with unexplained hypotension and excessive anticoagulation.

INTRODUCTION Cholecystectomy is the standard treatment for patients with acute cholecystitis. However, percutaneous cholecystostomy (PC) is an alternative for patients at high risk for surgery. We present our five-year clinical experience with the aim of evaluating the efficacy of PC in high risk patients. METHODS A retrospective review was performed on 30 consecutive patients who underwent PC at our institution. The indications for cholecystostomy, route of insertion, technical success, clinical improvement, length of hospitalisation, in-hospital or 30-day mortality, complications, subsequent admissions and performance of interval cholecystectomy were recorded. The median follow-up period was 25 months (range: 1–52 months). RESULTS Thirty-two PCs were performed in thirty patients (mean age: 76.1 years; range: 52–90 years). The indications for PC were acute calculous cholecystitis (29/32), acalculous cholecystitis (1/32) and emphysematous cholecystitis (2/32). The route of insertion was transperitoneal for 22/32 PCs (68.8%) and transhepatic for 10/32 (31.2%). The procedure was technically successful in all patients although 2/22 transperitoneal drains (9.1%) were dislodged subsequently. Twenty-seven PCs (84.4%) resulted in clinical improvement within five days. The in-hospital or 30–day mortality rate was 16.7% (5/30). Eleven patients (36.7%) had a subsequent cholecystectomy: 6 were laparoscopic and 5 converted to open procedures at a median interval of 58 days (range: 1–124 days). CONCLUSIONS PCs are straightforward with few complications. Most patients improve clinically and the procedure can therefore be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation.

Summary Background Reactive lymphoid hyperplasia (RLH) is a rare non-neoplastic extranodal pathology with exceedingly rare occurrence in the liver and pancreas. We present two cases of hepatic RLH, one which had coinciding pancreatic involvement. To the best of our knowledge, concomitant hepatic and pancreatic RLH has not been previously reported. We also present a comprehensive review of the literature on hepatic and pancreatic RLH. Methods An extensive literature search for all published reports on hepatic or pancreatic RLH was conducted. Data on clinical, radiographic and histopathological features were extracted in addition to therapeutic options and outcomes. Results Forty-two hepatic and three pancreatic cases of RLH were described in the literature. The mean age of hepatic cases was 58 years, with a male-to-female ratio of above 1:7. Almost 25% of cases were associated with internal malignancy. Four hepatic cases were managed through active observation. The remainder (84%) underwent surgical resection. Due to their small number, no meaningful analysis could be made on the pancreatic cases. No recurrences were identified in any of the reported cases. Conclusion RLH should be considered in the diagnosis of hepatic nodules where biopsies fail to demonstrate malignant cells. Confirmed RLH lesions should be managed by active observation. Investigation and treatment of any potential source of lymphoid reactivity should be undertaken. More reports on pancreatic RLH need to be studied prior to drawing any useful recommendations on its management.

Background. Most orthopaedic units do not have a policy for reversal of anticoagulation in patients with hip fractures. The aim of this study was to examine the current practice in a district general hospital and determine difference in the time to surgery, if any, with cessation of warfarin versus cessation and treatment with vitamin K. Methods. A retrospective review of the case notes between January 2005 and December 2008 identified 1797 patients with fracture neck of femur. Fifty seven (3.2%) patients were on warfarin at the time of admission. Patients were divided into 2 groups (A and B). Group A patients (16/57; 28%) were treated with cessation of warfarin only and group B patients (41; 72%) received pharmacological therapy in addition to stopping warfarin. Time to surgery between the two groups was compared. Results. The mean INR on admission was 2.9 (range 1.7–6.5) and prior to surgery 1.4 (range 1.0–2.1). Thirty eight patients received vitamin K only and 3 patients received fresh frozen plasma and vitamin K. The average time to surgery was 4.4 days in group A and 2.4 days in group B. The difference was statistically significant (P<.01). Conclusion. Reversal of high INR is important to avoid significant delay in surgery. There is a need for a national policy for reversing warfarin anticoagulation in patients with hip fractures requiring surgery. Vitamin K is safe and effective for anticoagulation reversal in hip fracture patients.

Coronary-subclavian steal syndrome results from atherosclerotic disease of the proximal subclavian artery causing reversal of flow in an internal mammary artery used as conduit for coronary artery bypass. This rare complication of cardiac revascularisation leads to recurrence of myocardial ischaemia. When feasible, subclavian angioplasty and/or stent placement can provide acceptable result for these patients. Vascular reconstruction through carotid to subclavian artery bypass has been the standard procedure of choice. Other interventions in literature include axilloaxillary bypass and subclavian carotid transposition. This case report describes the use of carotid axillary artery bypass for the treatment of coronary-subclavian steal syndrome.

Emphysematous gastritis is a rare variant of gastritis that is characterised by the presence of gas in the wall of the stomach with CT scan being the procedure of choice for diagnosis. It is a potentially fatal disease that is caused by gas forming organisms and usually presents with systemic toxicity. Predisposing factors include corrosive ingestion, alcohol abuse, abdominal surgery, diabetes, and immunosuppressant. Antimicrobial therapy with antibiotics covering gram-negative organisms and anaerobes, and surgery in appropriate cases may enhance survival. We report a new case of emphysematous gastritis following pelvic surgery, diagnosed with a CT scan that showed gas in both stomach wall and liver portal venous distribution and recovered with conservative management.

We aimed to conduct a systematic review of the evidence for structured, home-based exercise programmes (HEPs) in patients with intermittent claudication. The Medline, PsycINFO, EMBASE, and Cochrane databases were searched up to April 2013 for terms related to walking, self-management, and intermittent claudication. Descriptive, methodological and outcome data were extracted from eligible articles. Trial quality was assessed using the GRADE system. Seventeen studies were included with 1,457 participants. Six studies compared HEPs with supervised exercise training, five compared HEPs with usual care/observation control, and seven evaluated HEPs in a single-group design. Trial heterogeneity prevented meta-analysis. Nevertheless, there was "low-level" evidence that HEPs can improve walking capacity and quality of life in patients with intermittent claudication when compared with baseline or in comparison to usual care/observation control. In addition, improvements with HEPs may be inferior to those evoked by supervised exercise training. Considerable uncertainty exists regarding the long-term clinical and cost effectiveness of HEPs in patients with intermittent claudication. Thus, more robust trials are needed to build evidence about these interventions. Nevertheless, clinicians should consider using structured interventions to promote self-managed walking in patients with intermittent claudication, as opposed to simple "go home and walk" advice, when supervised exercise training is unavailable or impractical.