Subclavian artery laceration following clavicle fracture, successfully treated with a combined endovascular and open surgical approach.

Subclavian artery injury is a rare complication of clavicle fracture. The fractured clavicle can lacerate the underlying subclavian artery. Life-threatening haemorrhage can occur secondary to arterial laceration, and if distal blood flow is impaired, upper limb ischaemia can develop. There is little discussion in the literature regarding combined (or 'hybrid') endovascular and open surgical management of acute subclavian injuries secondary to clavicle fracture. We report a case of subclavian artery laceration secondary to clavicle fracture, managed with a combined endovascular and open surgical approach. An endovascular balloon was used for proximal arterial control, while surgical exposure and primary repair of the subclavian artery was completed, followed by fixation of the clavicle. There was no sustained vascular or neurological impairment at follow-up. We suggest that select traumatic injuries of the subclavian artery can be safely and successfully managed with a combined endovascular and open surgical approach.

Primary brachial artery aneurysm with associated basilic vein aneurysm.

There are but a handful of reported brachial artery aneurysms, the majority of which are pseudoaneurysms or false aneurysms caused by trauma or fistula creation. True or primary brachial artery aneurysms are even more rare, and if they occur, they often do so in isolation. In this case report, we discuss the interesting finding of a large primary brachial aneurysm together with an adjacent aneurysmal basilic vein identified intra-operatively. This presentation was 21 years after the renal transplant and ligation of an arteriovenous fistula in that same arm. It is noteworthy that the fistula was in the forearm and far away from the site of the untouched brachial area.

Introduction and validation of a surgical ward round checklist to improve surgical ward round performance in a tertiary vascular service.

BACKGROUND: Surgeons administer care in an increasingly complex clinical environment. Time constraints put strain on individual clinicians and the multidisciplinary team, increasing the risk of human errors. The World Health Organization surgical checklist has shown to mitigate this risk perioperatively. We describe the development, introduction and outcomes of a novel ward round safety checklist. METHODS: The vascular team ward rounds at Christchurch Hospital were assessed over a 2-week period for ward round quality indicators. A ward round safety checklist was developed and then introduced. Two further assessments were conducted to evaluate for improvement in the ward round quality indicators. Ward rounds were timed with the length of each consultation recorded and staff perception assessed. RESULTS: Significant gains across both clinical indicators and staff feedback measures were observed. Of the 21 ward round quality indicators, 20 showed statistically significant improvement, as did all subjective measures. Significant improvements included observation chart review (20% to 75% to 81%), drug chart review (10% to 54% to 78.6%) and anticoagulation/antiplatelet treatment (32% to 61% to 58.1%) (P < 0.05). Mean consultation time per patient did not increase (3 min 58 s to 3 min 48 s and 4 min 30 s) (P = 0.857 and P = 0.119). CONCLUSION: This study provides evidence that introducing a structured ward round safety checklist improved ward round quality, without adversely affecting consultation time. The familiar checklist structure promotes its acceptance and team cohesion. Whether the improvements observed translate to improved patient outcomes and reduced adverse events reporting is the subject of ongoing study.

Timeliness and outcomes of carotid endarterectomy for symptomatic carotid artery stenosis: a single centre audit.

BACKGROUND: For patients presenting with symptomatic internal carotid artery stenosis, carotid endarterectomy (CEA) surgery is recommended to be performed generally within a 48-hr to 14-day window. This study aimed to assess timeliness of delivery, and outcomes, of CEA surgery in a tertiary vascular centre. METHOD: Patients with symptomatic internal carotid artery stenosis who underwent CEA between 1 June 2014 and 31 June 2017 were identified and data were obtained from hospital records. The timeline of their journey from presentation to surgery was then mapped together with their outcomes. RESULTS: One hundred and seventy-two cases were included in the study. Overall, the median time from development of presenting symptoms to surgery was 9 days and 119 (69%) cases were operated on within 14 days. The median time from development of presenting symptoms to ultrasound imaging was 2 days and the median time from symptoms to vascular referral was also 2 days. There were no deaths, strokes or transient ischaemic attacks within 30 days of CEA. At 1 year, survival was 100% but 15 (8.7%) had experienced at least one transient ischaemic attack or stroke. In the 53 cases operated upon beyond 14 days the dominant cause of delay in 32 (60%) was accessing surgery after review by the vascular service. CONCLUSION: The aim of delivering CEA within 14 days of developing relevant symptoms was achieved in most cases with good outcomes. Nevertheless, points of delay in the patient journey that could be targeted for future quality improvement were identified.

Rapid access carotid endarterectomy: winning the RACE following a natural disaster.

AIMS: Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. METHODS: Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. RESULTS: Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patients had CEA within two weeks from the index event. The number of CEA procedures doubled since 2009. CONCLUSIONS: Despite many challenges following a major natural disaster, delivery of RACE has been maintained at an acceptable standard. Some delays persist and these remain areas for improvement in future.

Aorto-gastroduodenal bypass grafting for an inferior pancreaticoduodenal aneurysm and celiac trunk thrombosis.

We present a case of a male patient diagnosed with a large inferior pancreaticoduodenal artery (IPDA) aneurysm, associated with a fresh thrombotic occlusion of the celiac trunk. Given the risk of splanchnic ischaemia, radiologic embolisation of the aneurysm combined with celiac axis stenting was deemed unsafe. Management was therefore modified to elective revascularisation of the celiac axis prior to surgical resection of the aneurysm. A retropancreatic aorto-gastroduodenal artery bypass graft was performed prior to exposing and resecting the pancreaticoduodenal artery aneurysm. This ensured near uninterrupted retrograde supply to the celiac axis during the procedure. This is an effective, efficient and expeditious patient pathway for these rare and complex aneurysms complicated by celiac trunk involvement.

Vascular reconstruction in lower limb musculoskeletal tumours.

BACKGROUND: Individual experience in the investigative, planning and operative aspects of lower limb musculoskeletal tumours is often small, making comparison between results difficult. The aim of the study was to describe the recent experience of a single tertiary referral unit performing limb salvage surgery, to identify areas of concern that are amenable to intervention and to provide clinicians an understanding of the surgical options. METHODS: Nine patients with peripheral limb musculoskeletal tumours are described. Four patients had a leiomyosarcoma, and one each of osteosarcoma, synovial chondrosarcoma, synovial sarcoma, liposarcoma and recurrent malignant peripheral nerve sheath tumour. RESULTS: Thirty-day mortality was nil. Two patients (one with a leiomyosarcoma and one with an osteosarcoma) died at 6 months follow-up because of pulmonary metastases. One patient with synovial chondrosarcoma developed a local recurrence and underwent an above-knee amputation. Six patients at 18 months follow-up are alive with no evidence of local recurrence and a functional lower limb. CONCLUSION: These cases are a challenge to the clinicians, radiologists and pathologists. Review by a multidisciplinary team can produce successful results with low post-operative morbidity and mortality. Longer follow-up is required to determine the long-term implications.

Statins inhibit neutrophil infiltration in skeletal muscle reperfusion injury.

BACKGROUND: Neutrophil infiltration is a major determinant of ischemia-reperfusion injury (IRI). Statins improve endothelial function by elevating nitric oxide synthase activity and inhibiting adhesion molecule expression and may, therefore, inhibit IRI-induced neutrophil extravasation. Although statins are protective against myocardial IRI and stroke, a role for statins in ameliorating skeletal muscle IRI has not yet been confirmed. This study, therefore, addressed the hypothesis that simvastatin would attenuate the severity of tissue damage during skeletal muscle IRI. METHODS: Rats were administered simvastatin for 6 d before 4 h hind limb ischemia and 24 h reperfusion. Neutrophil infiltration was assessed using myeloperoxidase (MPO) assays and tissue damage by quantitative immunohistochemical analysis of collagen IV. The effect of reducing nitric oxide levels on the severity of IRI was assessed by administering the NOS inhibitor, N-Imino-L-ornithine (L-NIO), before ischemia. RESULTS: Simvastatin significantly inhibited IRI-induced MPO activity but not collagen degradation in postischemic skeletal muscle. Inhibition of nitric oxide synthase by L-NIO markedly inhibited neutrophil infiltration and protected against IRI-induced collagen degradation. When both simvastatin and L-NIO were administered before IRI, the IRI-induced elevation in MPO activity was completely inhibited. However, paradoxically, simvastatin counteracted the protective effect of L-NIO against IRI-induced collagen IV degradation. CONCLUSIONS: The inhibition by simvastatin of IRI-induced neutrophil infiltration in skeletal muscle suggests that statins may be a useful therapy to attenuate the severity of IRI but their precise mechanisms of action remains to be determined. Nitric oxide also plays a cytotoxic, rather than protective, role in mediating IRI in this model.

Subtotal hepatectomy: a porcine model for the study of liver regeneration.

BACKGROUND: This study aimed to devise a simple, reproducible method of subtotal hepatectomy in a large animal model. Such an experimental model could be useful in the investigation of liver regeneration and liver insufficiency after partial hepatectomy. Equally, this technique could be used for assessing the effect of artificial liver support systems on both liver function and regeneration. MATERIALS AND METHODS: Twenty pigs were subjected to either 70-80% liver resection (n = 11), or 85-90% liver resection (n = 9), using a simplified technique. RESULTS: Most tolerated the procedure well and showed restoration of full liver volume within 3 weeks. Three animals in the 90% resection group died with significantly raised levels of International Normalized Ratio (INR) and ammonia. CONCLUSIONS: These two techniques have been shown to be easily reproducible and well tolerated by the animals and allow easy assessment of liver function and regeneration in the postoperative period. The deaths in the 90% resection group supports the hypothesis that 90% partial hepatectomy represents a model of critical residual liver parenchyma.