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Aim. To evaluate the effectiveness of a novel approach to followup monitoring of patients with lower extremity peripheral artery disease (PAD) using telemedicine technologies. Material and methods. The study included 175 patients (mean age, 68, 1+/-7, 7 years). Two following groups of patients were formed: the main group (n=86), which used an optimized monitoring program using telemedicine techniques, and the control group (n=89), which assumed traditional monitoring by a cardiologist and a vascular surgeon. The mean followup period was 11, 77+/-1, 5 months. The optimized monitoring program included the implementation of audio communication with patients by an employee with a secondary medical education with an assessment of the current health status according to original unified questionnaire, with the definition of personalized management tactics. At the primary and final stages, the patient underwent an assessment of clinical and anamnestic data, mental and cognitive status, and compliance. Results. At the final stage, uncompensated hypertension was revealed in 36, 0% and 49, 4% (p=0, 0001), smoking - in 30, 6% and 42, 9% (p=0, 05) in the main and control group, respectively. In the main group, a greater painfree walking distance was revealed - 625, 8+/-395, 3 m (control group - 443+/-417 m (p=0, 013)). The average systolic blood pressure was 125, 2+/-10, 2 mm Hg and 138, 8+/-15, 8 mm Hg (p=0, 0001) in the main and control group, respectively. In the control group, a greater number of patients with a high level of personal and situational anxiety were revealed (p=0, 05). In the main group, a higher level of adherence to therapy was established at the final study stage (p=0, 001). Conclusion. The optimized monitoring program for patients with limited mobility is effective and can be implemented in practical healthcare for patients with lower extremity PAD.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.
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Aim To conduct comparative analysis of the activities of the department of vascular surgery before and during the spread of new coronavirus infection COVID-19 (SARS-CoV-2). Methods The analysis was performed on the number of outpatient visits of vascular surgeon for types of diagnosis, number and type of surgeries performed at the inpatient facilities of the LLC "Grand Medica" over 2019 (whole year) and 2020 (quarterly). Results Significant decrease was noted in the number of visits of patients with cardiovascular diseases to vascular surgeon in the outpatient facility. The number of surgeries on limb arteries in patients among Kuzbass residents decreased by 26.4 %, among residents of other regions - by 59.5 %;in brachiocephalic arteries - by 12.5 % and 54.5 %, respectively. The number of percutaneous transluminal coronary angioplasty (PTCA) in patients among Kuzbass residents increased by 25.3 %, among residents of other regions remained unchanged. Conclusion Decrease in the volume of provision of care for patients with cardiovascular diseases over 2-4 quarters of 2020 is caused by two groups of factors. The first one is associated directly to the epidemiological situation and countermeasures against the spread of SARS-CoV-2 while the second one is associated indirectly.Copyright © 2021 Russian Academy of Sciences. All right reserved.
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Funding: None. Synopsis: Once a subspecialty of general surgery, vascular surgery has transitioned to an entity with its own training paradigms and board certification. Part of this transition is due to many advances in technology, devices, and techniques. The management of vascular pathology that was at one time relegated to open procedures has now shifted to a field where endovascular options can be performed. These advances come with the concern of training competent vascular surgeons who are already under stringent duty hours restrictions, deal with heightened scrutiny associated with patient safety, and recently have had their operative volumes decreased due to COVID-19-related cancellations and shut downs. Simulation has been offered as a possible means to mitigate these limitations and shift the learning curve to competency. Despite this, little is known regarding the efficacy and best practices of incorporating simulation into vascular training. Method(s): A literature review was performed of English language articles on the EBSCO database without publication date restrictions on vascular surgery simulation. Search terms included vascular surgery simulation, endovascular surgery simulation and vascular education simulation. Additional studies were found by searching reference lists of relevant articles. All study designs were included if they pertained to simulation for open vascular or endovascular procedures. Simulator fidelity, educational efficacy, validity of the simulator, transfer of skill, and cost and time effectiveness were assessed. With endovascular simulation we assessed the amount of handling error, procedure time, fluoroscopy time, and the amount of contrast used. Result(s): Using these methods, twenty-two articles were identified. In regards to simulation used for open procedures in vascular surgery, the analysis showed that the most important factors in determining efficacy were the involvement of expert level (attending) proctors and the use of high fidelity (cadaver) simulators. Other important determinants were the use of trainee-specific models and the employment of specific learning objectives. The use of virtual endovascular simulators in enhancing trainee competence is supported by better quality data in the literature. Specifically measured and proven outcomes are a decrease in catheter handling errors, a reduction in both procedure and fluoroscopy time, and a diminished volume of contrast used. Endovascular simulators also allowed for reliable and consistent assessment of operator performance and showed a good transfer of skill to actual cases. Conclusion(s): Simulation is an important tool for both the assessment and training of vascular residents. The use of expert proctors, appropriate simulators, and well-designed curricula are the keys to success. Further studies connecting simulation training to patient-centered outcomes are still needed to define the true potential of these tools and methods. Institution: Lousiana State University HSC, New Orleans, LACopyright © 2022
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Coronavirus disease 19 (COVID-19) is the worst pandemic ever recorded in history, as of this day more than 545 million people infected and more than 6 million cumulative deaths. COVID 19 is primarily respiratory disease, however non-respiratory presentations that could be manifested are venous and arterial thromboembolic events. Both pulmonary embolism (PE) and deep vein thrombosis (DVT) are the most frequently thrombotic events in COVID-19. Knee arthroscopy surgery is the one of the most common orthopedic surgical procedures nowadays, with the most common procedures are meniscectomy, meniscal repair and cruciate ligament reconstruction. Although knee arthroscopy is known to be a safe procedure, several complications could be found with the 3 most common complications are DVT, effusion and synovitis, and PE. We reported a case series of four patients with DVT post knee arthroscopy anterior cruciate ligament reconstruction during 2021. The DVT diagnosis was retained on clinical presentation and elevated of D-dimer testing. The patient's mean age was 35,25 years, and all of the patients had no risk factors of DVT, although they had COVID-19 infection within 3 months before surgery. The most common clinical presentation was swelling on the lower leg (around the ankle) with slightly pain and numbness. Only one patient had severe pain around the thigh. All of the patients had elevated D-dimer testing result with mean of D-dimer 1250 (normal value < 500). Only one patient had sonography testing and found proximal DVT. One of the patients had DVT at post operative day (POD) 3, one at POD 4 and the other two at POD 5. Three of the patients improved with oral anticoagulant therapy using rivaroxaban (XARELTO). In one patient the symptom was not improved after two days oral anticoagulant therapy and underwent thrombectomy by vascular surgeon. DVT is the most common complication of knee arthroscopy and also the most common non-respiratory events of COVID-19 infection. Routinely administration of thromboprophylaxis agent was not recommended, pre-operative risk assessment of DVT should be used, especially in post-COVID 19 patients.
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Introduction: It is now well established that COVID-19 is linked to acute thrombosis. We present a case of an intubated and ventilated patient who received thrombolysis for acute limb ischemia. Shortly after intubation for respiratory failure secondary to COVID-19, a patient in their 50s developed a cold pulse less hand which was reviewed by vascular surgeons and radiologically diagnosed as acute arterial thrombosis resulting in an ischaemic hand. Objectives: Provide evidence for the use of systemic thrombolysis to treat thrombotic complications of COVID-19. Methods: Different treatment modalities were discussed within the multidisciplinary team. It was decided that the patient was unstable for transfer to theatre as he was in the proned position with severe respiratory failure. Therefore, systemic thrombolysis was administered to the patient twice over a period of 24 hours. Results: Following administration of Alteplase the patient went on to recover perfusion to the hand as well as making a remarkable respiratory improvement. This allowed for extubation within a matter of days. The patient survived to discharge without functional limitation of the hand. 6 months post discharge the patient is working full time in a manual capacity. Conclusions: We provide evidence that systemic thrombolysis can be considered as an option for acute limb ischemia in ventilated patients with COVID-19 for which conventional treatment options are not viable. With the knowledge that COVID-19 is a prothrombotic illness, it is possible that the thrombolysis of intercurrent pulmonary emboli contributed to respiratory recovery.
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Objectives: The COVID-19 pandemic has drastically altered the medical landscape. Not in our lifetime have we seen such a rapid and widespread cancellation of scheduled vascular surgical operations. The objective of this study was to evaluate the impact of COVID-19 on the care of patients with carotid disease. Methods: An interim data analysis of the Carotid module of VASCC Project 1: Impact of COVID-19 on Scheduled Vascular Operations was performed. The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March of 2020. Modules were developed by international vascular surgeon working groups and extensively beta tested before implementation. Each participating site agreed to share a collection of patient data whose vascular surgeries were postponed due to the COVID-19 pandemic. The REDCap database, housed at the University of Colorado, was determined to be exempt from Institutional Review Board review. A total of 57 patients with carotid stenosis whose surgeries were postponed during the COVID-19 pandemic surge in the USA were included in the interim data analysis. Patients whose surgeries were scheduled but not postponed were not included. Results: The mean ± SD age of the 57 patients was 70.5 ± 10.8 years. Seventy per cent were male and 28.1% were female. Seventy-two per cent of patients were white, 17.5% were Hispanic, 1.8% were Asian or Pacific Islander, and 1.8% were black. Seventy-five per cent of patients were asymptomatic, 8.8% had a cerebrovascular accident (CVA), 8.8% had a transient ischaemic attack (TIA), 3.5% had amaurosis fugax, and no patients presented with crescendo TIA (Table 1). The average length of surgical delay was 78.3 ± 36.1 days, with a median of 73 days (interquartile range 45.75 days) (Table 2). Of the 57 patients, 33 (57.9%) had surgeries postponed and successfully completed surgery at time of data entry. Seventy-two per cent of the postponement were due to intuitional policy (Table 3). No patients (0%) decompensated or required an emergency surgery during the delay. Two patients (4.0%) with carotid disease died while waiting for surgery. The cause of death of both patients was unrelated to cerebrovascular disease. Conclusions: None of the asymptomatic patients became symptomatic during the surgery delay. Two patients with carotid disease died while waiting for surgery due to causes not related to cerebrovascular disease. Our interim analysis supports institutional and national guidelines in the USA that patients with asymptomatic carotid stenosis may be safely postponed during a COVID-19 pandemic surge. Further data are needed to evaluate the impact of patients with symptomatic carotid stenosis. [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented]
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Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disease which is characterised by capillary, venous and lymphatic malformations. We describe the anaesthetic management of a 36 year old parturient with COVID-19 and KTS, who underwent an elective caesarean section. Very few such cases have been described and the multi-system nature of condition poses various challenges to both the obstetrician and the anaesthetist. Case Report: We had a 36-year-old woman who had experienced three previous normal vaginal deliveries and an elective caesarean section (CS) four years previously under general anaesthetic(GA) at 36 weeks gestation. She was told by a vascular surgeon that she was not suitable for regional anaesthesia. There was no recent imaging of her back to rule out arteriovenous(AV) malformations. Her past history included gastric bypass surgery under GA two years ago. She also had depression, varicose veins and three previous deep venous thrombosis andwas on prophylactic lowmolecularweight heparin. She had tested positive for COVID-19 4 days previously, and had mild symptoms of cough and sore throat. After a multi-disciplinary discussion involving an obstetrician, vascular surgeon, haematologist and anaesthetist, a decision was made to proceed with GA despite recent COVID-19, because of the possibility of AV malformations, in agreement with the patient. After securing two wide bore cannulae and adequate preoxygenation, a modified Rapid Sequence Induction was performed, and a tracheal tube was secured. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. After delivery of the baby, oxytocin 5U, followed by an infusion, midazolam, morphine, ondansetron and dexamethasone were administered. Extubation was performed when the patient was fully awake. In recovery, further opioids were given for pain. There were no concerns for the newborn. Estimated blood loss was 200 mL. Discussion: Gestation and its physiology may further exacerbate the manifestations of KTS, with increased obstetric risk. The success in the management of these patients requires the participation of a multidisciplinary team, consisting of obstetrician, anaesthetist, urologist, haematologist and vascular surgeon, with appropriate collaboration among the professionals involved. Periodic imaging and clotting tests are recommended to evaluate the evolution of vascular malformations in the pelvis, uterus and vagina, and identify neuraxial changes, to guide the safest way of delivery and anaesthesia.
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Aim: To analyse the feasibility of online training sessions on open vascular surgery techniques during the COVID-19 pandemic. Methods: Vascular trainees on their third, fourth, and fifth years, accompanied by a local tutor (senior vascular surgeon), were the targets of the training sessions. There were two types of sessions: carotid endarterectomy and bypass anastomosis. We planned three meetings for every workshop, with 10 expected participants in each meeting. A training box with all the material to perform the exercise (artery model, surgical instrumental, and sutures) was specially designed. The participants received a bovine patch to close the carotid endarterectomy and a biological prosthetic bypass to perform the anastomosis. Every group shared a link to complete the online connection for two hours. They were asked to video record the carotid patch closure and the bypass anastomosis, showing their hands and the model. Every session started with a brief online introduction to the materials and the expected performance of the exercise. The tutors were asked not to give advice to the trainees, and only help them during the training. At the end of the activity, the model was kept in a container that was sent to the organisers. The video recordings were sent online for further analysis. Finally, a telematic pooling took place between all the participants, and they fulfilled a quality questionnaire. An operative performance rating system accounting for five different items and time spent performing the exercise, and an end product rating score (EPRS) considering four items, were applied by two blinded examiners after all the products were collected. The participants received their results via e-mail. Results: The six planned workshops were performed on six consecutive Mondays from 22 June to 27 July. Sixty-three trainees from 18 different Spanish hospitals were invited to join the workshops. For carotid exercises, there were 32 participants (10 third year, 12 fourth year, and 10 fifth year trainees). For bypass exercises, 31 invitations were sent out, but only 21 participated (five third year, 11 fourth year, and five fifth year trainees). The connection during all the sessions was good, with no technical problems encountered with the online audio and video connections. Two blinded senior vascular surgeons analysed the exercises: 25 carotid videos (two videos were not legible and five were not sent) and 17 bypass videos (four videos were not sent). The evaluators analysed the 53 samples provided according to EPRS means. The results were sent to the participants via e-mail after completing the analysis. All participants reported that they would recommend the course to other trainees and would repeat the course. Conclusion: A practical training session on simulators is feasible online, with a high participation rate and good participant rating of the training. Sharing experiences through online exercises could supplement face to face activities during the COVID-19 pandemic.
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We herein report a rare case of mycotic aneurysm of the superior mesenteric artery caused by Klebsiella pneumoniae. A 66-year-old man, a known case of hypertension and aorto-oesophageal fistula with stented aorta in 2010 and 2018, presented to the emergency department multiple times over 2 months with severe postprandial abdominal pain associated with vomiting and fever. On his last presentation, the obtained blood cultures grew ESBL positive K. pneumoniae and a repeated computed tomography (CT) showed a growing aneurysm at the origin of the ileocecal branch of the superior mesenteric artery measuring 17 × 10 mm (the aneurysm was 8 × 7.5 mm in the CT angiography on the previous admission). Extensive workup did not reveal the underlying cause of the mycotic aneurysm, thus we believe the cause to be the infected aortic stent, leading to bacteraemia and vegetations to the mesenteric artery causing the aneurysm. The management plan was placed by a multidisciplinary team consisting of vascular surgeons and infectious disease specialists along with review from a dietician to evaluate the patient's nutritional status. The patient was started on total parenteral nutrition due to his postprandial pain and on antibiotic therapy according to the infectious disease team's recommendation. He underwent surgical resection of the mycotic aneurysm, which showed a thrombosed aneurysm in the jejunoileal mesenteric area. The histopathology of the resected tissue demonstrated inflammatory aneurysm of the mesenteric artery. Following the surgery, the patient continued his antibiotic therapy and was discharged on the 13th post-operative day with follow-up appointments in the vascular surgery and infectious disease clinic.
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Patients requiring above (AKA) or below-knee amputation (BKA) often have complex medical histories, are at high risk for surgery and have an estimated in hospital mortality of 7.7% [1]. The COVID-19 pandemic has led to a disruption of standard multidisciplinary patient care. It is of interest to assess our current care of this patient group within the COVID-19 pandemic and contrast this to previous data. Methods Our audit study population was derived from the National Vascular Register (NVR) and included all patients who had a BKA or AKA in 2020 with a complete dataset of notes. Our audit domains were established through the Royal College quality-improvement compendium. Results Seventy-five patients from the NVR fulfilled all inclusion criteria, which included 66.7% AKA and 33.3% BKA. Urgent cases made up the majority of the workload (84%). Pre-operatively, 90.6% of patients saw a senior vascular surgeon within 12 h of admission and 50.7% of amputations were discussed at a multidisciplinary team meeting. Eighty-four per cent of patients were seen by a senior anaesthetist before surgery. The average time to theatre was 32.8 h. Intra-operatively, all patients had a consultant anaesthetist present in theatre with 61.3% of cases performed on dedicated vascular lists and 74.7% of patients having some form of regional anaesthesia with 91.1% of these being spinal anaesthesia. Postoperatively, 49.3% of patients were seen by the pain team on the first postoperative day and 98.6% had input postoperatively by the physiotherapy and occupational health teams. Peripheral nerve catheters were used in 17.3%. Discussion With only a small proportion of elective cases and 39% of amputations happening on emergency lists, these patients potentially miss out on formal pre-operative assessment, experienced staff, and are more likely to be done out of hours. Interestingly, nearly three-quarters of patients had a form of regional anaesthesia, which was dramatically higher than the national statistic of 51% reported last year [1]. Several areas of good practice were identified including high levels of input from surgical, anaesthetic, physiotherapy and occupational therapy. Our aims over the next audit cycle will be to maximise the number of amputations done on dedicated vascular lists through liaison with the vascular team and theatre management. In addition, we plan to increase routine pain team follow-up and the use of sciatic catheters in an attempt to increase non-opioid postoperative pain management [2].
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OBJECTIVE: The COVID-19 pandemic has had major implications for the United States health care system. This survey study sought to identify practice changes, to understand current personal protective equipment (PPE) use, and to determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers vs in states with low case numbers. METHODS: A 14-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons' current practice was sent to 365 vascular surgeons across the country through REDCap from April 14 to April 21, 2020, with responses closed on April 23, 2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania, and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeons responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE. The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between states with high and low COVID-19 case volumes (P = .285). States with high case volume were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs 77.5%; P = .046), but otherwise case types did not differ. Most attending vascular surgeons worked with residents (90.8%) and limited their exposure to procedures on suspected or confirmed COVID-19 cases (56.0%). Thirty-eight percent of attending vascular surgeons have been redeployed within the hospital to a vascular access service or other service outside of vascular surgery. This was more frequent in states with high case volume compared with low case volume (P = .039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons think that they do not have adequate PPE to perform their clinical duties. CONCLUSIONS: The initial response to the COVID-19 pandemic has resulted in reduced elective cases, with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty; however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.