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The objective of medical research is the quest for scientific truth, as well as the communication of new knowledge to the medical society through publication of novel results. Journals publishing these results rely on the trust that all persons involved (authors, peer reviewers, editors, and publishers) remain honest, following the rules and ethics of scientific integrity. Unfortunately, this is not always the case and a wide spectrum of pitfalls and misconducts may occur, ranging from less serious violations of ethical rules to most serious ones. In ascending order of severity, these include borderline questionable practices (HARKing [Hypothesizing After the Results are Known] and hyping), redundant publications, authorship misconducts, plagiarism, and all types of fraud (data falsification or fabrication). Awareness of all these fraudulent practices is essential to mitigate misconduct in academic writing.

Thigh arteriovenous grafts are required in a number of patients with exhausted upper extremity veins and comprise 1%–5% of the total access procedures performed. Alternative autogenous lower extremity options are the rarely used sapheno-tibial arteriovenous fistulae, the saphenous vein transpositions, and the femoral vein transpositions. The latter have proven to be the most durable lower limb access procedures, with low infection rates and their primary patency rates ranged from 74% up to 87% at 2 years. Synthetic thigh grafts are suitable for patients who are not good candidates for any upper limb or any autogenous lower limb access and their secondary patency rates ranged from 54% up to 83% at 2 years. Thigh grafts often get infected and their average weighed infection rate in 920 such grafts included in eight large series was 22.9%. A literature search was performed to evaluate thigh grafts compared with alternative options using meta-analysis. Lower limb accesses were found superior compared to HeRO® device regarding 1-year primary failure rate (odds ratio = 0.28, confidence interval = 0.09–0.88, p = 0.03) and additionally autogenous lower limb accesses were found superior compared to thigh grafts regarding the 1-year primary failure rate (odds ratio = 6.54, confidence interval = 2.29–18.72, p = 0.0005).

Posters are an established mode of disseminating scientific research. They require careful preparation and presentation. During the former, the authors need to pay attention to the following features: choice of text, fonts and colors, illustrations and graphics, adequate presentation of methods and results, as well as to-the-point discussion of key messages. The latter is regrettably slightly neglected but very important. Indeed, poster presenters need to give a brief talk highlighting the research question and communicating the findings of the study, their novelty, and the anticipated clinical implications. In conclusion, practice is needed to create successful posters, but the result may be useful and pleasing.

The aim of this study was to evaluate the efficacy of heparin-bonded vascular grafts to offer improved outcomes compared with standard prosthetic grafts in access surgery. A systematic review and meta-analysis was performed and eight studies (seven observational studies and one randomized controlled trial) were included. The pooled 6-month and 1-year primary patency was not significantly different between heparin-bonded arteriovenous (AV) grafts and standard prosthetic AV grafts in seven studies reporting on 1,209 access procedures. The assisted primary patency and secondary patency at 1-year was not significantly different either. Heparin-bonded AV grafts offer no distinct advantage over standard prosthetic AV grafts and their preferential use in access surgery cannot be recommended based on the available evidence.

This study aimed to examine the rates and risk factors for ipsilateral re-amputation in 121 patients with diabetic foot and prior amputation. Twenty-six (21.5%) patients required re-amputation during a mean follow-up of 18 months. Most re-amputations were performed within the first 6 months of the initial amputation. Re-amputation was more common among patients in whom the initial amputation had only affected one or two toes. Age (hazard ratio: 1.06) and heel lesions (hazard ratio: 2.69) were significantly associated with re-amputation. There is a high risk of re-amputation in the diabetic foot, especially within the first 6 months of the initial amputation, mainly due to poor selection of the original amputation level in an effort to save a greater part of the lower extremity. Patients 70 years and those with heel lesions are at greatest risk of re-amputation.

There is a need for quantitative investigations in the vascular laboratory to manage lower extremity ulcers. The majority of leg ulcers are of venous (45%-60%) or arterial origin (10%-20%). Despite the increasing complexity of new devices used in vascular surgical practice, the anklebrachial pressure index (ABPI) remains the cornerstone for the differential diagnosis of ischemic ulcers. The toe-brachial pressure index and the pole test represent attractive alternative tests especially in patients with diabetes. Color flow Doppler imaging (CFDI) is advantageous over ABPI in cases in which wounds and ulcers prevent the use of a cuff by virtue of their size or location; additionally CFDI technology can detect nonflow limiting lesions, lesions to nonaxial arteries such as the deep femoral artery, or lesions limited to a single tibial artery. Continued improvements in the accuracy of CFDI have prompted some vascular surgeons to replace contrast arteriography in distal bypass procedures. Transcutaneous partial oxygen tension measurement (TcPO2) is another noninvasive method that is reliable to select the level of amputation and recommended to determine tissue viability in critically ischemic limbs and in the management of the diabetic foot. CFDI has revolutionized the diagnostic approach to venous disorders and it is considered the gold standard for the assessment of the venous system of the lower limb, causes minimal inconvenience to patients, and is easily repeatable, but it is considered highly operator dependent. Various plethysmography techniques are of limited application in ulcer investigations, because of their difficulty to calibrate signal, unless time measurements such as the postexercise refilling time are used.

The peroneal artery is injured less frequently than the popliteal and tibial arteries, because of its anatomical relationships. Pseudo-aneurysm of the peroneal artery due to a blunt injury is a rare complication. These injuries are usually occult, but more have been identified with the introduction and increasing use of angiography, following a high clinical suspicion of the trauma team involved. We report a case of peroneal artery false aneurysm following blunt trauma, presented with intermittent haemorrhage. In trauma, isolated peroneal artery pseudo-aneurysms, although rare, may occur. Early diagnosis can be confirmed by angiography and when less-invasive procedures cannot be applied, a posterior approach is an attractive surgical option in the management of proximal peroneal artery traumatic lesions.

The diabetic foot represents one of the major complications of diabetes, posing a tremendous impact on morbidity and mortality. Overall, 1 out of 4 patients with diabetes runs the risk of developing a foot lesion throughout his or her life. Worldwide, the prevalence of the diabetic foot in population-based studies ranges between 1.4% and 5.9%. In Greece, this prevalence has been reported at 4.75%. Diabetic foot ulcers represent the main cause of amputations. Hence, both established and emerging treatment modalities should be diligently applied in an attempt to reduce ulcers and amputations. In Greece, Doupis et al reported that the majority of diabetic foot patients had neuropathic (64.9%) rather than neuroischemic ulcers (35.1%). By contrast, Skoutas et al reported 52.1% frequency of neuroischemic, 17.9% frequency of ischemic, and 30% frequency of neuropathic ulceration. The latter authors have suggested that the frequency of the neuroischemic foot is rising in Greece. Of note, there is some evidence of significantly greater age and longer diabetes duration, male preponderance, as well as increased morbidity among neuroischemic in comparison with neuropathic foot patients and significantly higher frequency of smoking, hypertension, dyslipidemia, retinopathy, nephropathy, and coronary artery disease. Very little is known on the frequency of amputations in Greece. Karagianni reported a prevalence of 12.5/1000 patients in 1999, equivalent to 2.48/10 000 general population, mean 10-year incidence of amputations (1990-1999) was 3.7/1000 patients per year, equivalent to 0.59/10 000 general population per year. It was also reported that amputees suffered a mortality of 56%, which represented a 3-fold increase compared with the general population. Above knee amputations were 18%, below knee 18%, foot 29%, and toe 35%; importantly, 15% of amputations were bilateral. Furthermore, revascularization was only attempted in a minority of those patients, whereas the majority was treated by general surgeons of district hospitals. Repeat amputations are also reported to be more frequent. Papazafiropoulou et al observed that patients with diabetes required a second amputation and a contralateral amputation significantly more frequently than their nondiabetic peers. Skoutas et al found that ipsilateral re-amputation was required in 21.5% of patients during a mean follow-up of 18 months, whereas most re-amputations were performed within the first 6 months of the initial operation, age (hazard ratio 1.06 by increase of 1 year) and heel lesions (hazard ratio 2.69) were significantly associated with ipsilateral re-amputations based on multiple regression analysis of the data. Paradoxically, an initial choice of distal amputation in an attempt to minimize tissue loss increased the risk of ipsilateral re-amputation, especially in older subjects (≥70 years). Revascularization procedures, which may be either bypass surgery or percutaneous transluminal angioplasty, appear not to be used enough, although data are sparse. In 1999, underuse of femorodistal bypass surgery and similar revascularization procedures in Greece was reported. Since then, considerable progress seems to have been made. There are now 14 vascular departments accredited for training and about 200 vascular surgeons in the country. Substantial progress has also been accomplished in interventional radiology facilities, resulting in increased number of angioplasties. However, actual data of this progress are not yet available. Of further significance, revascularization is possible in large cities, but remains little available in small hospitals, leading to substantial geographical variation. Infection of chronic foot ulcers represents a major problem, especially in the presence of ischemia. Methicillin-resistant Stapylococcus aureus (MRSA) is a notorious microorganism, whose prevalence is very high in patients with infected foot ulcers. It is also alarming that MRSA infection or colonization was not associated with known risk factors, reflecting its increased prevalence in the community. When conservative medical measures fail to heal, surgery offering either wound incision and drainage, or amputation should follow. However, there is a lack of unanimity concerning the optimal timing and aggressiveness for such intervention. Against this background, the improvement in the study of the diabetic foot in Greece that has taken place since 2005 is of some reassurance. It was in this, the year of the diabetic foot, that specialists established the Greek Association for the Study of the Diabetic Foot and the Study Group of Neuropathy–Diabetic Foot of the Greek Diabetes Association. Thanks to these societies, more than 10 scientific meetings on the diabetic foot, targeting both local and nationwide

We read with interest the article by Sulkowski and Schutle offering an autogenous approach in all patients presenting for hemodialysis access creation. Unfortunately, the title seems not to correlate with the text since any native vein either used in situ, transposed or translocated is termed autogenous and not homologous. There is no doubt that autogenous AV fistulas are the first choice access for incidence end stage renal disease (ESRD) patients and the authors achieved to create such an access in all but one of their 102 patients. However, it seems that their population was much different than the average ESRD patient. The mean age of their patients was only 62 years, two thirds were men and most AV fistulas were used during the third week after their creation or even earlier! Interestingly NKF/DOQI suggests first use of an autogenous access not earlier than one month and preferably after 3 months. The reader of the article has the impression that the majority of the patients were young athletic men with healthy veins allowing early puncture within 3 weeks. The authors also specify that the success of the autogenous approach is based in the use of atraumatic techniques and magnifying lenses, however, it is generally accepted that the main problem in trying to create an autogenous fistula is the quality of the outflow vein. Despite the importance of the preoperative physical examination, which seems that the authors favour, the cornerstone of the preoperative evaluation is non-invasive testing in the vascular laboratory. At least one randomised trial suggested better success rate for native AV fistulas in patients with preoperative non-invasive imaging compared with physical examination alone. Additionally, guidelines for vascular access monitoring recommend bimonthly evaluation by access flow measurement and not twice a year as the authors suggested. Monitoring should be followed by appropriate interventions when necessary. Surgical or endovascular interventions produce better primary assisted patency rates when revision is performed on still patent failing fistulae with stenosis than on thrombosed accesses. It has also been suggested that the majority of nonmaturing fistulae can be salvaged radiologically. Surprisingly not surveillance protocol neither a policy for non-matured accesses was suggested in the article’s algorithm, while the maturation failure rate of radiocephalic fistulas is reported high by various authors ranging 13–70%. Late referral is another point of concern as patients experienced primary failure had to wait more time for a new access, however, this interval represents time at risk for catheter-related complications such as bacteraemia; every additional month of maturation time is associated with a 9% risk of catheter-related bacteraemia. Subgroups of ESRD patients as those older than 70-years of age—particularly female—with unfavorable anatomy or those on long-term steroids having poor vascular integrity are especially vulnerable to primary failure and we believe that in these cases more liberal use of synthetic grafts is justified, PTFE is not evil! In elderly patients parameters such as long-term patency and conservation of proximal access sites are of minimal importance because of their limited life expectancy. This is why NKF/DOQI recommends that at least 50% of access in incident patients should be autogenous fistulae, and not 90%. This particular recommendation was unchanged in the revised guidelines. In conclusion, the suggested algorithm was impressively successful applied in the given ESRD population. The ‘all autogenous’ policy is not always possible in a ‘difficult’ older ESRD population with increased late referral rate, in units willing to keep permanent catheters’ percentage below the DOQI limits.

Objective/backgroundExisting guidelines suggest routine use of pre-operative color Doppler ultrasound (DUS) vessel mapping before the creation of arteriovenous fistulae (AVF); however, there is controversy about its benefit over traditional clinical examination or selective ultrasound use.MethodsThis was a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing routine DUS mapping before the creation of AVF with patients for whom the decision for AVF placement was based on clinical examination and selective ultrasound use. A search of MEDLINE/PubMed, SCOPUS, and the Cochrane Library was carried out in June 2014. The analyzed outcome measures were the immediate failure rate and the early/midterm adequacy of the fistula for hemodialysis. Additionally, assessment of the methodological quality of the included studies was carried out.ResultsFive studies (574 patients) were analyzed. A random effects model was used to pool the data. The pooled odds ratio (OR) for the immediate failure rate was 0.32 (95% confidence interval [CI] 0.17–0.60; p

Objective The hemodynamic consequences of misaligned stent-grafts (SG) in fenestrated endografts (EG) have not been adequately studied. Our aim was to study the hemodynamic effects of positional variations of SG, investigating the potential influence on the total displacement forces acting on the EG and the shear stress values at the stented segments. Methods This was a computational study. An idealized EG model with two renal fenestrations was computationally reconstructed and centrally extended up to the suprarenal level to treat a suprarenal aneurysm. The misalignment of SG was represented by a variable take-off angle between the SG and the EG centerline axis, corresponding to angles of 90°, 176°, 142°, 38°, and 4°, respectively. Accordingly, the maximum EG displacement forces and the shear stress within the stented segments were calculated, using commercially available software. Results The variable positions of the SG caused no effect on the maximum displacement force acting on the EG, being quite steady and equal to 5.55 N. On the contrary, the values of maximum shear stress acting on the stented segments were influenced by their orientation. The narrow transition zone between the distal end of the mating stent and the target artery showed higher stresses than any other segment. The right-angle take off SG position (90°) was associated with the lowest stresses (12.5 Pa), whereas the highest values were detected at 38° and 142° (16.5 and 16.1 Pa, respectively). The vessel segments distal to the SG exhibited constantly lower stress values (1.9–2.2 Pa) than any other segment. Conclusion We detected differences in the values of shear stress exerted on the stented arteries, depending on different positions that SG can adapt after the deployment of fenestrated EG. The pathophysiologic implication of our findings and their potential association with clinical events deserve further investigation and clinical validation.