Office Based Endovenous Radiofrequency Ablation of Truncal Veins: A Case for Moving Varicose Vein Treatment out of Operating Theatres.

OBJECTIVES: This study aims to assess the efficacy and outcomes at one year after office based endovenous radiofrequency ablation (OBEVRFA) as a standalone procedure for varicose veins under local anaesthesia. METHODS: A retrospective study of prospectively collected data of all OBEVRFAs done in the vascular unit from April 2014 to June 2016 was performed. The demographics, clinical findings, initial venous duplex ultrasound (DUS) findings, the vein ablated, and immediate complications were recorded. Patients were reviewed at six weeks and again if necessary with or without a repeat DUS. The follow up period ranged from 12 to 38 months. Patients undergoing further procedures for symptomatic residual veins within the follow up period were recorded. Average cost and income were obtained from the hospital Patient Level Information and Costing Systems data. RESULTS: A total of 523 limbs were listed for OBEVRFA during the study period. Ninety-four (18%) were cancelled on the day of surgery for various reasons. A total of 429 procedures in 394 patients were performed. There were 35 bilateral cases; each limb performed on separate occasions. The female to male ratio was 1.2:1. The median age was 54 years (range 17-88 years). The CEAP (Clinical, Etiologic, Anatomic and Pathophysiologic) classification was C2 to C3, 291 (68%); C4 to C5, 11 (26%), and C6, 26 (6%). Forty-seven (11%) recurrent varicose veins were treated. There were three recorded cases of endovenous heat induced thrombosis (EHIT). Sixty (14%) patients were lost to follow up. One hundred and five (29%) patients underwent repeat DUS for persistent symptoms. In the follow up period, only 86 patients (23%) needed further multiple avulsions. CONCLUSIONS: OBEVRFAs of the truncal veins for the treatment of varicose veins is safe and effective and could be performed in all suitable patients to free up theatre capacity.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia.

GUIDELINE SUMMARY: Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Carotid bypass using the Gore Hybrid Vascular Graft as a rescue technique for on-table failed carotid endarterectomy.

Carotid endarterectomy (CEA) remains the "gold standard" for atherosclerotic lesions involving the carotid bifurcation. Carotid bypass grafting using either polytetrafluoroethylene or long saphenous vein is a suitable alternative technique, especially in challenging endarterectomy and on-table failed CEA. We report our initial experience of using the Gore Hybrid Vascular Graft (W. L. Gore & Associates, Flagstaff, Ariz) in six patients as a rescue technique when standard CEA failed.

Critical limb ischemia-need to look beyond limb salvage.

BACKGROUND: Revascularization is the optimal treatment for critical limb ischemia (CLI). Traditional measures of outcome of intervention are as follows: graft patency, limb salvage rates, and patient survival rates; however, these have little meaning for a patient if he/she cannot ambulate independently or go back to work. This study was undertaken to assess the functional outcome of intervention in these patients. METHODS: Fifty patients with CLI treated over a 3-year period were included in this prospective clinical study. After evaluation, treatment was given to each patient on the basis of the Transatlantic Inter-society Consensus II guidelines. The outcome of treatment and the functional restoration to pre-illness lifestyle were assessed at the end of 1 month, and then at 6 months. RESULTS: Fifty patients with CLI were included in the study; male to female ratio was 9:1, and the mean age at presentation was 45 years. After evaluation, only 38 patients (76%) were found suitable for revascularization. Traditional measures of success showed a graft patency rate of 75%, limb salvage rate of 89.5%, and patient survival rate of 96% at 6 months after treatment. All eight parameters of quality-of-life analysis showed significant improvement as assessed by the Research and Development (RAND) 36-Item Health Survey 1.0 form. However, among the 38 patients who were revascularized, 20 (52.6%) went back to their initial occupation after 6 months, 12 (31.6%) remained at home even though they were ambulant, and five (13.2%) were able to manage only limited activities; one patient succumbed to death. CONCLUSION: With only 53% of revascularized patients returning to work, a salvaged leg does not equate with return to premorbid ambulatory/occupational status, although there might be improvement in quality of life because of other reasons. As surgeons, we need to look beyond leg salvage and graft patency and take on a more holistic approach.