Application of Novosorb biodegradable temporising matrix in wounds of different aetiologies: a case series.

DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Microindentation of fresh soft biological tissue: A rapid tissue sectioning and mounting protocol.

Microindentation of fresh biological tissues is necessary for the creation of 3D biomimetic models that accurately represent the native extracellular matrix microenvironment. However, tissue must first be precisely sectioned into slices. Challenges exist in the preparation of fresh tissue slices, as they can tear easily and must be processed rapidly in order to mitigate tissue degradation. In this study, we propose an optimised mounting condition for microindentation and demonstrate that embedding tissue in a mixture of 2.5% agarose and 1.5% gelatin is the most favourable method of tissue slice mounting for microindentation. This protocol allows for rapid processing of fresh biological tissue and is applicable to a variety of tissue types.

Systematic Review and Meta-analysis of Fenestrated and Chimney/Snorkel Techniques for Endovascular Repair of Juxtarenal Aortic Aneurysms.

OBJECTIVES: Comparative effectiveness of fenestrated endovascular aneurysm repair (FEVAR) and chimney graft endovascular aneurysm repair (ChEVAR) for juxtarenal aortic aneurysms (JAAs) remains unclear. Our objective was to identify and analyze the current body of evidence comparing the effectiveness of both techniques for JAA. METHODS: We performed a systematic review and meta-analysis comparing the effectiveness of FEVAR and ChEVAR for JAA repair. We searched MEDLINE, EMBASE, and Cochrane Register for Controlled Trials from January 1, 1990, for randomized and non-randomized studies assessing outcomes of FEVAR and ChEVAR for JAA repair. Screening, data extraction, risk of bias assessment, and GRADE (Grading of Recommendations, Assessments, Development, and Evaluations) certainty of evidence were performed in duplicate. Data were pooled statistically where possible. RESULTS: Nine retrospective cohort studies comparing the use of FEVAR and ChEVAR for juxtarenal aneurysm were included for meta-analysis. The FEVAR and ChEVAR arms of the meta-analysis consisted of 726 participants and 518 participants, respectively. There were 598 (86.8%) and 332 (81.6%) men in each arm. The mean diameter was larger in the ChEVAR arm (59 mm vs 52.5 mm). Both techniques had similar rates of postoperative 30-day mortality, 3.38% (8/237) versus 3.52% (8/227), acute kidney injury, 16.76% (31/185) versus 17.31% (18/104), and major adverse cardiac events, 7.30% (46/630) versus 6.60% (22/333). The meta-analysis supported the use of FEVAR for most outcomes, with significant advantage for technical success (odds ratio [OR]: 3.24, 95% CI: 1.24-8.42) and avoidance of type 1 endoleak (OR: 5.76, 95% CI: 1.94-17.08), but a disadvantage for spinal cord ischemia (OR: 10.21, 95% CI: 1.21-86.11), which had a very low number of events. The quality of evidence was "moderate" for most outcomes. CONCLUSION: Both endovascular techniques had good safety profiles. The evidence does not support superiority of either FEVAR or ChEVAR for JAA. CLINICAL IMPACT: While lack of equipoise has hampered the design of randomised trials of open versus endovascular repair of juxtarenal aortic aneurysms, concern about the durability of endovascular repair highlights the need for stronger evidence of the comparative efficacy of endovascular techniques. This review performed meta-analysis and evidence appraisal of recent data from large observational studies comparing fenestrated and chimney techniques, using a comprehensive outcome set. Superiority of either intervention could not be established due to differences in participants' baseline risk in each study arm. However, data suggests that both techniques are safe and suitable for use when indicated.

Long-term outcome of cervical artery dissection.

OBJECTIVE: The aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. METHODS: A retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. RESULTS: Thirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner's syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. CONCLUSIONS: The majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Necrotising fasciitis in the COVID-19 era: A consequence of caution - A case series.

Necrotising fasciitis (NF) is a severe soft tissue infection that is associated with a high risk of morbidity and mortality. During the coronavirus disease 19 (COVID-19) pandemic, the population has been actively discouraged from presenting to emergency medical services unless absolutely necessary. While this was an important step in allowing for preservation of limited resources in a time of crisis, it may have resulted in immeasurable 'secondary victims' of the pandemic as patients with time-critical conditions delay hospital presentation. In this case series, we describe three patients that noted symptoms of soft tissue infection, but delayed seeking healthcare advice due to concerns regarding COVID-19 exposure. All three progressed to NF, requiring highly morbid wide surgical debridement and prolonged hospital admission, with a high risk of potential mortality. The findings of this series demonstrate the importance of consistently delivering appropriate and timely healthcare interventions to patients with non-COVID-19-related conditions. While efforts must be made to ensure preservation of valuable healthcare resources in a global pandemic, patients must also be empowered to seek timely care for non-COVID-19-related conditions even in this time of crisis.

Effect of Pseudomonas colonisation on lower limb venous ulcer healing: a systematic review.

OBJECTIVE: Pseudomonas aeruginosa is a Gram-negative bacillus that commonly colonises lower limb venous ulcers. Its effects on venous ulcer healing are widely debated. It produces exotoxins and elastase, as well as forming biofilms in hard-to-heal wounds. It is postulated that these virulence factors lead to slower healing times in patients with lower limb venous ulcers colonised with Pseudomonas. This review aimed to summarise the available evidence pertaining to this topic. METHOD: A systematic review was performed in August 2019, where the Pubmed, Cochrane and Embase databases were searched for relevant literature according to PRISMA guidelines. Retrospective and prospective studies examining the effect of Pseudomonas colonisation on any measure of ulcer healing were included. RESULTS: Some 282 articles were screened, of which seven studies including 491 patients were ultimately included for analysis. Of these, no study demonstrated a significant association between Pseudomonas colonisation and delayed healing of venous ulcers. In five of the seven studies, the effect of Pseudomonas aeruginosa on initial ulcer size at presentation was recorded. CONCLUSION: All the studies demonstrated an association between ulcer size and the presence of Pseudomonas aeruginosa. While Pseudomonas aeruginosa may colonise larger ulcers or those with a worse prognosis, no evidence was found to support the hypothesis that this colonisation had a negative impact on lower limb venous ulcer healing.

Outcomes of Acute Limb Ischaemia in Patients with Underlying Malignancy: A Systematic Review.

OBJECTIVE: Previous studies have demonstrated amputation and mortality rates to be 14.3% - 30% and 11.4% - 28.9%, respectively, for all patients presenting with acute limb ischaemia (ALI). Rates of ALI are higher in patients with malignancy than in those without. Despite this, there remains uncertainty with regards to the most appropriate management for patients with cancer presenting with ALI. This is because of previously published high rates of associated morbidity and mortality in this population. The aim of this review was to summarise the available evidence reporting on outcomes of ALI in patients with underlying malignancy. METHOD: A systematic review was performed in August 2020 in accordance with the PRISMA guidelines. The Medline, Scopus, Cochrane, and Embase databases were searched with the following search string ((acute limb ischaemia) OR (acute limb ischemia)) AND ((cancer) OR (malignancy)). A total of 849 papers were identified and reviewed; six studies were included. Studies were assessed for bias using the National Institute of Health/National Heart, Lung and Blood Institute Quality Assessment Tool. Data including demographics, Rutherford classification, baseline performance scores, method of revascularisation, and peri-procedural outcomes were extracted and analysed. Data were pooled based on outcomes of interest and pooled prevalence was reported with 95% confidence intervals (CI). RESULTS: Six studies with 284 patients with cancer were included for analysis. The pooled overall risk of amputation was 15% (95% CI 5.9 - 26.9). The pooled 30 day mortality rate was 24% (95% CI 14.7 - 34.6). CONCLUSION: Despite limitations of interstudy selection bias and some clinical heterogeneity, the included studies demonstrated acceptable short and medium term outcomes for patients with cancer undergoing revascularisation for acute limb ischaemia. This is in line with current recommendations that patients with underlying malignancy should be considered strongly for revascularisation.

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.

On the association between circulating biomarkers and atherosclerotic calcification in a cohort of arterial disease participants.

BACKGROUND AND AIMS: Atherosclerotic calcification is a powerful predictor of cardiovascular disease. This study aims to determine whether circulating levels of a local/systemic calcification inhibitor or a marker of bone formation correlate with measures of coronary or extracoronary calcification. METHODS AND RESULTS: Clinical computed tomography (CT) was performed on 64 arterial disease participants undergoing carotid and lower extremity endarterectomy. Coronary artery calcium (CAC) scores and volumes were acquired from the CT scans (n = 42). CAC scores and volumes were used to derive CAC density scores. Micro-CT was performed on excised carotid (n = 36) and lower extremity (n = 31) plaques to quantify the volume and volume fraction of extracoronary calcification. Circulating levels of dephospho-uncarboxylated Matrix Gla Protein (dp-ucMGP), fetuin-A, carboxylated and uncarboxylated osteocalcin (ucOC) were quantified using commercial immunoassays. Carotid participant CAC density scores were moderately negatively correlated with plasma dp-ucMGP (rs = -0.592, P = 0.008). A weak negative association was found between CAC scores and %ucOC for all participants (rs = -0.335, P = 0.040). Another weak negative correlation was observed between fetuin-A and the volume of calcification within excised carotid specimens (rs = -0.366, P = 0.031). Despite substantial differences in coronary and extracoronary calcium measurements, the levels of circulating biomarkers did not vary significantly between carotid and lower extremity subgroups. CONCLUSION: Correlations identified between circulating biomarkers and measures of coronary and extracoronary calcium were not consistent among participant subgroups. Further research is required to determine the association between circulating biomarkers, coronary and extracoronary calcium.

Open repair of a type II endoleak facilitated by temporary disconnection of graft components.

Endoleaks are a frequent indication for reintervention after endovascular repair of an abdominal aortic aneurysm. Here we present a method of open repair of a persistent type II endoleak involving graft component separation and reconstruction, in a patient with symptomatic interval aneurysmal sac enlargement despite endovascular coiling and embolization. This case report demonstrates an alternative open technique of endograft component separation and reconstruction that may be required in cases where open repair with sac exploration and vessel oversewing is hindered by the graft position.

Systematic review on the incidence and management of endovenous heat-induced thrombosis following endovenous thermal ablation of the great saphenous vein.

OBJECTIVE: A systematic review and meta-analysis was performed to determine the incidence of endovenous heat-induced thrombosis (EHIT) and evaluate its management after endovenous thermal ablation of the great saphenous vein (GSV). METHODS: MEDLINE and Embase were searched for studies with at least 100 patients who underwent great saphenous vein endovenous thermal ablation and had duplex ultrasound follow-up within 30 days. Data were gathered on the incidence of thrombotic complications and on the management of cases of EHIT. The primary outcome for the meta-analysis was EHIT types 2 to 4 and secondary outcomes were deep venous thrombotic events (which we defined as types 2-4 EHIT plus deep vein thrombosis [DVT]), DVT, and pulmonary embolism (PE). Pooled proportions were calculated using random effects modelling. RESULTS: We included 75 studies (23,265 patients). EHIT types 2 to 4 occurred in 1.27% of cases (95% confidence interval [CI], 0.74%-1.93%). Deep venous thrombotic events occurred in 1.59% (95% CI, 0.95%-2.4%). DVT occurred in 0.28% (95% CI, 0.18%-0.4%). Pulmonary embolism occurred in 0.11% (95% CI, 0.06%-0.18%). Of the 75 studies, 24 gave a description of the management strategy and outcomes for EHIT and there was inconsistency regarding its management. Asymmetrical funnel plots of studies that reported incidence of EHIT 2 to 4 and DVT suggest publication bias. CONCLUSIONS: The recently published guidelines on EHIT from the Society for Vascular Surgery/American Venous Forum provide a framework to direct clinical decision-making. EHIT and other thrombotic complications occur infrequently and have a benign course.

An international experience of electronic communication and implementation of eHealth solutions in a vascular surgery clinic.

INTRODUCTION: Communication is key to any successful relationship with the patient-physician partnership being no different. Recent advances in technology have provided us with an array of new communication tools such as the mobile phone, computer, internet, and email. This new technology has revolutionized communications; however, limitations to their widespread use include access, literacy, and willingness for both the physician and patient to change. METHODS: To gather international data, questionnaires were completed by patients attending vascular surgery outpatient clinics in hospitals in Ireland and Canada. RESULTS: Five hundred ninety-seven patients participated in the study. Of the participants, 83.2% were over 50 years old. The mean age was 63.1 years, with a range of 18-95 years. Overall, home phone call was the most preferred method of communication with 41.0% of patients selecting this option. Of the patients, 82.4% had a mobile phone but just 48.5% use text message. In those over the age of 70, 72.1% use a mobile phone and just 25.3% use text message. Of the participants, 64.1% had access to a computer, and 67.2% had access to the internet with a decline in the usage of both with increasing age. DISCUSSION: Within this patient population, the use of technologies decreases with increasing age of the patients. This demonstrates a large population of service users who are contented with conventional methods of communication. Change within healthcare ICT is inevitable, and therefore, these patients need to be guided and educated to allow a smooth transition from the old to the new.

Hybrid covered endovascular reconstruction of the aortic bifurcation (CERAB) procedure is preferable to aortobifemoral bypass for limb-threatening aortoiliac occlusive disease during the COVID-19 crisis.

The COVID-19 pandemic is disrupting the provision of acute vascular surgery across the globe. Limited evidence of the impact of nosocomial infection on patient outcomes as well as concerns about critical care capacity will likely have an impact on surgical decision-making. Endovascular therapy offers a way by which perioperative risk can be reduced for vascular patients while also reducing the impact of acute surgery on intensive care unit capacity. This case report describes the management of a patient with complex aortoiliac occlusive disease by a hybrid endovascular approach in light of these constraints, with a successful outcome.

Correlating Ex Vivo Carotid Calcification Measurements With Cerebrovascular Symptoms: A Proof-of-Concept Study.

BACKGROUND AND PURPOSE: The purpose of this study is to examine the ability of ex vivo derived Agatston, Volume, and Density-Volume calcium scores or calcium density measurements to differentiate between carotid plaques based on preoperative cerebrovascular symptomatology. METHODS: Thirty-eight carotid plaques were acquired from standard endarterectomy. Micro-computed tomography was performed on the ex vivo samples. Image series were downsampled to represent the resolution of clinical multidetector computed tomography. Agatston, Volume, and Density-Volume carotid calcium scores were then calculated using coronary methodologies. The fractions of low- and high-density calcification were also determined. RESULTS: The coronary calcium scores could not differentiate between carotid plaques from asymptomatic versus symptomatic patients. However, plaques from asymptomatic patients contained significantly lower fractions of low-density calcification and higher fractions of high-density calcification. CONCLUSIONS: Screening for carotid calcium density in noncontrast computed tomography could reflect plaque stability.

Reducing the risk of venous thromboembolism following superficial endovenous treatment: A UK and Republic of Ireland consensus study.

OBJECTIVES: Venous thromboembolism is a potentially fatal complication of superficial endovenous treatment. Proper risk assessment and thromboprophylaxis could mitigate this hazard; however, there are currently no evidence-based or consensus guidelines. This study surveyed UK and Republic of Ireland vascular consultants to determine areas of consensus. METHODS: A 32-item survey was sent to vascular consultants via the Vascular and Endovascular Research Network (phase 1). These results generated 10 consensus statements which were redistributed (phase 2). 'Good' and 'very good' consensus were defined as endorsement/rejection of statements by >67% and >85% of respondents, respectively. RESULTS: Forty-two consultants completed phase 1. This generated seven statements regarding risk factors mandating peri-procedural pharmacoprophylaxis and three statements regarding specific pharmacoprophylaxis regimes. Forty-seven consultants completed phase 2. Regarding venous thromboembolism risk factors mandating pharmacoprophylaxis, 'good' and 'very good' consensus was achieved for 5/7 and 2/7 statements, respectively. Regarding specific regimens, 'very good' consensus was achieved for 3/3 statements. CONCLUSIONS: The main findings from this study were that there was 'good' or 'very good' consensus that patients with any of the seven surveyed risk factors should be given pharmacoprophylaxis with low-molecular-weight heparin. High-risk patients should receive one to two weeks of pharmacoprophylaxis rather than a single dose.

Autologous bone marrow mesenchymal stromal cell therapy for "no-option" critical limb ischemia is limited by karyotype abnormalities.

BACKGROUND: Critical limb ischemia (CLI) is the most severe manifestation of peripheral vascular disease. Revascularization is the preferred therapy, but it is not achievable in 25%-40% of patients due to diffuse anatomic distribution of the disease or medical comorbidities. No-option CLI represents an unmet medical need. Mesenchymal stromal cells (MSCs) may provide salvage therapy through their angiogenic and tissue-trophic properties. This article reports a phase 1b clinical study examining the safety and feasibility of intramuscular transplantation of autologous bone-marrow MSCs for patients with no-option CLI. METHODS: Twelve patients were enrolled in the clinical trial, and nine proceeded to bone marrow aspiration and culture expansion of MSCs. RESULTS: A high rate of karyotype abnormality (>30%) was detected in the produced cell batches, resulting in failure of release for clinical administration. Four patients were treated with the investigational medicinal product (IMP), three with a low dose of 20 × 106 MSCs and one with a mid-dose of 40 × 106 MSCs. There were no serious adverse events related to trial interventions, including bone marrow aspiration, IMP injection or therapy. CONCLUSIONS: The results of this trial conclude that an autologous cell therapy approach with MSCs for critical limb ischemia is limited by the high rate of karyotype abnormalities.

Comparative analysis of calcification parameters with Agatston Score approximations for ex vivo atherosclerotic lesions.

BACKGROUND: The Agatston Calcium Score is a predictor of major adverse cardiovascular events but it is unable to identify high-risk lesions. Recent research suggests that examining calcification phenotype could be more indicative of plaque stability. OBJECTIVE: To examine the Agatston score's ability to determine atherosclerotic calcification phenotype. METHODS: Micro-Computed Tomography was performed on 20 carotid and 20 peripheral lower limb lesions. ImageJ pixel histogram analysis quantified the non-calcified (≥30HU, <130HU) and calcified (≥130HU) tissue volumes. ImageJ '3D Objects Counter' plugin determined the calcified particle count, volumes and maximum attenuation density of each particle. Image stacks were subsequently downsampled to a resolution of 0.7 × 0.7 × 3 mm and an approximation for the Extra-Coronary Calcium Scores (ECCS) were calculated. Spearman's correlation examined the relationships between ECCS approximations and calcification parameters. RESULTS: ECCS has a strong positive correlation with the Calcified Volume Fraction (CVF) (rs = 0.865, p < 0.0005), weak positive correlations with Calcified Particle Fraction (CPF) (rs = 0.422, p = 0.007) and Microcalcification Fraction (micro-CF) (rs = 0.361, p = 0.022). There is no correlation evident between ECCS and Calcified Particle Index (CPI) (rs = -0.162, p = 0.318). It is apparent that there is a high prevalence of microcalcifications in both carotid and peripheral lower limb lesions. Additionally, an inverse relationship exists between calcified particle volume and maximum-recorded attenuation density. CONCLUSION: The density-weighted Agatston calcium scoring methodology needs to be reviewed. Calcium scoring which differentiates between critical calcification morphologies, rather than presenting a density-weighted score, is required to direct high-risk plaques towards tailored treatment.

Transient iatrogenic Horner's syndrome following carotid endarterectomy.

We present a case of a 72-year-old man who developed a transient Horner's syndrome in the immediate postoperative period after right carotid endarterectomy which resolved within 3 months. Although Horner's syndrome has been reported with several disorders of the carotid artery, our case documents a rare iatrogenic oculosympathetic paresis after elective carotid endarterectomy.