UNASSIGNED: Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting.
UNASSIGNED: A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed.
UNASSIGNED: The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy.
UNASSIGNED: Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.

We present the case of a 75-year-old man with a symptomatic penetrating aortic ulcer located in zone 2 on the arch inner curve between the left subclavian artery and left carotid artery treated using a single branch thoracic endovascular aortic repair combined with in situ laser fenestration. The patient underwent a successful procedure with no neurologic impairment and was discharged on the second postoperative day. The postoperative follow-up showed a well-excluded penetrating aortic ulcer.

People with lower limb loss, especially of dysvascular etiology, are at substantial risk for both ipsilateral and contralateral reamputation. Additionally, while not as well documented for reamputation, there is recognition that amputation incidence is influenced by not only sociodemographic factors such as sex, race, socioeconomic status, but also by system factors such as service access. A systems strategy to address this disparity within the field of limb-loss rehabilitation is for Limb-loss Rehabilitation Programs (LRP) to partner with medical specialists, mental health professionals, and Limb Preservation Programs (LPP) to provide comprehensive limb care. While LPPs exist around the nation, design principles for such programs and their partnership role with LRPs are not well established. Using a socioecological model to incorporate hierarchical stakeholder perspectives inherent in the multidisciplinary field of limb care, this review synthesizes the latest evidence to focus on LPP design and implementation principles that can help policymakers, healthcare organizations and limb-loss rehabilitation and limb-preservation professionals to develop, implement, and sustain robust LPP programs in partnership with LRPs.

UNASSIGNED: Penetrating aortic ulcers (PAUs) are the rarest subset of acute aortic syndromes, and a thoraco-abdominal (TA) location is uncommon. Endovascular surgery is considered first line treatment. Custom made branched/fenestrated endografts have been successfully applied in this disease but are unavailable in the urgent setting. Off the shelf solutions may be required in high risk patients. The case of a symptomatic rapidly expanding TA-PAU without a distal seal zone that underwent urgent endovascular repair is described.
UNASSIGNED: An 81 year old male presented with acute intense thoracic pain. Workup revealed a large TA-PAU. As pain was refractory and computed tomography angiography confirmed rapid expansion, urgent repair was proposed. Due to multiple comorbidities and absence of adequate distal seal zone, an off label endovascular treatment was proposed. The patient underwent successful endovascular repair with two aortic stent grafts (GORE cTAG) with 30% oversize and 50-55 mm overlap between modules, combined with chimney self expanding stent grafts (GORE VIABAHN) to the coeliac trunk and superior mesenteric artery in a sandwich configuration. The post-operative course was uneventful. Follow up at 18 months revealed no endoleaks and patent bridging stent grafts without visceral compromise.
UNASSIGNED: Thoracic endovascular aortic repair (TEVAR) is considered the first treatment option for urgent PAU. However, anatomic requirements limit its use in the thoraco-abdominal aorta. Parallel graft techniques have been described to overcome these anatomic constraints in TA aneurysms. The use of a \"sandwich technique\" to successfully exclude a PAU without a distal sealing zone for standard TEVAR is described. The advantage was limited aortic coverage compared with a branched device or an \"octopus\" technique. This solution is particularly useful in urgent situations when patients cannot wait for a custom made device and the morbidity associated with open or hybrid repair is unacceptably high. An off the shelf sandwich technique is a potential safe and long lasting therapeutic option for the urgent treatment of TA-PAU.

Although women have lower age-standardized cardiovascular disease incidence, prevalence, and death-related rates than men, there are also reports indicating that women with cardiovascular disease receive less care, fewer investigations, and have poorer outcomes after a coronary event. The aims of this study were to compare the characteristics of men and women hospitalized for peripheral artery disease (PAD), their cardiovascular and limb outcomes, and their 1-year mortality. The study is a prospective registry collecting data about all consecutive patients hospitalized for PAD within the vascular department of the tertiary center Georges-Pompidou European Hospital (Paris, France). Patients were required to have one of three inclusion criteria: previous revascularization of the lower limb or any lower limb artery occlusion due to an atherosclerotic vascular disease or hemodynamic evidence of PAD. Exclusion criteria were patients with lower extremity arterial occlusion due to another cause. All patients were followed-up for at least 12 months after the initial hospitalization. Among the 235 patients included, there were 61 women (26%), older than men with a median age of 75.6 and 68.3 years, respectively. Main cardiovascular risk factors and comorbidities were similar for men and women except more former or current smokers [145 (83.4%) vs. 33 (54.1%)] and more history of coronary heart disease [42 (24.1%) vs. 7 (11.5%)] in men. Most patients [138 (58.8%)] had critical limb ischemia and 97 (41.3%) had claudication, with no difference for sex. After discharge, 218 patients received an antithrombotic therapy (93.2%), 195 a lipid-lowering drug (83.3%), 185 an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker (78.9%), similarly between sex. At 1-year, overall mortality, major adverse cardiovascular events, major adverse limb events did not differ with 23 (13.2%), 11 (6.3%) and 32 (18.4%) in men, and 8 (13.1%), 3 (4.9%), 15 (24.6%) in women, respectively, despite the difference in age. Overall mortality, cardiovascular outcomes, limb revascularization or amputation did not differ between men and women, 1-year after hospitalization for PAD although the latter were older, less smoker and had less coronary artery disease. Due to the small size of this cohort, larger studies and future research are needed to better understand sex-specific mechanisms in the pathophysiology and natural history of PAD.

We report a vein surgery procedure for popliteal venous aneurysms (PVAs). A 73-year-old woman with a long, irregularly shaped, PVA and thrombus underwent graft replacement using a manually made triple vein panel graft. Simple bypass grafting with a saphenous vein was unsuitable because of long defects and a size mismatch. We harvested the great saphenous vein from the right thigh, divided it into three segments, anastomosed it side-by-side on the long side, and created a venous panel graft. Good graft patency was confirmed at 4 years postoperatively, and the clinical course was stable without pulmonary embolism recurrence.

Due to its versatile applicability, many reconstructive surgeons use the radial forearm flap (RFF) as the first choice for soft tissue replacement. Donor site limitations of the flap arise with an insufficient blood supply along the ulnar artery. This study presents a simple and safe method for RFF preconditioning by recruitment of the deep palmar arch via the ulnar artery. Fourteen patients scheduled for RFF surgery between 2013 and 2018 showed an insufficient vascular supply according to the Allen test, which was confirmed by digital subtraction angiography (DSA). These 14 patients underwent temporary ligature of one or both radial arteries with elastic vessel loops under local anaesthesia and continuous pulse oximetry. A control DSA was performed about 24hours later in 10 of the 14 patients. Recruitment of the blood supply along the enlarged ulnar artery or reanimated collaterals was confirmed in all 10 patients. No local complications such as ischemia of the hand were seen. All flaps could be harvested regularly and were used for different reconstructive purposes. This simple technique may help to overcome vascular limitations of the RFF via the rapid, efficient, and reliable recruitment of the biological vascular reserve. Within the limits of a case series, this procedure appears practicable and safe.

Risk calculators and prediction models are available to assist clinicians and patients with peri-operative decision making to optimise outcomes. In a vascular surgical setting, the majority of these models is based on open AAA repair outcomes, and in general their clinical use is limited. The objective of this study was to develop and validate a simple and accurate vascular surgical risk prediction model.
A national administrative database was accessed to collect information on all adult patients undergoing vascular surgery between 1 July 2011 and 30 June 2016 in New Zealand. The primary outcomes were mortality at 30 days, one year, and two years. Previously established covariables including American Society of Anaesthesiologists (ASA) physical status score, sex, surgical urgency, cancer status and ethnicity were tested, and other covariables such as smoking status, presence of renal failure, diabetes, anatomical site of operation, structure operated, and type of procedures (open or endovascular) were explored. LASSO regression was used to select variables for inclusion in the model.
A total of 21 597 cases formed the final risk prediction models, with covariables including ASA score, gender, surgical urgency, cancer status, presence of renal failure, diabetes, anatomical site, structure operated, and endovascular procedure. The area under the receiver operating curve (AUROC) for 30 day, one year, and two year mortality using L-min model was 0.869, 0.833, and 0.824, respectively, demonstrating very good discrimination. Calibration with the validation dataset was also excellent, with slopes of 0.971, 1.129, and 1.011, respectively, and McFadden\'s pseudo-R2 statistics of 0.250, 0.227, and 0.227, respectively.
A simple and accurate multivariable risk calculator for vascular surgical patients was developed and validated using the New Zealand national dataset, with excellent discrimination and calibration for 30 day, one year, and two year mortality.

The benefits of best medical therapy (BMT) for secondary prevention of cardiovascular events in patients with peripheral arterial disease are well established. Guidelines recommend prescription of BMT should consist of anti-platelet, statins and angiotensin-converting enzyme inhibitor or angiotensin receptor blocking therapy, with evidence this regimen reduces cardiovascular mortality following vascular surgery and improves vascular bypass graft patency. This multicentre study examines the BMT prescription on discharge after infrainguinal bypass (IIB) in Australia and New Zealand (ANZ). Primary outcome measure was discharge prescription of three BMT pharmacological agents, defined for study purposes as an anti-platelet/anti-coagulant, a lipid-lowering agent, and an anti-hypertensive medication if hypertension was diagnosed.
This study retrospectively examined discharge prescriptions and summaries of all patients discharged following IIB in five ANZ hospitals, between January 2015 and April 2018.
A total of 688 admissions for IIB were included (76.9% male; mean age 67.8 ± 12.0). A total of 72.4% of procedures were for chronic limb ischaemia, compared to acute limb ischaemia (12.6%), and aneurysmal disease (15%). The primary outcome of adherence with complete BMT prescription occurred in 66.9% of admissions. Anti-thrombotic agents were most frequently prescribed (96.4%), followed by anti-lipidaemic agents (82.1%). Of the patients with documented hypertension, 43.8% were not prescribed an angiotensin-converting enzyme inhibitor/angiotensin receptor blocking, while 19.2% were discharged without any anti-hypertensive medications.
Almost one third of patients were not prescribed complete BMT following IIB. There is potential to improve the outcomes after IIB in ANZ through a focus on risk-factor control and BMT prescription.

Frailty has persistently been associated with unfavorable short-term outcomes after vascular surgery, including an increased complication risk, greater readmission rate, and greater short-term mortality. However, a knowledge gap remains concerning the association between preoperative frailty and long-term mortality. In the present study, we aimed to determine this association in elective vascular surgery patients.
The present study was a part of a large prospective cohort study initiated in 2010 in our tertiary referral teaching hospital to study frailty in elderly elective vascular surgery patients (Vascular Ageing Study). A total of 639 patients with a minimal follow-up of 5 years, who had been treated from 2010 to 2014, were included in the present study. The Groningen Frailty Indicator, a 15-item self-administered questionnaire, was used to determine the presence and degree of frailty.
Of the 639 patients, 183 (28.6%) were considered frail preoperatively. For the frail patients, the actuarial survival after 1, 3, and 5 years was 81.4%, 66.7%, and 55.7%, respectively. For the nonfrail patients, the corresponding survival was 93.6%, 83.3%, and 75.2% (log-rank test, P < .001). Frail patients had a significantly greater risk of 5-year mortality (unadjusted hazard ratio, 2.09; 95% confidence interval, 1.572-2.771; P < .001). After adjusting for surgical- and patient-related risk factors, the hazard ratio was 1.68 (95% confidence interval, 1.231-2.286; P = .001).
The results of our study have shown that preoperative frailty is associated with significantly increased long-term mortality after elective vascular surgery. Knowledge of a patient\'s preoperative frailty state could, therefore, be helpful in shared decision-making, because it provides more information about the procedural benefits and risks.