Background: The lack of availability of test results in vascular surgery outpatient clinics impedes the medical management of vascular risk factors, such as dyslipidaemia and diabetes mellitus. This study sought to evaluate the feasibility of using computer-assisted processes to promote the ordering of routine investigations to promote this management. Method: After consultation with specialist clinicians, clinician-programmers developed a rule-based system to facilitate the ordering of lipid studies and HbA1c prior to vascular clinic appointments. A four-week historical control period prior to the initiation of the intervention was compared to a four-week period following the intervention. Results: There were 1165 patients in the study. In the pre-intervention period, 38.0% of patients had HbA1c and 17.9% had lipid studies in the preceding 6 months. In the post-intervention period, HbA1c and lipid studies were ordered for 100% of vascular outpatients (p < 0.001). Conclusions: The use of computer-assisted processes to facilitate the requesting of routine outpatient investigations is feasible and shows early signs of being effective. Follow-up studies examining clinical endpoints are required.

Dittman et al. provide a retrospective analysis of Vascular Quality Initiative (VQI) data for 337 patients with prior infrarenal aortic aneurysm repair who subsequently underwent intervention for a ruptured infrarenal aortic aneurysm. 1 Dittman JM, Murphy B, Dansey KD, French B, Karim M, Quiroga E, et al. An endovascular approach to abdominal aortic aneurysm rupture is associated with improved outcomes for patients with prior aortic repair. Eur J Vasc Endovasc Surg 2024 [epub ahead of print] [in this issue]. Google Scholar Importantly, they evaluated whether open surgical repair (OSR) or endovascular aneurysm repair (EVAR) had more favourable outcomes, as well as comparing this cohort with a larger group of patients who ruptured without prior aortic repair. Their study addressed patients who proceeded to surgery and did not account for patients who were turned down for operation, thus presenting a source of significant selection bias. An Endovascular Approach to Abdominal Aortic Aneurysm Rupture is Associated With Improved Outcomes for Patients With Prior Aortic RepairEuropean Journal of Vascular and Endovascular SurgeryPreviewTo assess whether outcomes of rupture repair differ by aortic repair history and determine the ideal approach for rupture repair in patients with previous aortic repair. Full-Text PDF

Background/Objective: Low muscle mass and sarcopenia have been explored as risk factors for poor outcomes following vascular surgery. The findings have been variable. The use of a diverse range of techniques to identify low muscle mass is a confounder in establishing the true relationship between low muscle mass, sarcopenia and outcomes. Our aim was to establish if different scoring methods identified the same patients as sarcopenic. We also explored which method best predicted outcomes. Method: 70 patients undergoing vascular surgery were prospectively assessed for sarcopenia using dual-energy x-ray absorptiometry (DEXA) scan, grip strength and gait speed. These patients underwent abdominal CT imaging as routine care. The muscle mass of each patient was determined using DEXA and by both psoas muscle and total skeletal muscle area on CT, normalised for patient height (PMI and CT-SMI, respectively). Low muscle mass was defined by published age- and sex-specific cut-offs. Grip strength data was combined with muscle mass to define sarcopenic patients. One- and 3-year mortality and time to readmission was recorded. Conclusion and Results: 10-22% of patients had low muscle mass and 4-10% of patients were sarcopenic, depending on the method employed. PMI did not correlate with DEXA or CT-SMI for low muscle mass, but CT-SMI correlated with DEXA (p = 0.0007). For sarcopenia, CT-SMI and DEXA scoring correlated (p = 0.002); PMI correlated with CT-SMI (p = 0.0006) but not DEXA. Low muscle mass by PMI predicted 1-year mortality (p = 0.02, X2 = 5.34, Effect size = 1.04) but the applicability of this finding is limited by the diverse pathologies explored. No other method predicted 1- or 3-year mortality or readmissions in this heterogenous cohort. The psoas area did not correlate with muscle mass defined by DEXA or total lumbar skeletal muscle area. Low psoas muscle index may be an independent marker of poor outcome, unrelated to generalised sarcopenia, and this warrants investigation in specific pathologies. A lower total number of patients were sarcopenic than had been expected, emphasising the need to use population-based pre-defined cut-offs.

Post-surgical complications following endovascular aneurysm repair (EVAR) remain a risk, arising from technical difficulties imposed by highly calcified or tortuous iliac arteries. Automated methods enable segmentation of the iliac artery to potentially better define perioperative risk prediction. This study uses imaging software to characterise segmental iliac artery anatomy and aims to establish if iliac artery abnormalities can predict adverse outcomes following EVAR. Pre-operative clinical information and CT angiograms were obtained from 189 patients who underwent elective EVAR. Patients were followed for up to 3 years to detect stent-related complications and mortality. Aneurysm morphology was manually measured on CT scans. Automated measurements of vessel shape, curvature and calcification were taken for multiple subdivisions of the common and external iliac arteries. Logistic regression models were trained to assess the influence of iliac artery and aneurysm morphology on outcomes. Combining iliac and aortic features improved predictions of both stent-related complications and morbidity over using either alone. Models predicting death and both early and late stent complications had respective areas under the curve (AUCs) of 0.761, 0.935 and 0.833. Iliac artery calcification and curvature were significant predictors of poor outcomes. Automated morphological assessment of the common and external iliac artery improves the prediction of complications following EVAR. The improved power of iliac morphology to predict late complications and death implies that regional abnormalities of the iliac arteries are important when assessing surgical risk. This allows further rationalisation of the selection of individuals for treatment and may improve patient outcomes.

Objectives Ankle brachial pressure index (ABPI) is an invaluable tool for assessing the severity of peripheral arterial disease. In addition, it can be used as an independent marker of cardiovascular risk, with a predictive ability similar to the Framingham criteria. Identification of an abnormal ABPI should therefore trigger aggressive cardiac risk factor modulation for a patient. Unfortunately, the significance of abnormal ABPIs is poorly understood within the general medical community. This is compounded by the influence of various comorbidities on accurate measurement of ABPI, potentially leading to a wide variability in readings that need to be considered before interpretation in these patient populations. We aim to address these issues by revealing several common misunderstandings and pitfalls in ABPI measurement, describing accurate methodology, and highlighting patient cohorts in whom additional or alternative approaches may be required. Methods We present a narrative review of the role of ABPI in both the community and hospital setting. We have performed a literature review, exploring the validity and reproducibility of methodology for obtaining ABPI, alongside the utility of ABPI in different clinical scenarios. Results The measurement of ABPI is often performed incorrectly. Common pitfalls include inadequate patient preparation, failure to obtain the blood pressure from the correct lower limb artery in patients with tibial disease, failure to account for differences in brachial blood pressure between the arms, inappropriately chosen equipment and patient factors such as highly calcified arteries. Standardisation of methodology greatly improves reliability of the test. Exercise ABPI can identify significant peripheral arterial disease in patients with normal resting ABPI. In addition to its role in peripheral arterial disease, ABPI measurement has a role in assessing venous ulcers, entrapment syndromes and injured extremities; conversely, it has a more limited utility in the diabetic population. Conclusions A thorough understanding of the correct technique and associated limitations of ABPI measurement is essential in accurately generating and interpreting the data it provides. With this knowledge, the ABPI is an invaluable tool to help manage patients with peripheral arterial disease. Perhaps more importantly, ABPI can be used to identify and risk stratify patients with asymptomatic peripheral arterial disease, itself a major indicator of significant underlying cardiovascular disease. With the emergence of best medical therapy, targeted pharmacotherapy and lifestyle changes can reduce the risk of major cardiovascular events in high-risk patients by approximately 30%, particularly in diabetic patients. Therefore, the utility of ABPI transgresses vascular surgery, with an essential role in general practice and public health.

Objective: Preoperative sarcopenia is an established risk factor for poor outcomes after surgery. Methods for assessing sarcopenia are either complex, time consuming, or poorly validated. We aimed to assess the interobserver reliability of scoring psoas area at the level of the L3 vertebra and to evaluate whether sarcopenia scored by this simple and rapid method correlated with other fitness scoring methods or impacted on mortality and duration of stay for patients undergoing endovascular aneurysm repair (EVAR). Methods: We had access to 191 preoperative computed tomography scans of patients who underwent EVAR. For each scan the axial slice at the most caudal level of the L3 vertebra was extracted. Three observers independently calculated the combined cross-sectional area of the left and right psoas muscle at this level. Interobserver variability was calculated as per Band and Altman. Psoas area was normalized for patient height with sarcopenia defined as total psoas area of <500 mm(2)/m(2). The effect of sarcopenia on patient survival was assessed using Cox proportional hazards models. Kaplan-Meier curves are also presented. Results: Interobserver reliability of scoring psoas area was acceptable (reproducibility coefficient as percent of mean for each observer pair: 7.92%, 7.95%, and 14.33%). Sarcopenic patients had poorer survival (hazard ratio, 2.37; P = .011) and an increased hospital duration of stay (4.0 days vs 3.0 days; P = .008) when compared with nonsarcopenic patients. Sarcopenic patients were more likely to self-report as unfit (12.4% vs 33.3%; P = .004). Sarcopenia did not correlate with an increased rate of postprocedure complications. Conclusions: Psoas area scoring has good interobserver reliability. Preoperative sarcopenia as defined by psoas area was associated with poorer survival and of longer length of stay. As all patients being worked up for an endovascular aortic aneurysm repair will undergo a computed tomography scan, this method is a rapid and effective way to highlight patients in the clinic setting who have an increased risk of morbidity and mortality after EVAR.

Journal Vascular Surgery VS001 CURRENT CONCEPTS IN CLASSIFICATION OF DIABETIC FOOT ULCERATION

To compare a novel cooling product, Physicool (P, Physicool Ltd, London, England, UK) with a well-established cryotherapy system, Cryocuff (C, Aircast, DJO Global, Vista, California, USA) using pain scores, range of movement (ROM), and cost as outcome measures in the early phase following total knee arthroplasty. We prospectively studied 90 consecutive patients undergoing unilateral total knee arthroplasty by a single surgeon. Following exclusions, 40 patients were recruited to each group. Visual analogue scale (VAS) for pain and ROM before and after application of cooling device was recorded at 24 and 48 hours after surgery. The cost of treatment per patient was also calculated. The VAS were significantly reduced in P on day 1 postsurgery (p = 0.013) and day 2 (p = 0.001) compared to C. A significant increase in ROM was recorded in P at 24 hours (p = 0.004) and at 48 hours (p = 0.009) postsurgery compared to C. The cost benefit of using P over C was approximately £25 per patient. The Physicool system is a safe and effective cooling method for improving pain and ROM in the early postoperative phase following total knee arthroplasty. Furthermore, it offers substantial cost savings.

Background. Haemorrhage is responsible for about a third of in-hospital trauma deaths. The CRASH-2 trial demonstrated that early administration of tranexamic acid, ideally within 3 hours, can reduce mortality from trauma-associated bleeding by up to 32%.Objective. To explore whether, in our trauma network in a middle-income country, patients arrived at hospital soon enough after injury for tranexamic acid administration to be effective and safe.Methods. A prospective cohort study of 50 consecutive patients admitted to our trauma unit was undertaken. Inclusion criteria were as for the CRASH-2 study: systolic blood pressure <90 mmHg and/or heart rate >110 beats per minute, with injuries suggestive of a risk of haemorrhage. Patients with isolated head injuries were excluded. The mechanisms of injury, time since injury and any reasons for delay were recorded.Results. Thirteen (26%) patients presented early enough for tranexamic acid administration. Of these, only three patients presented within the 1st hour. Eleven patients had a documented time of injury >3 hours prior to presentation. We were unsure of the time of injury for 26 patients, although for most of these it was likely to be >3 hours before presentation.Conclusions. The majority (74%) of bleeding trauma patients did not present within the timeframe allowed for safe administration of tranexamic therapy. Of those who did, most would have benefited from even earlier commencement of therapy. This raises the possibility that tranexamic acid may be more effective on a population basis if incorporated into prehospital rather than in-hospital protocols; future studies should explore the benefits and risks of this approach.

Arterial tortuosity and calcification are both potentially linked to complications subsequent to endovascular aneurysm repair (EVAR). However, it is unclear whether these two factors are independent and if calcification is predictive of future complications. Hence, this study examined tortuosity and calcification in the context of predicting problems ≤30 days of EVAR. A previously published vessel-tracking algorithm was used to extract the iliac arteries from a preoperative computed tomography angiograms of patients who underwent EVAR. Maximal tortuosity on each side was computed at a scale of 10 mm. The algorithm was also used to identify the location and size of all calcified regions adjacent to vasculature. Probability distributions of tortuosity at all vessel locations and at the locations proximal calcifications were compared using the Kullbach-Liebler divergence. A scatter plot of number of calcifications sized >0.2 mL (calcification burden) vs the maximum tortuosity was generated. From an initial 71 patients, 15 were censored due to algorithmic failures. For the remaining 56 patients, the Kullbach-Liebler divergence between curvature at all locations and restricted to calcifications was 0.076, indicating that the two distributions were almost identical. Calcification burden and tortuosity did not appear to separate patients with and without early problems, although six of the 10 patients with early problems had a relatively high burden or high tortuosity, but not both. Calcifications does not appear to particularly favor regions of high or low tortuosity, and calcification is likely to be independent of tortuosity. A clear separation between patients with and without early problems could not be established. However, most patients with early problems had unusually high calcification or tortuosity, implying that together the two factors may be prognostic, although more data would be needed to confirm this.

Introduction Rosette-forming glioneuronal tumour of the fourth ventricle is a rarely described entity. While usually having an indolent course and hence classified as a WHO grade 1 tumour, the precise characteristics and risk of recurrence of this tumour are still unknown. In addition, the preferred treatment modality remains unclear.Discussion We present a case of an 8-year old with an early recurrence of 9 months after undergoing a sub-total resection of her tumour. Following further resection, there was no tumour present on the 3-month follow-up. In order to better characterise this tumour entity, we performed a review of the available literature on the subject. We found that it mainly affected young adults and had a female predominance. While initially these tumours were described in the fourth ventricle, the current literature suggests that they may be found in a larger variety of sites within the brain and spinal cord. There are several reports of recurrence occurring between 9 months and 10 years following surgery. There is as yet no feature of the tumour that appears to predict the risk of recurrence.Conclusion This phenomenon warrants further examination to discover if there is a sub-section of tumours that is likely to recur, and until this is established, all patients should be followed up at regular intervals.