Development of a coordinated acute diabetic foot pathway for management of acute diabetic foot infection and ulceration.

BACKGROUND: Diabetic foot ulceration (DFU) has become an increasingly common emergency presentation. These patients are presenting at a younger age and with increasingly complex co-morbidities. They require frequent hospitalisation for management of DFU which has significant consequences for management of health resources but also for quality of life in the diabetic patient population. AIM: The aim of this study was to evaluate the impact of the development of a coordinated, streamlined acute diabetic foot pathway for management of in-patients presenting as emergencies with DFU on length of stay, re-admission to hospital and minor and major amputations. METHODS: A dedicated acute diabetic foot pathway was introduced to St. Vincent's University Hospital (SVUH) in April 2016. Management of patients admitted urgently to the emergency department or out-patient clinics of St. Vincent's University Hospital during the 3-year period before April 2016 was compared to that of patients admitted in the 3 years after April 2016 following introduction of the acute diabetic foot pathway. Demographic data hospital length of stay, need for re-admission, major and minor amputations performed and cost of hospital stay were compared before and after introduction of the pathway. RESULTS: There were 931 admissions with acute diabetic foot ulceration or infection between January 2012 and December 2019; 419 were admitted between January 2012 and March 2016 and 512 between April 2016 and December 2019. There was no difference in demographic data between the two time periods. Length of stay decreased from 13 +/- 4.24 to 3 +/- 1.41 days between the two time periods (p < 0.001). Re-admission rates within 30 days decreased from 21.7 to 10.1% (p < 0.05). The number of major lower limb amputations decreased over the two time periods from 8.8 to 7.2% with a concomitant increase in minor amputations from 16.7 to 25.3%. Risk of major lower limb amputation was significantly higher in those patients living more than 20 km from the hospital. Costs associated with in-patient stay for management of DFU decreased from €9,247,700 to €8,988,100 despite an 18% increase in the number of patients treated and a 9.9% increase in hospital admissions. CONCLUSION: Introduction of a dedicated, streamlined pathway involving multi-disciplinary input resulted in a significant improvement in patient management as assessed by length of hospital stay and need for re-admission. While the number of major lower limb amputations has decreased there has been a significant increase in the number of minor amputations.

Reliability of the modified Frailty Index (mFI) for intervention and continued surveillance in elective infrarenal abdominal aortic aneurysm (AAA).

INTRODUCTION: Frailty has been proven to lead to higher morbidity and mortality rates in surgical patients, independent of age. The modified Frailty Index (mFI) is a validated means of assessing for frailty. AIM OF STUDY: The aim of this study is to ascertain if the mFI correlates with clinician experience in turning down patients for abdominal aortic aneurysm (AAA) surgery and/or AAA surveillance. METHODS: A contemporaneously recorded database of all AAA patients treated during 2017 at a large University Hospital was reviewed. Patients were categorised into the following groups; continued surveillance, turned down for surveillance, patient declined surveillance, patient offered surgery, patient turned down for surgery and patient declined surgery. RESULTS: One hundred and forty two patients were included. Twenty-eight patients <5.5 cm were turned down for surveillance with a mFI of 0.27. Forty-one patients <5.5 cm continued with surveillance, with a mFI of 0.09 (p < 0.0001). Eighteen patients >5.5 cm were turned down for surgical intervention with a median mFI of 0.36. Forty-two patients were offered surgical intervention had a median mFI of 0.09 (p < 0.0001). CONCLUSION: Frailty is associated with higher morbidity and mortality amongst frail patient cohorts. mFI is a valid and easy to use tool to predict perioperative outcomes in AAA intervention. It correlates well with senior, experienced clinicians' decision-making in relation to who should and who should not undergo elective AAA surgery and those patients who should have ongoing aneurysm surveillance.

Traumatic open brachial plexus injuries: The importance of interdisciplinary collaboration.

Open traumatic brachial plexus injuries are rare, yet can be life threatening and require rapid clinic assessment. Early interdisciplinary collaboration is critical to achieve superior patient outcomes. This case of a 24-year-old female of a traumatic neck injury with contralateral brachial plexus injury demonstrates the limitations of early clinical assessment due to the potential for haemodynamic instability and highlights the priority of patient stabilisation. Early and active interdisciplinary collaboration in this case demonstrates its importance in accurate diagnosis and timely intervention to achieve better patient outcomes. As published in recent guidelines, this report shows the importance of early interdisciplinary involvement following stabilisation and resuscitation of the patient.

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.

A study of outcomes in conservatively managed patients with large abdominal aortic aneurysms deemed unfit for surgical repair.

BACKGROUND: The current advancement and increasing use of diagnostic imaging has led to increased detection of abdominal aortic aneurysms (AAA). Many of these patients are unfit for elective AAA surgery. AIM: To investigate the outcome of conservative management of unfit patients with large AAA (>5.5 cm) who are turned down for elective surgical intervention. PATIENTS AND METHODS: Between January 2006 and April 2017, 457 patients presented with AAA >5.5 cm. Seventy-six patients (M: F 54:22) were deemed unfit for elective repair. Mean age was 79.8 years (range 64-96). Mean AAA size was 60.22 mm (55-83). RESULTS: Forty-nine of the 76 patients (64%) had died by April 2017. Fifteen (19.7%) patients died directly because of their aneurysm rupture. A further 34 (44.7%) patients died from non-aneurysm-related causes. CONCLUSION: Patients with large AAA deemed unfit for elective surgery have an overall poor prognosis and die mainly from other causes than AAA. Surgical intervention when rupture occurs results in poor survival.

Lipoxins Protect Against Inflammation in Diabetes-Associated Atherosclerosis.

Increasing evidence points to the fact that defects in the resolution of inflammatory pathways predisposes individuals to the development of chronic inflammatory diseases, including diabetic complications such as accelerated atherosclerosis. The resolution of inflammation is dynamically regulated by the production of endogenous modulators of inflammation, including lipoxin A4 (LXA4). Here, we explored the therapeutic potential of LXA4 and a synthetic LX analog (Benzo-LXA4) to modulate diabetic complications in the streptozotocin-induced diabetic ApoE-/- mouse and in human carotid plaque tissue ex vivo. The development of diabetes-induced aortic plaques and inflammatory responses of aortic tissue, including the expression of vcam-1, mcp-1, il-6, and il-1ß, was significantly attenuated by both LXA4 and Benzo-LXA4 in diabetic ApoE-/- mice. Importantly, in mice with established atherosclerosis, treatment with LXs for a 6-week period, initiated 10 weeks after diabetes onset, led to a significant reduction in aortic arch plaque development (19.22 ± 2.01% [diabetic]; 12.67 ± 1.68% [diabetic + LXA4]; 13.19 ± 1.97% [diabetic + Benzo-LXA4]). Secretome profiling of human carotid plaque explants treated with LXs indicated changes to proinflammatory cytokine release, including tumor necrosis factor-α and interleukin-1ß. LXs also inhibited platelet-derived growth factor-stimulated vascular smooth muscle cell proliferation and transmigration and endothelial cell inflammation. These data suggest that LXs may have therapeutic potential in the context of diabetes-associated vascular complications.

Midterm Analysis of Survival and Cause of Death Following Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: To assess rates of complications, secondary interventions, survival, and cause of death following endovascular abdominal aortic aneurysm (AAA) repair over a 10-year period. MATERIALS AND METHODS: Single-institution retrospective cohort study of all patients undergoing primary endovascular aortic aneurysm repair (EVAR) between July 2006 and June 2015. The population constituted 175 patients with 163 fusiform and 12 saccular AAAs. Of these, 149 (85%) were male, with mean age 75.4 (±7.1) years. Patients were followed up until June 30, 2016. Cause of death was determined from the national death register. RESULTS: Mean follow-up was 34.4 (±24.4) months. The secondary intervention rate was 9.7%, and there were 4 aneurysm ruptures (0.8% annual incidence). Thirty-day mortality was 0.6%. Survival at 1, 3, and 5 years was 93.1%, 84%, and 64.9%, respectively. Forty-eight patients died during follow-up, 3 secondary to rupture, leading to overall and aneurysm-related death rates of 9.7 and 0.6 per 100 person-years. All other deaths were due to nonaneurysm causes, most commonly cardiovascular (n = 15), pulmonary (n = 13), and malignancy (n = 9). Baseline renal impairment ( P < .001), ischemic heart disease ( P < .05), age greater than 75 years ( P < .05), and urgent/emergency EVAR were associated with inferior long-term survival. Type II endoleak negatively influenced fusiform aneurysm sac regression ( P = .02), but there was no association between survival and occurrence of any complication or secondary intervention. CONCLUSION: The majority of deaths during medium-term follow-up post-EVAR are due to nonaneurysm-related causes. Survival is determined by the following baseline factors: renal impairment, ischemic heart disease, advanced age, and the presence of a symptomatic/ruptured aneurysm.

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.

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.

Contemporary analysis of descending thoracic and thoracoabdominal aneurysm repair: a comparison of endovascular and open techniques.

BACKGROUND: Endovascular repair of thoracic aneurysm has demonstrated low risks of mortality and spinal cord ischemia (SCI), but few large series have been published on endovascular thoracoabdominal aneurysm repair, and reports suffer from a lack of accurate comparison with similar open surgical procedures. METHODS AND RESULTS: A consecutive cohort of patients with thoracic and thoracoabdominal aneurysms treated electively with endovascular repair (ER) or surgical repair (SR) techniques between 2001 and 2006 were analyzed. The association between repair technique and SCI was evaluated with univariable analysis. Adjustments for potential confounders and for the propensity to receive ER or SR were also performed in multivariable analysis. A total of 724 patients (352 ER, 372 SR) underwent repair. The mean age was 67 years, and 65% were male. ER patients were on average 9 years older (P<0.001), had more comorbid conditions, and more frequently had prior distal repair (P<0.001) or underwent a type I or IV repair. SR patients more commonly had chronic dissection or required type II or type III repairs (P<0.001). Mortality at 30 days (5.7% ER versus 8.3% SR, P=0.2) and 12 months (15.6% ER versus 15.9% SR, P=0.9) was similar. A borderline difference in SCI was found between repair techniques: 4.3% of ER and 7.5% of SR patients (P=0.08) had SCI. In patients with ER, prior distal aortic operation was associated with the development of SCI in univariable analysis (odds ratio 4.1, 95% confidence interval 1.4 to 11.7). Multivariable analysis showed that the type of required repair (type I, II, III, or IV) was the primary factor associated with the development of SCI in ER and SR patients. CONCLUSIONS: No significant difference in the incidence of mortality or SCI was found between ER and SR techniques. The strongest factor associated with SCI remains the extent of the disease. Further studies are indicated to compare ER with patients considered eligible for SR.

The use of right ventricular pacing to facilitate stent graft deployment in the distal aortic arch: a case report.

Stent graft repair of aortic pathology involving the distal aortic arch requires precise device deployment based on excellent imaging and stable hemodynamics. An inadequate proximal seal may result in a type I endoleak, which may require an additional device or even conversion to open surgery to control. This case report describes transvenous rapid pacing, a safe and reproducible technique to allow precise deployment or balloon dilation of a stent graft in the distal arch or proximal thoracic aorta.