Abstract Purpose The treatment of critical limb-threatening ischemia (CLTI) is revascularization. Lumbar sympathectomy (LS) could be attempted when this is not amenable. Using laparoscopic techniques to perform LS adds the advantages of minimally invasive surgery. Methods Twenty-four patients, presenting with non-reconstructable CLTI and rest pain, were randomly divided into group I (14 patients) who underwent retroperitoneoscopic lumbar sympathectomy (RPLS) and group II (10 patients) who had conventional open lumber sympathectomy (COLS). Results RPLS patients had shorter hospital stays, fewer intraoperative complications, and less postoperative pain. However, the mean operative time was significantly longer (86.4 ± 9.1 min, p-value: 0.02) in the RPLS group but decreased with each subsequent case after that. The differences in post-operative capillary refill time, ABI, TBI, and TcPO2 were not statistically significant between both groups (p-values: 0.97, 0.13, 0.32, 0.10, respectively). However, the difference in the quality-of-life score was statistically significant; the mean (± SD) SF-36 score increased from 48 ± 6.8 to 81 ± 4.4 (p-value < 0.001) in RPLS group compared to 52 ± 8.8 to 59 ± 1.2 (p-value: 0.52) in COLS group. Conclusion RPLS is feasible, safe, and has the advantages of minimally invasive surgery: minimal blood loss, less intraoperative complications, shorter hospital stay, and less postoperative pain. However, the operative time in RPLS cases is longer than in the COLS; training on the procedure is recommended to improve the learning curve.

IntroductionIn a kidney transplant tertiary referral center; we compared three operating team configurations of different surgical specialties to highlight the effect of the operating surgeon’s specialty on various operative details and procedural outcome.Materials and MethodsA total of 50 cases of living donor transplantations were divided into three main groups according to the operating surgeons’ specialty, the first group (A) includes 12 patients exclusively operated on by urologists with advanced training in transplantation, the second group (B) includes 35 patients operated by combined surgical specialties; a urologist and a vascular surgeon both with advanced transplantation training, and a third group (C) includes 3 cases where the transplant operation commenced with operating urologists as in group (A) but required intra-operative urgent notification of a vascular surgeon to manage unexpected intraoperative technical difficulties or major complications. Cases were studied according to operative details, anastomosis techniques, ischemia times, total procedure time, recovery of urinary output, ICU (intensive care unit) stay, postoperative surgical complications and serum creatinine level for up to three years of follow-up.ResultsStudy of operative details revealed that total duration of graft ischemia was significantly shorter in group (B) and significantly longer in group (C) (P-value 0.001), Total procedural duration also varied significantly between the three groups, group (B) being the shortest while group (C) was the longest (P-value less than 0.001). Technically; group (A) used only end to end arterial anastomosis as a standard technique, while group (B) used both end-to-end and end-to-side anastomoses as required per each case. End to side anastomosis in group (B) yielded better immediate graft response in the form of change in colour , texture, earlier and more profuse postoperative urine volumes (P-value 0.025). Furthermore, anastomosis to common and external iliac arteries (group B) yielded earlier and higher urine volumes than the internal iliac artery (P-values 0.024 and 0.031 respectively). Group (B) recorded significantly less postoperative peri-graft hematomas and lymphoceles compared to the other two groups. Equal rates of urine leaks, ICU stay, creatinine levels, patient and grafts survival rates among groups (A) and (B), while post-operative recovery and ICU stay duration were more lengthy in the complicated group (C).ConclusionA vascular surgeon operating in a transplantation team would deal comfortably and efficiently with various vascular related challenges and complications, thus avoiding unnecessary time waste, complications and costs.

Blunt trauma of the brachial artery (BA) in pediatric age is often associated with neurological and orthopaedic injuries. Acute ischemic hands warrant immediate exploration, but the management of warm-pulseless hands following elbow trauma is controversial. This study evaluates the role of conservative treatment of blunt BA injuries in children with non-threatened hands. Eleven children with blunt trauma onto the BA having warm-pulseless hands were studied retrospectively. After a mean follow-up period of 2.5 ± 0.9 years, all cases had thorough clinical examination and duplex scan to assess the treatment outcomes. At the end of follow-up period, all subjects had well-perfused hands with intact wrist pulses. The duplex scan revealed those who had interposition grafts to be patent and one case had an aneurysmal dilatation. There was no statistical significance difference between affected and healthy forearms regarding the mean peak systolic velocity at the wrist, affected side was 62 ± 0.82 cm/s versus 68 ± 0.57 cm/s for opposite side ( p -value = 0.14). Patients with blunt BA trauma and warm-pulseless hands could be managed safely with conservative treatment, leaving surgical exploration for those who did not regain pulses after 48 hours. Duplex ultrasound can safely verify the patency of surgical repair and can be used for surveillance to detect future complications.

Objective Investigating the early results of percutaneous transluminal angioplasty of chronic lower-limb ischemia in patients with chronic renal failure. Background The concern that endovascular treatment of chronic lower-limb ischemia in patients with chronic renal failure is gaining popularity nowadays since the increase in morbidity and mortality rates in bypass surgery makes the procedure difficult for these patients. Patients and methods In total, 40 limbs in 40 consecutive patients (28 male, mean +/- SD age 59.65 +/- 8.54) were analyzed, 28 with lesion, either gangrene or ulcer, and 12 with rest pain. The follow-up of healing and foot vascularity was done at regular periods and up to 1 year as ABI was not a good indicator for follow-up because of the high false results due to severe calcification. Results After 12 months, the end results of the study are as the following: 10 (25%) cases were relieved from rest pain, another 12 (30%) cases had healed lesion, and three (7.5%) cases had major amputation, 11 (27.5%) cases had return of the same complaint as preoperative by the end of 12 months. Conclusion Despite improvement in endovascular techniques and their increasing utilization for lower-extremity revascularization, peripheral revascularization in chronic renal-failure patients has not led to high limb-salvage rate. Poor outcomes may be related to the severity of ischemia on presentation, the cumulative burden of the atherosclerotic disease, and the distal location of the disease.

Background: We aimed to study variables affecting limb outcome following ligation of infected femoral pseudoaneurysms in intravenous drug abusers (IVDA)in the emergency setting and to propose an algorithm for management. Design: Prospective study. Methods: We studied short-term outcomes of 26 IVDA presenting with infected femoral pseudoaneurysms who underwent arterial ligation, hematoma evacuation, and debridement. Long-term results pertaining to limb functionality were unfeasible, as all patients were lost to follow-up. We aimed to study the potential predictors that might impact limb outcome in the emergency setting, namely: 1) mode of presentation (impending versus ruptured), 2) site of arterial ligation (above versus below inguinal ligament), 3) presence or absence of pedal Doppler flow post-ligation, and 4) ankle brachial pressure index (ABI) pre- and post-ligation. Results: Arterial ligation without revascularization was done in 19 (73.1%) of our patients, requiring no further intervention for limb salvage during their hospital stay. Four patients (15.4%) required iliopopliteal bypass, and 3 patients (11.5%) required major amputations (2 hip disarticulations and one above-knee amputation). In total, 23 limbs (88.5%) were salvaged. Proximal arterial ligation was done below the inguinal ligament (common femoral artery) in 21 patients (80.8%), while in the remaining 5 patients (19.2%), higher ligation was done above the inguinal ligament (external iliac artery). All 19 patients who were compensated had pedal Doppler flow post-ligation, and 18 of them had arterial ligation done below the inguinal ligament. The mean preoperative ABI (+/- SD) was 0.87 +/- 0.34, and the mean postoperative ABI (+/- SD) was 0.37 +/- 0.27. The mean change in ABI (+/- SD) was 0.50 +/- 0.32. Conclusions: Arterial ligation with local debridement alone is a safe procedure and would have salvaged 73.1% of limbs in this study. However, implementing a selective approach for postligation revascularization and our proposed algorithm increased limb salvage rate to 88.5%. The detection of pedal Doppler flow after ligation can stratify patients in whom urgent revascularization might not be required for limb salvage. Additionally, all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches.

Results: 417 consecutive reviews of IR Attendings' cases by their peers were performed in 163 consecutive patients over 18 months.94% of cases were reviewed by 2 or 3 IR Attendings.Each question was answered 99-100% of the time.Participation rate improved significantly over time, currently 3.2% over the last semester.Answers showed disagreement in 10% of cases (2% by a single reviewer, 8% by several reviewers).Most disagreements related to procedural technique (24% disagreements vs. 3-5% in other four questions).Although IR Peer alone is an imperfect tool to detect complications (it failed to find 89% of cases discussed at MandM), it could still capture many more (11%) adverse events than its alternative (i.e., not doing IR Peer: 1.7% adverse events found; p o 0.001).Conclusion: IR Peer is feasible, relevant, and easy to implement in a multi-physician IR practice.When used along with other QA processes, it might help detecting adverse events for MandM Conferences; the latter will require further confirmatory research.