Editor's Choice - Influence of Proximal Aortic Neck Diameter on Durability of Aneurysm Sealing and Overall Survival in Patients Undergoing Endovascular Aneurysm Repair. Real World Data from the Gore Global Registry for Endovascular Aortic Treatment (GREAT).

OBJECTIVES: Aortic neck diameter is an independent anatomical feature that is poorly understood, yet potentially linked to proximal seal failure and adverse outcome following standard EVAR. The aim of this study was to assess whether large proximal aortic neck (LAN) diameter is associated with adverse outcome using prospectively collected individual patient data from The Global Registry for Endovascular Aortic Treatment (GREAT). METHODS: A total of 3166 consecutive patients, from 78 global centres, receiving Gore Excluder stent grafts for infrarenal abdominal aortic aneurysm repair between 2011 and 2017 were included. Patient demographics, biometrics, operative details, and clinical outcome were analysed. Patients were divided into two groups: normal baseline proximal aortic neck (NAN) diameter (<25 mm on computed tomography aortography), and LAN (≥25 mm). Clinical follow up (including imaging) was available for 76.5% of patients 5 years post-intervention. Primary endpoints analysed were Type IA endoleak and any aortic re-intervention up to 5 years post-procedure. A composite endpoint of Type IA endoleak, re-intervention, aortic rupture, or aortic related mortality was also assessed. RESULTS: A total of 1977 (62.4%) patients were classified NAN and 1189 (37.6%) were LAN. Immediate technical success was achieved in 3164 out of 3166 (>99.9%) of cases. Freedom from Type IA endoleak was achieved in 99.3% at 1 year and 97.3% at 5 years (lower in LAN vs. NAN: 96.8% [CI 93.7-98.4] vs. 98.6% [CI 94.5-99.6], p = .007). Freedom from aortic re-intervention was 93.7% at 1 year and 83.2% at 5 years (78.6% [CI 66.0-87.0] LAN vs. 86.0% [CI 81.8-89.3] NAN, p = .11). Freedom from primary composite endpoint was 95.9% at 1 year and 84.9% at 5 years (81.3% [CI 69.2-89.0] LAN vs. 87.0% [CI 81.6-91.0] NAN, p = .066). Five year survival was lower in the LAN group; 64.6% (CI 50.1-75.7) vs. 76.5% (CI 70.7-81.3), p = .03). CONCLUSION: LAN is associated with delayed Type IA endoleak occurrence and lower overall survival.

Severe bilateral renal artery stenosis after transluminal radiofrequency ablation of renal sympathetic nerve plexus.

Percutaneous renal sympathetic denervation is an evolving therapy for resistant hypertension. Evidence to date demonstrates a reduction of blood pressure in the short term to medium term. Reported complications relate to problems with vascular access vessels and dissection of the renal artery. Renal artery stenosis has not been described in the literature. We present a patient with hypertensive crisis, flash pulmonary edema, and deterioration of renal function, secondary to bilateral renal artery stenosis, 9 months after renal sympathetic radiofrequency ablation denervation.

Pharmacist influence on prescribing in peripheral arterial disease (PIPER).

The objective of this study was to determine the association between a specialist clinical pharmacist working in collaboration with medical staff and prescribing in peripheral arterial disease (PAD). A retrospective cohort study was conducted comparing the influence of a dedicated clinical pharmacist on two samples of patients admitted to a single vascular surgery unit in either 2007 (control group) prior to implementation of a comprehensive clinical pharmacy service or 2009 (comparison group) post implementation. Data were obtained via review of medical records and electronic reports. A total of 685 patients were identified, resulting in 964 admissions. The patient to pharmacist ratio decreased from 62 to 33 patients per day in 2009. More patients were initiated on an antiplatelet (OR 4.6, 95% CI 2.26 to 9.53, p<0.001) and statin (OR 3.4, 95% CI 1.97 to 6, p<0.001) in 2009 compared to 2007. Risk factor modification increased in 2009, resulting in action being taken more often for HbA1c>7% (OR 3.45, 95% CI 1.64 to 7.27, p=0.001), total cholesterol >4 mmol/L in females (OR 14.5, 95% CI 2.67 to 78.6, p=0.002) and blood pressure above target (OR 1.9, 95% CI 1.01 to 3.73, p=0.05) when a comprehensive clinical pharmacist service was available. There was a non-significant reduction in mortality (18.7% (65) to 14.2% (46), p=0.13) and cardiovascular outcomes (5.5% (19) to 4.3% (14), p=0.44) within 12 months of discharge. In conclusion, prescribing of evidence-based medication for PAD and risk factor modification increased with a comprehensive clinical pharmacist service. This study provides important insight into optimising treatment in this patient group and how a pharmacist can be a helpful addition to the multidisciplinary team.

A 3-year follow-up study of inpatients with lower limb ulcers: evidence of an obesity paradox?

OBJECTIVES: To determine whether body composition is related to long-term outcomes amongst vascular inpatients with lower limb ulcers. DESIGN: Prospective study with 3 years follow-up. MATERIALS AND METHODS: Body mass index (BMI), fat, and fat-free mass were measured and associations with readmission to hospital (number, cause, length of stay) and all-cause mortality were explored. RESULTS: Thirty patients (22 men, 8 women) participated in the study. Ten patients (33%) had a BMI ≥ 30 kg/m(2). 18/20 (90%) patients with a BMI < 30 kg/m(2) and 9/10 (90%) patients with a BMI ≥ 30 kg/m(2) were admitted to hospital in the 3 years of follow-up. Patients with a BMI < 30 kg/m(2) were admitted more frequently, earlier and for longer compared to those with BMI ≥ 30 kg/m(2) but these did not reach statistical significance. The 3 year mortality rate for patients with BMI ≥ 30 kg/m(2) was 20% (n = 2/10) compared to 70% (n = 14/20) with a BMI < 30 kg/m(2), P = 0.019. CONCLUSION: This preliminary study suggests that higher BMI may have a protective effect against mortality in vascular patients with lower limb ulcers. These findings contradict the universal acceptance that obesity leads to poor health outcomes. Further work is required to confirm these findings and explore some of the potential mechanisms for this effect.

Clinical governance: its effect on surgery and the surgeon.

Audit is the process by which clinical staff collectively review, evaluate and improve their clinical practice with the common aim of improving standards. Modern audit has developed from the initial concept promoted in the 1980s and is now part of the concept of clinical governance. Clinical governance is a framework through which health service organizations are accountable for continuously improving the quality of their services. Clinicians have always been accountable for maintaining high quality care; clinical governance merely imposes structure in this and makes it explicit. The features of this are: (i) full participation in audit by all hospital doctors; (ii) support and use evidence-based practice, including risk management, quality assurance and clinical effectiveness; and (iii) continuing professional development.