Outcomes of periarterial sympathectomy in patients with digital ischemia.

INTRODUCTION: Digital ischemia with subsequent severe pain and tissue loss is often difficult to treat, with no obvious guidelines or strong evidence in the literature to support a specific treatment modality. Patients who fail medical treatment remain with very limited surgical options due to the difficulty of any intervention in this "no man's land" area of the hand, as described since 1918. Extended distal periarterial sympathectomy is reported as an effective treatment option since the eighties of last century. The procedure entails large incisions and major technical difficulties. In this study, we describe a less invasive approach with very promising results and equally high success rates. MATERIALS AND METHODS: This was a prospective study. All patients with severe digital ischemia manifesting with bluish discoloration, ulceration, and/or dry gangrene who failed medical treatment underwent distal periarterial sympathectomy for the radial and ulnar arteries, with added digital sympathectomy in very severe cases. Primary endpoints were ulcer healing and improvement in pain scores assessed by Visual Analog Scale pain scoring system. Secondary endpoints included complications and amputation rates. RESULTS: This study recruited 17 patients between January 2019 and January 2020. The mean follow-up was 14.6 months. The mean age was 33.71 (±SD 13.14) years. 41% were males. 59% suffered from vasculitis, 35% of patients had dry gangrene, and 71% had ulcers. Periarterial radial and ulnar sympathectomy was performed for all cases, with digital sympathectomy for 12 fingers. We had 50% complete ulcer healing within 1 month (p = 0.031), and 100% were completely healed at 6 months (p < 0.001). Pain scores showed significant reductions at 1 (p = 0.001) and 6 months (p < 0.001) of follow-up. CONCLUSION: Distal periarterial sympathectomy demonstrates high success rates in terms of pain relief and ulcer healing in severe digital ischemia.

Balloon-assisted maturation of autogenous arteriovenous fistulae: A randomized controlled prospective study.

BACKGROUND: Current guidelines recommend referral of patient with renal failure for access creation 6 months before planned dialysis. There is a growing cohort of patients that require long-term hemodialysis without adequate preparation. Temporary dialysis catheters and rapid access arteriovenous grafts (AVG) are far from being an ideal solution in this scenario. In an effort to expedite maturation of autogenous arteriovenous fistulae (AVF), balloon-assisted maturation (BAM) was advised by some authors. This technique still lacks the support of high-level evidence studies. We investigated the ability of intra-operative BAM to induce early functional maturation of AVFs. METHODS: This is a prospective randomized controlled study conducted in a tertiary referral center, with a catchment area of more than 15 million population. Cases were divided into two groups; Group (A), where BAM technique was performed, while in the control group (B), the standard technique was used (NO BAM) for creation of AVFs. RESULTS: Between June 2017 and May 2019, 300 cases were recruited from a total of 648 primary AVF creation instances. Patients' age ranged from 19 to 89 (mean 51.17 ±SD 15.5) years. Group A (BAM) included 52.3% (n = 157) AVFs, while Group B included 47.7% (n = 143) AVFs. The average maturation time was 3.7 weeks (SD ± 1.3, 95% CI 3.55-3.95) and 5.91 weeks (SD ± 2.2, 95% CI 5.55-6.26) for both groups, respectively (p = 0.0001). 78.3% of the AVFs that underwent BAM showed early maturation within 2-4 weeks vs 32.2% only in the NO BAM group (p = 0.002). Successful functional maturation was higher among cases of the BAM group (93%), compared to the NO BAM group (77%) (p = 0.001). Complication rates were 9.6% and 4.9% in the two groups, respectively (p = 0.042). CONCLUSION: BAM can play a pivotal role in helping the dialysis society meet the goals of the Fistula First Initiative, keeping in mind that this comes with an increased risk of complications. BAM should be considered only when unplanned early access to long-term dialysis is required.

Surgical management of venous aneurysms.

BACKGROUND: Venous aneurysms (VA) are often underestimated as a dangerous vascular condition that can lead to fatal complications. We have adopted a more aggressive surgical approach to treatment of venous aneurysms that seems to be safe and effective, and report herein the results of this approach. METHODS: A retrospective analysis of patients presented with VA between January 2013, and January 2018. RESULTS: We identified 13 VA in 13 patients. The mean patient age was 21.6 years (range, 7-42 years). Six patients were male (46.2%) and seven were female (53.8%). All patients presented with swellings in different areas, mostly in the neck (nine patients [69.2%]). Two patients had a short saphenous vein aneurysm complicated with paresthesia (15.3%). All patients underwent surgical correction. Tangential excision was done for noncomplicated saccular aneurysms (six patients [46.2%]), whereas ligation and excision were done for fusiform aneurysms (five patients) and two saccular aneurysms presenting with thrombosis (53.8%). No signification complications were noted. CONCLUSIONS: Surgical treatment of venous aneurysms is safe and may help to avoid possible pulmonary embolism.

End-to-side versus side-to-side anastomosis with distal vein ligation for arteriovenous fistula creation.

INTRODUCTION: There is lack of compelling evidence about the best technique to carry out the anastomosis between the artery and the vein: end to side or side to side. This issue was addressed by very few randomized controlled studies. This topic has recently re-emerged with the advent of the endovascular fistula creation using the side-to-side technique.Objectives: To compare the results of both surgical techniques for the creation of arteriovenous anastomosis. METHODS: This is a randomized controlled prospective study. All renal failure patients, 18 years and older, referred to our institution requiring creation of a new arm arteriovenous fistulas, including distal radio-cephalic, ulno-basilic, proximal brachio-cephalic or brachio-basilic configurations were included. RESULTS: Between February 2018 and October 2018, 378 patients underwent creation of permanent haemodialysis access. A total of 100 patients were randomized equally into the end-to-side and side-to-side groups. Follow-up for the study purpose continued until May 2019 (mean = 9 months, range 1-12). Patients' age ranged from 19 to 68 years. Sevety-seven arteriovenous fistulas were created at the elbow (37 brachio-basilic and 40 brachio-cephalic). Radio-cephalic fistulae were 23, created at wrist and in the forearm. Primary technical success was 97%, and 35 (70%) and 17 (34%) cases achieved functionally maturation in the end-to-side and side-to-side groups, respectively (P = 0.0001). Primary and secondary patency rates at 12 months were 76% end to side versus 78% STS (P = 0.381) and 84% end to side versus 86% STS (P = 0.225), respectively. CONCLUSION: End-to-side technique should be used in all instances of arteriovenous fistulas creation.

Clinical outcomes from profundoplasty performed as a sole procedure for revascularization in critically ischaemic limbs.

OBJECTIVES: The aim of this study is to investigate the durability and clinical efficacy of profundoplasty as a sole procedure in patients presenting with critical limb ischaemia associated with profunda femoral artery disease and superficial femoral artery occlusion. METHODS: Retrospective analysis of outcomes from all patients who underwent surgical profundoplasty in a single tertiary referral centre was performed. Patients who presented with either rest pain or tissue loss and had combined profunda femoral artery disease and superficial femoral artery occlusion were included in the study. Outcomes were compared between the rest pain and the tissue loss groups. RESULTS: Between 2009 and 2019, 51 procedures were performed in 49 patients; 27 (53%) procedures were performed for rest pain and 24 (47%) for tissue loss. Technical success was 100% in both groups. Procedure success was significantly better in the rest pain group owing to lower procedure-related complications (p = 0.037). Incidence of major adverse cardiovascular events was higher in the tissue loss group with five reported cases compared to only one in the rest pain group (p = .05); 85.2% of patients with rest pain experienced clinical improvement compared to only 33.3% in the tissue loss group (p < .001). Higher rates of re-intervention were recorded in the tissue loss group, but this was not statistically significant. Amputation-free survival at 3, 6 and 12 months was 96%, 96% and 92% in the rest pain group, respectively, compared to 77%, 67% and 54% in the tissue loss group (p = .004). At one-year, freedom from major adverse limb events was lower in patients with tissue loss at 43% compared to 81% in patients with rest pain (p = .009). CONCLUSIONS: Profundoplasty performed as a sole procedure for revascularisation of the critically ischaemic limb is a viable straightforward option. However, our results suggest that it may be more effective in the treatment of rest pain rather than in the setting of tissue loss when a combined superficial femoral artery angioplasty or distal bypass may be required.

Aorto-Uni-Iliac Stent Grafts with and without Crossover Femorofemoral Bypass for Treatment of Abdominal Aortic Aneurysms: A Parallel Observational Comparative Study.

We investigated the safety and efficacy of primary aorto-uni-iliac (AUI) endovascular aortic repair (EVAR) without fem-fem crossover in patients with abdominal aortic aneurysm (AAA) and concomitant aortoiliac occlusive disease. 537 EVARs were implemented between 2002 and 2015 in University Hospital Galway, a tertiary referral center for aortic surgery and EVAR. We executed a parallel observational comparative study between 34 patients with AUI with femorofemoral crossover (group A) and six patients treated with AUI but without the crossover (group B). Group B patients presented with infrarenal AAAs with associated total occlusion of one iliac axis and high comorbidities. Technical success was 97% (n = 33) in group A and 85% (n = 5) in group B (P = 0.31). Primary and assisted clinical success at 24 months were 88% (n = 30) and 12% (n = 4), respectively, in group A, and 85% (n = 5) and 15% (n = 1), respectively, in group B (P = 0.125). Reintervention rate was 10% (n = 3) in group A and 0% in group B (P = 0.084). No incidence of postoperative critical lower limb ischemia or amputations occurred in the follow-up period. AUI without crossover bypass is a viable option in selected cases.

Total endovascular management of ruptured aortocaval fistula: technical challenges and case report.

PURPOSE: Primary aortocaval fistula (ACF) is a rare complication of ruptured abdominal aortic aneurysms (rAAA). Endovascular repair for rAAA (REVAR) provides an efficient, elegant and safe option, minimizing the risk of massive bleeding with open repair. CASE REPORT: Case 1: An 84-year-old man presented with a rAAA and ACF. He exhibited manifestations of congestive heart failure, pulmonary and renal impairment. An endovascular aortic aneurysm repair was undertaken and a bifurcated stent graft was deployed to treat the aneurysm and a second stent graft was deployed within the inferior vena cava to simultaneously seal the rAAA and the ACF. Case 2: A 73-year-old male patient presented with a rAAA and ACF. He exhibited manifestations of congestive heart failure and renal impairment with haematuria. REVAR was the plan for management. A bifurcated stent graft was used to treat the aneurysm and another bifurcated stent graft was placed within the inferior vena cava to seal the rAAA and the ACF. CONCLUSION: Here in, we report the first two cases in the English literature of rAAA with ACF successfully managed with simultaneous endovascular stent-grafting of both the aorta and the inferior vena cava.