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The incidence of failed endovascular (EVAR) and open repair (OR) is increasing. Redo aortic repair is required in 10% of patients. Extension of the proximal sealing zone above the visceral arteries to adequate, healthier thoracic aorta using a fenestrated graft (FEVAR) can rescue a failing repair. A custom-made device can treat proximal type 1a endoleaks or proximal dilatation post endovascular or open repair, respectively. The aim of this investigation was to present a single-centre experience with FEVAR for patients with a failing aortic repair.A prospectively maintained database of FEVAR patients treated with a ZenithBetween January 1, 2011 and March 31, 2019, 17 ZFEN devices were implanted. 10 patients had a type 1a endoleak from a prior EVAR and 7 patients had proximal disease progression after prior OR. There were 12 males and 5 females, median age of 75 (interquartile range, IQR 7). 76.4% (n = 13) of patients had an American Society of Anaesthesiologists (ASA) grade of 3. Primary technical success was 70.5% (n = 12). Of the remainder, 4 cases (24%) had a type III endoleak at completion angiogram; of which, 2 patients (12%) required re-intervention within 30 days. One further case (6%) had primary assisted technical success as stenting of a flow limiting dissection flap in an iliac vessel was required. Peri-operative rate of deployment related complications and systemic complications were 5.8% (n = 1) and 35% (n = 6), respectively. Median length of hospital stay was 11 days (IQR 11). There was no mortality within the study follow up. Overall 30-day re-intervention rate was 23.5%. Overall survival was 92% at one year.FEVAR is a safe but technically challenging option for rescue of failing aortic repairs. These are a high-risk group of patients and this is reflected in the high post-operative morbidity rate. Technical success was high and 30-day mortality was low.

Objectives Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. Methods A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). ‘Good’ and ‘very good’ consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. Results Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, ‘good’ and ‘very good’ consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, ‘very good’ consensus was achieved for 3/3 statements. Conclusions The main findings from this study were that there was ‘good’ or ‘very good’ consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Purpose: To demonstrate the feasibility and potential utility of high-resolution angioscopy during common endovascular interventions. Methods: A 3.7-F scanning fiber angioscope was used in 6 Yorkshire pigs to image branch vessel selection, subintimal dissection, wire snaring, and stent placement. The angioscope was introduced in a coaxial fashion within a standard 6-F guide catheter. A clear field of view was provided using continuous heparinized saline flush through the outer guide catheter. The flush flow rate was manually adjusted to provide clear imaging depending on the diameter of the vessel and local blood flow conditions. Results: The scanning fiber angioscope was compatible with off-the-shelf catheters and devices commonly used in peripheral and aortic interventions. Video-rate, high-resolution images were obtained during all the interventions tested and provided information that was complementary to simultaneously acquired fluoroscopy. The scanning fiber angioscope was able to detect subintimal dissection and branch vessel stent coverage with higher resolution than fluoroscopy alone. Conclusion: Endoluminal imaging with the scanning fiber angioscope is feasible with current endovascular devices and provides additional relevant information that cannot be assessed fluoroscopically. The scanning fiber angioscope represents a novel optical platform on which new endovascular techniques may be developed that will minimize radiation and contrast doses for patients.

Objective A systematic review and meta-analysis was performed to determine the incidence of endovenous heat-induced thrombosis (EHIT) and evaluate its management after endovenous thermal ablation of the great saphenous vein (GSV). Methods MEDLINE and Embase were searched for studies with at least 100 patients who underwent great saphenous vein endovenous thermal ablation and had duplex ultrasound follow-up within 30 days. Data were gathered on the incidence of thrombotic complications and on the management of cases of EHIT. The primary outcome for the meta-analysis was EHIT types 2 to 4 and secondary outcomes were deep venous thrombotic events (which we defined as types 2-4 EHIT plus deep vein thrombosis [DVT]), DVT, and pulmonary embolism (PE). Pooled proportions were calculated using random effects modelling. Results We included 75 studies (23,265 patients). EHIT types 2 to 4 occurred in 1.27% of cases (95% confidence interval [CI], 0.74%-1.93%). Deep venous thrombotic events occurred in 1.59% (95% CI, 0.95%-2.4%). DVT occurred in 0.28% (95% CI, 0.18%-0.4%). Pulmonary embolism occurred in 0.11% (95% CI, 0.06%-0.18%). Of the 75 studies, 24 gave a description of the management strategy and outcomes for EHIT and there was inconsistency regarding its management. Asymmetrical funnel plots of studies that reported incidence of EHIT 2 to 4 and DVT suggest publication bias. Conclusions The recently published guidelines on EHIT from the Society for Vascular Surgery/American Venous Forum provide a framework to direct clinical decision-making. EHIT and other thrombotic complications occur infrequently and have a benign course.

Background Critical limb ischemia (CLI) is the most severe manifestation of peripheral vascular disease. Revascularization is the preferred therapy, but it is not achievable in 25%–40% of patients due to diffuse anatomic distribution of the disease or medical comorbidities. No-option CLI represents an unmet medical need. Mesenchymal stromal cells (MSCs) may provide salvage therapy through their angiogenic and tissue-trophic properties. This article reports a phase 1b clinical study examining the safety and feasibility of intramuscular transplantation of autologous bone-marrow MSCs for patients with no-option CLI. Methods Twelve patients were enrolled in the clinical trial, and nine proceeded to bone marrow aspiration and culture expansion of MSCs. Results A high rate of karyotype abnormality (>30%) was detected in the produced cell batches, resulting in failure of release for clinical administration. Four patients were treated with the investigational medicinal product (IMP), three with a low dose of 20 × 106 MSCs and one with a mid-dose of 40 × 106 MSCs. There were no serious adverse events related to trial interventions, including bone marrow aspiration, IMP injection or therapy. Conclusions The results of this trial conclude that an autologous cell therapy approach with MSCs for critical limb ischemia is limited by the high rate of karyotype abnormalities.

The rupture of atherosclerotic plaques is the prerequisite for adverse cardiovascular events. Calcification morphology plays a critical role in plaque stability, therefore accurate calcification classification is essential for favourable patient management. Blood biomarkers may be a worthwhile approach to stratify patients based on calcification phenotype. Vitamin K-dependent Matrix γ-carboxyglutamate (Gla) protein (MGP) is a potent inhibitor of vascular calcification. Recent studies have demonstrated the potential utility of circulating non-functional MGP (dp-ucMGP) measurements to determine arterial stiffness and calcification levels. The objective of this study was to examine the relationship between circulating dp-ucMGP and calcification phenotype within symptomatic atherosclerotic lesions. Consenting patients undergoing standard endarterectomy procedures were recruited (n = 29). Fasting venous blood was collected preoperatively. Circulating plasma levels of dp-ucMGP were quantified using the inaKtif MGP (dp-ucMGP) iSYS kit. A bicinchoninic acid assay was used to standardise the total protein content present in each sample. High-resolution micro-CT imaging was conducted on the excised atherosclerotic specimens postoperatively. ImageJ post-processing was used to accurately quantify the calcification volume (≥ 130 Hounsfield Units) and determine the total number of calcified particles (3D objects counter plugin). Thirteen carotid (average age 71 years, 9 male) and fourteen peripheral lower limb (average age 65 years, 12 male) patients were examined. One patient had a carotid and a peripheral lower limb plaque (age 79, male). Peripheral lower limb specimens have larger volumes of calcification and higher numbers of calcified particles than carotid samples (472 ± 310 vs 85 ± 113mm3, p < 0.0005; 13919 ± 16034 vs 3476 ± 6208, p = 0.061.) While a higher dp-ucMGP value was noted in carotid than peripheral lower limb patients (214 ± 52 vs 169 ± 36pmol/L, p = 0.014) there was no correlation between circulating dp-ucMGP and calcification volume or number of calcified particles (rs = -0.329 and rs = 0.046). Previous research also found that peripheral lower limb lesions contain higher volumes of calcification than carotid lesions. There is currently no published data on calcified particle comparisons. Patients with symptomatic carotid disease are assumed to have a degree of peripheral arterial disease, this could explain the higher levels of circulating dp-ucMGP in carotid patients. The current study did not examine the dietary patterns of individuals with regards to Vitamin K intake or analyse other areas of the vasculature for additional calcification. This may interfere with dp-ucMGP measurements. This study serves as a preliminary investigation into the potential of dp-ucMGP as a blood based biomarker to distinguish between symptomatic atherosclerotic calcification phenotypes.

BackgroundAntiplatelet and anticoagulant therapy are commonly used before, during and after peripheral arterial endovascular intervention. This survey aimed to establish antiplatelet and anticoagulant choice for peripheral arterial endovascular intervention in contemporary clinical practice.MethodsPilot-tested questionnaire distributed via collaborative research networks.ResultsOne hundred and sixty-two complete responses were collected from responders in 22 countries, predominantly the UK (48%) and the rest of the European Union (44%). Antiplatelet monotherapy was the most common choice pre-procedurally (62%). In the UK, there was no difference between dual and single antiplatelet therapy use post procedure (50% vs. 37%p = 0.107). However, a significant majority of EU respondents used dual therapy (68% vs. 20%p ConclusionsThere is widespread variation in the use of antiplatelet therapy, especially post peripheral arterial endovascular intervention. Clinicians would support the development of a randomised trial comparing dual antiplatelet therapy with monotherapy.

Endoleaks, defined as blood flow outside the graft but inside the aneurysm sac, are a common complication after endovascular aneurysm repair. Sometimes however, for reasons not fully understood, expansion of the aneurysm sac can occur with no identifiable endoleak, a phenomenon termed endotension, or a type V endoleak. We describe a case of endotension in a 71-year-old man that developed after recurrent stent graft thrombosis requiring thrombolysis 3 years after the initial endovascular implantation. To our knowledge, this is the first description in the literature of endotension after multiple rounds of thrombolytic treatment.

Objectives A systematic review and meta-analysis was performed to determine the incidence of thrombotic events following great saphenous vein (GSV) endovenous thermal ablation (EVTA). Methods MEDLINE, Embase and conference abstracts were searched. Eligible studies were randomised controlled trials and case series that included at least 100 patients who underwent GSV EVTA (laser ablation or radiofrequency ablation [RFA]) with duplex ultrasound (DUS) within 30 days. The systematic review focused on the complications of endovenous heat induced thrombosis (EHIT), deep venous thrombosis (DVT), and pulmonary embolism (PE). The primary outcome for the meta-analysis was deep venous thrombotic events which were defined as DVT or EHIT Type 2, 3, or 4. Secondary outcomes for the meta-analysis were EHIT Type 2, 3, or 4, DVT and PE. Subgroup analyses were performed for both the RFA and EVLA groups. Pooled proportions were calculated using random effects modelling. Results Fifty-two studies (16,398 patients) were included. Thrombotic complications occurred infrequently. Deep venous thrombotic events occurred in 1.7% of cases (95% CI 0.9–2.7%) (25 studies; 10,012 patients; 274 events). EHIT Type 2, 3, or 4 occurred in 1.4% of cases (95% CI 0.8–2.3%) (26 studies; 10,225 patients; 249 events). DVT occurred in 0.3% of cases (95% CI = 0.2%–0.5%) (49 studies; 15,676 patients; 48 events). PE occurred in 0.1% of cases (95% CI = 0.1–0.2%) (29 studies; 8223 patients; 3 events). Similar results were found when the RFA and EVLA groups were analysed separately. Conclusion Thrombotic events occur infrequently following GSV EVTA. Given the large numbers of procedures worldwide and the potential for serious consequences, further research is needed on the burden of these complications and their management.

Background An arteriovenous fistula (AVF) is the best modality for hemodialysis access. The end-to-side (ETS) technique has been suggested in the literature to produce superior results to the side-to-side (STS) approach; however, in the absence of a systematic review, this practice remains debatable. Methods Online search for randomized controlled trials and observational studies that compared the ETS versus the STS anastomosis techniques in creating an upper limb AVF. Aims were to systematically assess the difference between both procedures in terms of access maturation, patency, and postoperative complications. Results Seven studies were included with 463 patients in the ETS group and 523 in the STS group. The difference between the 2 techniques was not significant in relation to patency rates at 3, 6, 12, and 24 months ( P values: 0.28, 0.82, 0.54, and 0.21, respectively). There were fewer cases of postoperative hematoma in the ETS group; however, the difference was not significant ( P = 0.09). Arterial steal syndrome was found to be significantly associated with the STS configuration in pooled analysis (pooled risk ratio = 0.11 [0.01–0.88], 95% CI, P = 0.04). Conclusions Similar maturation rates between ETS and STS fistula configuration, however, arterial steal syndrome was significantly associated with the STS technique. ETS will likely remain as the preferred AVF configuration as it is less technically demanding.

Aneurysm of the pedal arteries is uncommon. Dorsalis pedis aneurysms are a clinically rare phenomenon. We present a case of traumatic fusiform aneurysm of the dorsalis pedis artery in an otherwise well 53-year-old Caucasian man. Initial history was suggestive of micro-embolic disease to the medial toes of the left foot and on examination pulses were palpable throughout the lower limbs with a strong, palpable dorasalis pedis pulse. Ankle brachial pressure indexes were normal but reduced toe pressures to the left toes. Colour flow duplex imaging revealed aneurysmal dilation, involving all layers of artery wall, with irregular intraluminal thrombus across a 16-mm segment. Subsequent CTA run-off revealed all vessels were patent in the left lower limb. Due to concerns over further embolisation, our patient underwent successful ligation of the his dorsalis pedis. He had an uneventful post-operative recovery.

In patients undergoing an amputation secondary to vascular disease, little is known about the timing, mode of delivery, or amount of information needed. The purpose of this study was to explore the perspectives of patients who have undergone a major lower limb amputation as a result of vascular disease, regarding the information healthcare professionals should provide to them during their acute hospital stay. A qualitative study using descriptive methodology was used. Patients were included if they had a major lower limb amputation 1 week to 2 years before the interview. Purposive sampling was used. Sixteen patients participated in a semistructured interview, either face to face or by telephone. Interviews were transcribed verbatim. Thematic analysis was used. Transcripts were coded by two researchers and compared. N-vivo, descriptive and interpretative analyses were used to assess transcribed interviews. Patients stated that there was insufficient information on a variety of topics, including the recovery process, expectations for rehabilitation, and prosthetics. They went on to describe that high pain levels, age, and emotional status affected the delivery of information to them. Patients had different perspectives on timing of information, mode of delivery, and amount of information. An individualized approach to the delivery of information should be considered for patients undergoing major lower limb amputation. Involved healthcare professionals need to take into consideration patient-specific preferences and unique educational needs before the delivery of information. We anticipate that findings from this study will influence the development of an educational program to deliver effective patient centered care in this unique patient population.

Re-intervention on abdominal aortic aneurysm treated by endovascular aortic aneurysm repair for complications such as endoleak, graft migration, and graft failure is relatively common. However, re-do endovascular aortic aneurysm repair can be complex, as the failed graft still resides within the vessel. In addition, some re-do endovascular aortic aneurysm repairs call for an advanced custom graft, which can further increase the complexity and technical skill required. We describe a case of a 15-year-old endovascular aortic aneurysm repair originally implanted in a 71-year-old man, followed by three separate complications requiring intervention. We describe important procedural decisions taken into consideration when presented with failure of an older graft.

A patent false lumen with persistent flow after endovascular repair of type B aortic dissection (TBAD) is associated with an ongoing risk of aortic dilation and rupture. We describe the case of a 64-year-old man who initially underwent thoracic endovascular aortic repair for acute complicated TBAD, but continued to have symptomatic retrograde aneurysm filling and dilatation because of a patent false lumen. Coil embolization of the patent false lumen successfully excluded the aneurysmal thoracic aorta from further perfusion, and led to a decease in aneurysm size on follow-up. Our case report is followed by a discussion on this management strategy and a review of literature.

Background The enhanced recovery after surgery (ERAS) programme is a multimodal evidence-based approach to surgical care which begins in the preoperative setting and extends through to patient discharge in the postoperative period. The primary components of ERAS include the introduction of preoperative patient education; reduction in perioperative use of nasogastric tubes and drains; the use of multimodal analgesia; goal-directed fluid management; early removal of Foley catheter; early mobilization, and early oral nutrition. The ERAS approach has gradually evolved to become the standard of care in colorectal surgery and is presently being used in other specialty areas such as vascular surgery. Currently there is little evidence available for the implementation of ERAS in this field. We plan to conduct a systematic review of this literature with a view to incorporating ERAS principles into the management of major elective vascular surgery procedures. Methods We will search EMBASE (OVID, 1947 to June 2012), Medline (OVID, 1948 to June 2012), and Cochrane Central Register of Controlled Trials (Wiley, Issue 1, 2012). Searches will be performed with no year or language restrictions. For inclusion, studies must look at adult patients over 18 years. Major elective vascular surgery includes carotid, bypass, aneurysm and amputation procedures. Studies must have evaluated usual care against an ERAS intervention in the preoperative, perioperative or postoperative period of care. Primary outcome measures are length of stay, decreased complication rate, and patient satisfaction or expectations. Only randomized controlled trials will be included. Discussion Most ERAS approaches have been considered in the context of colorectal surgery. Given the increasing use of multiple yet different aspects of this pathway in vascular surgery, it is timely to systematically review the evidence for their independent or combined outcomes, with a view to implementing them in this clinical setting. Results from this review will have important implications for vascular surgeons, anaesthetists, nurses, and other health care professionals when making evidenced-based decisions about the use of ERAS in daily practice.

Objectives: The aim of this study was to evaluate the 30-day results and in-hospital costs of elective fenestrated (fEVAR) and branched (bEVAR) endovascular aneurysm repair of juxtarenal and thoracoabdominal aortic aneurysm at a single academic institution. Methods: All elective fenestrated (fEVAR) or branched (bEVAR) cases treated between July 2007 and March 2014 were included. Procedural details, 30-day outcomes, and in-hospital costs (excluding professional fees) of the index procedure were analyzed. The relatively small sample size and skewness of cost data were addressed by using the nonparametric bootstrap to compare means between groups and calculate confidence intervals. Results: There were 84 consecutive fEVAR (n 1⁄4 61) and bEVAR (n 1⁄4 23) procedures. In-hospital and 30-day mortality was 3.3% (fEVAR) and 4.3% (bEVAR). This was related to bowel ischemia in two patients (fEVAR) and respiratory failure in one (bEVAR). Mean hospital stay was 7.2 6 0.8 days for fEVAR and 12.6 6 2.2 days for

A 43-year-old man presented to the emergency department with left leg claudication. CT angiogram confirmed an acute left leg arterial occlusion from a left ventricular thrombus. During intra-arterial thrombolysis, he developed severe abdominal pain and a CT angiogram confirmed an acute occlusive thromboembolism to his left renal artery. Prior to left renal artery intra-arterial embolectomy, temporary intra-arterial occlusion balloons were inflated within his (1) right renal artery to protect this kidney from acute embolism and (2) left iliac artery to protect his left leg from further clot burden. Following the left renal embolectomy, an angiogram demonstrated patent renal arteries, acute occlusion of the right common iliac artery and persistent clot in his left iliac/lower limb. These occlusions were retrieved by surgical embolectomy. Final angiogram demonstrated patent bilateral iliac/lower limb arteries. The patient was discharged on lifelong anticoagulation and remains asymptomatic with bilateral palpable distal pulses and normal serum creatine.