Staged treatment for pancreaticoduodenal artery aneurysm with coeliac artery revascularisation: Case report and systematic review.

BACKGROUND: Despite being rare, pancreaticoduodenal artery aneurysms (PDAAs) carry a risk of rupture of up to 50% and are frequently associated with coeliac artery occlusion. METHODS: PubMed and Embase databases were searched using appropriate terms. The systematic review was conducted according to PRISMA guidelines. RESULTS: We present the case of a 2 cm pancreaticoduodenal artery aneurysm pre-operative angiography demonstrated that the coeliac artery was occluded and the pancreaticoduodenal artery was providing collateral blood supply to the liver. Treatment was a staged hybrid intervention inclusive of an aorto-hepatic bypass using a 6 mm graft, followed by coil embolisation of the aneurysm. We also present a systematic review of the management of PDAAs. Two hundred and ninety-two publications were identified initially with 81 publications included in the final review. Of the 258 peripancreatic aneurysms included, 175 (61%) were associated with coeliac artery disease either occlusion or stenosis. Abdominal pain was the main presentation in 158 cases. Rupture occurred in 111 (40%) of patients with only ten (3.8%) cases being unstable on presentation. Fifty (18%) cases were detected incidentally while investigating another pathology. Over half the cases (n=141/54.6%) were treated by trans arterial embolisation (TAE) alone, while 37 cases had open surgery only. Twenty-one cases needed TAE and a coeliac stent. Seventeen cases underwent hybrid treatment (open and endovascular). Sixteen cases were treated conservatively and in 26 cases, treatment was not specified. CONCLUSION: PDAAs are commonly associated with coeliac artery disease. The most common presentation is pain followed by rupture. The scarcity of literature about true peripancreatic artery aneurysms associated with CA occlusive disease makes it difficult to assess the natural history or the appropriate treatment. Revascularisation of hepatic artery is better done with bypass in setting of median arcuate ligament compression and occluded celiac trunk.

Ambulatory outpatient venous surgery service: An examination of patient satisfaction and experiences.

BACKGROUND: This study aimed to ascertain patients' experience of the out-patient venous service being provided,; identify the level of patient satisfaction with the service and identify areas for further improvement and development. METHOD: A prospective descriptive quantitative study. A questionnaire was distributed to all patients who used the service between June 2017 and March 2018. A total of 195 questionnaires was distributed with 162 valid questionnaires returned; response rate of 83%. RESULTS: This study found high satisfaction levels with endovenous ablation procedures, with concomitant phlebectomy, in the ambulatory outpatient setting and patient experiences of the service are overwhelmingly positive. CONCLUSION: Study findings support the management of ambulatory outpatient varicose vein endovenous ablation procedures as a feasible alternative to day surgery theatre settings and is the blueprint for future management of varicose vein surgery in Ireland.

Rescue of Failed Aortic Repair with Fenestrated Endovascular Device.

INTRODUCTION: 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. METHODS: A prospectively maintained database of FEVAR patients treated with a ZenithⓇ Fenestrated endovascular (ZFEN) device (Cook Medical LLC, Bloomington, Indiana, USA) was interrogated for individuals who had the device implanted as a rescue therapy after prior endovascular (EVAR) or open repair (OR). Statistical analysis was performed with SPSS v 25 software. RESULTS: Between 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. CONCLUSION: 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.

Acceptability of and symptom findings from an online symptom check-in tool for COVID-19 outpatient follow-up among a predominantly healthcare worker population.

INTRODUCTION: Health systems worldwide have had to prepare for a surge in volume in both the outpatient and inpatient settings since the emergence of COVID-19. Early international healthcare experiences showed approximately 80% of patients with COVID-19 had mild disease and therfore could be managed as outpatients. However, SARS-CoV-2 can cause a biphasic illness with those affected experiencing a clinical deterioration usually seen after day 4 of illness. OBJECTIVE: We created an online tool with the primary objective of allowing for virtual disease triage among the increasing number of outpatients diagnosed with COVID-19 at our hospital. Secondary aims included COVID-19 education and the promotion of official COVID-19 information among these outpatients, and analysis of reported symptomatology. METHODS: Outpatients with acute COVID-19 disease received text messages from the hospital containing a link to an online symptom check-in tool which they were invited to complete. RESULTS: 296 unique participants (72%) from 413 contacted by text completed the online check-in tool at least once, generating 831 responses from 1324 texts sent. 83% of text recipients and 91% of unique participants were healthcare workers. 7% of responses to the tool were from participants who admitted to a slight worsening of their symptoms during follow-up. Fatigue was the most commonly reported symptom overall (79%), followed by headache (72%). Fatigue, headache and myalgia were the most frequently reported symptoms in the first 3 days of illness. 8% of responses generated in the first 7 days of illness did not report any of the cardinal symptoms (fever, cough, dyspnoea, taste/smell disturbance) of COVID-19. Participants found the tool to be useful and easy to use, describing it as 'helpful' and 'reassuring' in a follow-up feedback survey (n=140). 93% said they would use such a tool in the future. 39% reported ongoing fatigue, 16% reported ongoing smell disturbance and 14% reported ongoing dyspnoea after 6 months. CONCLUSION: The online symptom check-in tool was found to be acceptable to participants and saw high levels of engagement and satisfaction. Symptomatology findings highlight the variety and persistence of symptoms experienced by those with confirmed COVID-19 disease.

COVID-19, when fourteen days are not enough-A case series of affected healthcare workers.

We highlight the need for planning for mass workforce absentees as we prepare for subsequent surges. We suggest a multicomponent intervention including guiding return dates more by symptomatology and fitness for work rather than infectivity status.

Preconditioning Shields Against Vascular Events in Surgery (SAVES), a multicentre feasibility trial of preconditioning against adverse events in major vascular surgery: study protocol for a randomised control trial.

BACKGROUND: Patients undergoing vascular surgery procedures constitute a 'high-risk' group. Fatal and disabling perioperative complications are common. Complications arise via multiple aetiological pathways. This mechanistic redundancy limits techniques to reduce complications that target individual mechanisms, for example, anti-platelet agents. Remote ischaemic preconditioning (RIPC) induces a protective phenotype in at-risk tissue, conferring protection against ischaemia-reperfusion injury regardless of the trigger. RIPC is induced by repeated periods of upper limb ischaemia-reperfusion produced using a blood pressure cuff. RIPC confers some protection against cardiac and renal injury during major vascular surgery in proof-of-concept trials. Similar trials suggest benefit during cardiac surgery. Several uncertainties remain in advance of a full-scale trial to evaluate clinical efficacy. We propose a feasibility trial to fully evaluate arm-induced RIPC's ability to confer protection in major vascular surgery, assess the incidence of a proposed composite primary efficacy endpoint and evaluate the intervention's acceptability to patients and staff. METHODS/DESIGN: Four hundred major vascular surgery patients in five Irish vascular centres will be randomised (stratified for centre and procedure) to undergo RIPC or not immediately before surgery. RIPC will be induced using a blood pressure cuff with four cycles of 5 minutes of ischaemia followed by 5 minutes of reperfusion immediately before the start of operations. There is no sham intervention. Participants will undergo serum troponin measurements pre-operatively and 1, 2, and 3 days post-operatively. Participants will undergo 12-lead electrocardiograms pre-operatively and on the second post-operative day. Predefined complications within one year of surgery will be recorded. Patient and staff experiences will be explored using qualitative techniques. The primary outcome measure is the proportion of patients who develop elevated serum troponin levels in the first 3 days post-operatively. Secondary outcome measures include length of hospital and critical care stay, unplanned critical care admissions, death, myocardial infarction, stroke, mesenteric ischaemia and need for renal replacement therapy (within 30 days of surgery). DISCUSSION: RIPC is novel intervention with the potential to significantly improve perioperative outcomes. This trial will provide the first evaluation of RIPC's ability to reduce adverse clinical events following major vascular surgery. TRIAL REGISTRATION: www.clinicaltrials.gov NCT02097186 Date Registered: 24 March 2014.

The effect of chemotherapy for malignancy on the natural history of aortic aneurysm.

OBJECTIVE: Surgical dogma holds that chemotherapy increases the risk of aneurysm growth and rupture. We sought to determine the effect of cytotoxic chemotherapy on the growth of aortic aneurysms. METHODS: All patients undergoing chemotherapy for malignancy with coexisting aortic aneurysms at our institution between 2000 and 2011 were identified. Review of electronic medical records and rereview of serial cross-sectional imaging was performed. An additional cohort of patients undergoing aneurysm surveillance during the same period was identified, and demographic and anatomic variables were collected. Planned analysis included descriptive analysis, change in aneurysm diameter over time, and association of growth or need for intervention with type of chemotherapy and type of malignancy. RESULTS: Between 2000 and 2011, 125 patients at our institution had a concurrent diagnosis of aortic aneurysm and malignancy requiring cytotoxic chemotherapy. Cross-sectional imaging was available for 91 patients. The predominant malignancy type was lung cancer (34 of 91 [38%]), followed by lymphoma (21 of 91 [23%]) and colorectal cancer (10 of 91 [11%]). Most aneurysms were infrarenal (53 of 91 [58%]). Most patients were treated with more than one class of chemotherapeutic agent over 267 days (interquartile range [IQR], 144-469 days), and most had at least one cycle of alkylating agents (73 of 91), in addition to antimetabolites (42 of 91) and plant alkaloids/terpenoids (40 of 92). Chemotherapy regimens included steroids in 84 patients (92%). The baseline aneurysm diameter was 41.4 mm (IQR, 34.9-51.3 mm) for patients who received chemotherapeutic agents and 46.0 mm (IQR, 40-52 mm) for those who did not. Eight of the 91 patients (9%) underwent aneurysm repair during chemotherapy, but only two required urgent repair due to aneurysm rupture. The rate of aneurysm growth per year for patients who did and did not receive chemotherapy was similar at 2.3 mm vs 2.4 mm (P = .69). CONCLUSIONS: In 91 patients over 10 years at our institution, chemotherapy did not increase aneurysm growth compared with patients not undergoing treatment for malignancy.

Late rescue of proximal endograft failure using fenestrated and branched devices.

OBJECTIVE: Endovascular aneurysm repair (EVAR) will fail over time in a percentage of patients. Mechanical failure of the device, progression of aortic disease, or interface complications between the device and the native vasculature may contribute. Our aim was to evaluate the role of fenestrated and branched endografts as treatment options for failed devices. METHODS: Between January 2001 and June 2013, 970 patients were enrolled into a physician-sponsored investigational device exemption (PSIDE) study and treated with a fenestrated/branched endograft. All patients treated for nonurgent proximal neck failure of an infrarenal endoprosthesis previously implanted during EVAR comprised the study group. Patients treated for a primary aneurysm within the PSIDE were evaluated as a comparison group to identify preoperative risk factors for failure. A retrospective review was undertaken to determine the details of the initial EVAR, whereas the prospective PSIDE database was used to assess outcomes of secondary treatment. Three-dimensional imaging techniques were used to define all morphologic measurements. Statistical analysis included comparisons between categoric variables with the χ(2) test and between continuous variables with the Wilcoxon rank sum test between patients with late failures and those with native aortic repair. Kaplan-Meier curves were used to analyze overall survival. RESULTS: Of 970 patients enrolled in the PSIDE, 54 (5.6%) had late failure of a prior endograft. Fenestrated/branched devices were used to address the failure in each patient. The etiology of failure was related to a proximal neck issue in all patients: type Ia endoleak in 38, stent migration in 18, neck degeneration in 28, or some combination of these factors. The endovascular rescue procedure took place a mean of 61 months after the primary procedure. The mean aneurysm diameter at reintervention was 67 mm. Patients requiring a secondary fenestrated procedure were younger at the time of their primary intervention (P = .039) and were more likely to have a history of chronic renal insufficiency (P = .05) compared with other patients in the PSIDE. Technical success rate in the study group was 85% (44 of 52). Successful stenting was achieved in 71 of 77 (92%) target vessels. Thirty-day mortality was 3.8% (two of 52). Fluoroscopy dose and operating time were longer in the rescue group (P = .07) than in the control group (P = .008). Secondary interventions were required in 36.5% (19 of 52) of patients. CONCLUSIONS: Our series demonstrates the risk for late failure after EVAR is greater in patients who are younger and have chronic renal impairment at the time of implantation. Branched and fenestrated repair after failed EVAR is more complex than repair in the native aorta. More research is needed to identify patients at higher risk of failure after EVAR to prevent the need for rescue in the future.

Hybrid management of a spontaneous ilio-iliac arteriovenous fistula: a case report.

INTRODUCTION: Spontaneous iliac arteriovenous fistulae are a rare clinical entity. Such localized fistulation is usually a result of penetrating traumatic or iatrogenic injury. Clinical presentation can vary greatly but commonly includes back pain, high-output congestive cardiac failure and the presence of an abdominal bruit. Diagnosis, therefore, is often incidental or delayed. CASE PRESENTATION: We report a case of a spontaneous ilio-iliac arteriovenous fistula in a 68-year-old Caucasian man detected following presentation with unilateral claudication and congestive cardiac failure. Following computed tomography evaluation, the fistula was successfully treated with a combined endovascular (aorto-uni-iliac device) and open (femoro-femoral crossover) approach. CONCLUSION: Endovascular surgery has revolutionized the management of such fistulae and we report an interesting case of a high-output iliac arteriovenous fistulae successfully treated with a hybrid vascular approach.

Endovascular management of patients with Takayasu arteritis: stents versus stent grafts.

Our objective was to report the experience of endovascular therapy to treat patients with Takayasu arteritis (TA) and evaluate outcomes. A review was undertaken of TA patients treated with endovascular means during a 9-year (2004 to 2011) period. Patients were diagnosed using the American College of Rheumatology criteria and classified, based on angiographic criteria, using the Numano's Classification. The primary assessment of our analysis included patency of stent and stentgrafts. The secondary outcome measures included technical success, secondary interventions, and any periprocedural complications. A total of 25 arteritis patients were identified of which 14 patients had confirmed TA and were treated. Open surgical procedures were used in six patients, while the remaining eight underwent pure endovascular procedures or hybrid procedures, of which four had follow-up beyond 1 year. All four patients (all female), underwent six primary and five secondary vascular interventions. All lesions were stenotic in nature and the majority of patients (n = 3) had angiographic findings consistent with a combination of type I and type IV disease. Two abdominal stent grafts, one carotid stent, one innominate stent, one vertebral stent, one superior mesenteric stent, and bilateral renal stents were placed. Technical success was 100%, with the stent grafts staying patent longer than bare metal stents and patients with stent grafts undergoing fewer secondary interventions as opposed to those who had uncovered stents. Historically endovascular treatment of TA has been associated with poor outcomes with respect to patency. Newer endovascular techniques have allowed the use of alternatives methods that appear to be associated with better results. The use of stent grafts over uncovered stent will likely mitigate the risk of in-stent restenosis and occlusions.

Computed tomography-based anatomic characterization of proximal aortic dissection with consideration for endovascular candidacy.

BACKGROUND: Proximal aortic dissections are life-threatening conditions that require immediate surgical intervention to avert an untreated mortality rate that approaches 50% at 48 hours. Advances in computed tomography (CT) imaging techniques have permitted increased characterization of aortic dissection that are necessary to assess the design and applicability of new treatment paradigms. METHODS: All patients presenting during a 2-year period with acute proximal aortic dissections who underwent CT scanning were reviewed in an effort to establish a detailed assessment of their aortic anatomy. Imaging studies were assessed in an effort to document the location of the primary proximal fenestration, the proximal and distal extent of the dissection, and numerous morphologic measurements pertaining to the aortic valve, root, and ascending aorta to determine the potential for an endovascular exclusion of the ascending aorta. RESULTS: During the study period, 162 patients presented with proximal aortic dissections. Digital high-resolution preoperative CT imaging was performed on 76 patients, and 59 scans (77%) were of adequate quality to allow assessment of anatomic suitability for treatment with an endograft. In all cases, the dissection plane was detectable, yet the primary intimal fenestration was identified in only 41% of the studies. Scans showed 24 patients (32%) appeared to be anatomically amenable to such a repair (absence of valvular involvement, appropriate length and diameter of proximal sealing regions, lack of need to occlude coronary vasculature). Of the 42 scans that were determined not to be favorable for endovascular repair, the most common exclusion finding was the absence of a proximal landing zone (n = 15; 36%). CONCLUSIONS: Appropriately protocoled CT imaging provides detailed anatomic information about the aortic root and ascending aorta, allowing the assessment of which dissections have proximal fenestrations that may be amenable to an endovascular repair.

Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients.

PURPOSE: Colorectal cancer commonly presents first as an emergency and is likely to be complicated by bowel obstruction/perforation requiring more difficult procedures, with poorer outcomes. Analysis of all of the procedures performed on patients diagnosed in Wexford General Hospital, Ireland, during the period 2000 to 2006 was carried out to validate this hypothesis in our western European population. METHODS: Retrospective analysis of a prospectively maintained database of patient demographics, diagnosis, procedures, and mode of presentation (elective, emergency) was undertaken. RESULTS: A total of 356 patients with colorectal cancer underwent 498 procedures during the years 2000 to 2006. Eighty-four emergency endoscopies and 100 emergency bowel resections were performed. Obstructive lesions were more likely to require emergency resection (P < 0.001). Median survival time for patients treated electively was 82 months vs. 59 months for patients treated on an emergency basis. CONCLUSIONS: Of all colonic resections, 34 percent were carried out as emergencies and were significantly more likely to be complicated by obstruction or perforation (P < 0.001). Emergency resections were associated with a significantly poorer perioperative mortality and five-year survival rate (P < 0.001). Forty-one percent of colorectal cancers diagnosed at endoscopy were first seen emergently. These data raise concerns regarding public awareness of colorectal cancer and resource allocation and reemphasize the need for a national colorectal screening program.

Peroral and transgastric esophageal anastomosis with flexible shaft remote-control stapler (SurgASSIST).

Stapled cervical esophageal anastomoses are technically challenging and are associated with relatively high complication rates, particularly in leaks and anastomotic strictures. We describe the use of a flexible shaft, remote-control, circular stapling device in forming high esophageal anastomoses in 2 patients. Retrograde transgastric and prograde peroral approaches are evaluated comparing ease of technical application and outcomes. Both procedures were performed after total esophagectomy for cancer in a 72-year-old male patient with preoperative down-staging and a 78-year-old female who proceeded directly to surgery. The introduction of rigid staplers in the esophagus by either route can be difficult and technical pointers and the potential applications of the flexible SurgASSIST device are discussed. Potential benefits include shorter time for constructing the anastomosis and a wider lumen resulting in possible cost benefit. Both patients had uneventful technical construction of stapled anastomoses, and the only complication in the female was a leak in the gastric close-off at the site of introduction of the flexshaft. Both are alive and well without recurrence at 2 years and 22 months.