The frozen elephant trunk (FET) is used to treat patients with arch and descending aortic diseases. This study evaluates the early clinical outcomes and postoperative aortic remodelling in patients with chronically dissected aorta who were treated with the FET procedure. A retrospective analysis of prospectively collected data from 23 patients who underwent aortic arch replacement with descending thoracic aorta stenting using a branched hybrid FET prosthesis at Southampton General Hospital between 2017 and 2022. All patients received Thoraflex™ prostheses. Patient characteristics, surgical outcomes, follow-up data, and postoperative aortic remodelling, including false lumen thrombosis and changes in aortic dimensions, were assessed using CT imaging. The mean age was 63.8 ± 12.1 years, 17(74

Abstract Aim Aortic graft infections (AGI) are rare with no global consensus for diagnosis and management, we report our experience of management and complex in situ reconstruction. Methods Retrospective cohort study of 49 patients who developed AGI following EVAR and open aortic intervention from January 2010 to December 2020. Results Primary intervention was open aortic repair in 40 (81.6%) patients (7 ruptured aneurysm (rAAA), 22 aneurysmal disease and 11 aortoiliac-occlusive disease). Nine (18.4%) patients had an EVAR (3 for rAAA). AGI was identified at a median of 18 months post primary intervention. All patients were commenced on long term antibiotics. 22 (45%) patients were unfit for explantation, 8 (16.3%) were on surveillance for low grade infection, while 15 (30.6%) had an explant and aortic graft in situ reconstruction, with 2 (13.3%) requiring interval aortic stent prior to explant. Femoral vein (53%) and bovine pericardium (20%) were most commonly used conduit. Post-operative 30 day mortality was 13.3% (2 patients). Survival post-explant was 69% and 65% at 2 years and 5 years respectively versus 43% and 29% in the non-operative group. Conclusion Infrarenal aortic graft in situ reconstruction is safe following AGI with a reasonable 5 year survival rate. Patient fitness assessment is pertinent due to high perioperative risk.

OBJECTIVE:The prevalence of peripheral artery disease (PAD) is on the rise due to an aging population. This study aimed to gain insight into the clinical role of infrared thermography (IRT) as a diagnostic method and prognostic tool for below-the-knee (BTK) PAD patients. MATERIALS AND METHODS:The study prospectively recruited 64 patients who received lower limb revascularization for symptomatic BTK PAD (ChiCTR2400083847). IRT was used to detect lower limb skin temperature. Locations on the lower extremity sampled with IRT were dorsal areas, plantar areas, and medial and lateral areas of the calves. RESULTS:One hundred twenty-eight limbs of 64 patients were divided into normal (n=35), mild (n=22), moderate (n=55), and severe (n=16) groups based on the ankle-brachial index (ABI) testing. Limbs in the moderate and severe groups showed an obvious decrease in surface temperature when compared to the normal baseline measurements, particularly in the dorsal areas (all p values <0.01). Further analysis revealed IRT increased the sensitivity of ABI from 75.8% (69/91) to 96.7% (88/91) in PAD diagnosis. In addition, our results showed maximum temperature variations (ΔTEMP) on treated limbs decreased significantly after endovascular treatment. Further analysis revealed showed a negative correlation between maximum ΔTEMP on treated limbs and walking distance. CONCLUSIONS:Our findings showed the use of IRT increased the diagnostic efficacy of ABI in BTK PAD patients. This noninvasive technique has the potential to be applied in PAD diagnosis, preoperative, and postoperative evaluation.Clinical ImpactAn ankle-brachial index (ABI) is the most commonly used diagnostic method for evaluating vascular disorders in the lower limb. The high prevalence of medial sclerosis, which can render arteries incompressible upon cuff inflation, may lead to falsely elevated ABI values (ABI>1.4) in patients with diabetes mellitus. Infrared thermography (IRT) is a novel potential diagnostic method that does not require physical contact. The use of IRT may increase the diagnostic efficacy of ABI in BTK PAD patients. This non-invasive technique has the potential to be applied in PAD diagnosis, preoperative, and postoperative evaluation.

Purpose: The aim of this study was to review the results of fenestrated stent-graft (Fenestrated Endovascular Aortic Repair [FEVAR]) implantation to treat patients with type IA endoleaks after prior infrarenal endovascular aortic repair (EVAR). Methods: A retrospective single-center analysis of prospectively collected data was conducted, including consecutive patients who underwent FEVAR to correct a type IA endoleak between November 2009 and April 2021. All devices were manufactured by Cook Medical (INC, Bloomington, Indiana). Demographic details, anatomical features, fenestrated stent-graft configuration, technical success, and major adverse events (MAEs) were recorded according to current SVS standards. The primary endpoint was freedom-from-significant aneurysm sac expansion (≥5 mm) and survival according to the Kaplan-Meier analysis. Secondary endpoints included 30-day outcomes, freedom-from-all-cause mortality, and aortic-related secondary interventions. Multivariate Cox regression was performed to identify factors associated with the study endpoints. Results: Overall, 47 patients (89% male, median age 80) were included. Median time from initial EVAR was 60 months [41-72]. Median pre-FEVAR maximal aneurysm diameter was 68mm [62-79]. Median fluoroscopy time and dose area product were, respectively, 49 min [36-63] and 66 Gy.cm 2 [38-101]. Technical success rate was 96% with no 30-day deaths reported. Two (4.3%) renal MAE occurred. Median follow-up was 22 months [12-36]. Two-year freedom-from-aneurysm sac expansion and aortic-related secondary intervention were 80% [66-96] and 69% [55-87], respectively. From the multivariate analysis, the configuration of the fenestrated device was not predictive of aneurysm sac expansion, whereas only the preoperative aneurysm maximal diameter was an independent predictor (hazard ratio [HR] [per 1 mm increment]=1.05 [1.01-1.10]; p=0.016) and was associated with a higher risk of aortic-related secondary intervention (HR [per 1 mm increment]=1.07 [1.02-1.12]; p=0.006). Other predictors of aortic-related secondary intervention were pre-existing type IB or III endoleak (HR=7.89 [1.39-44.8]; p=0.020) and aortic degeneration above the primary EVAR (HR=16.6 [1.88-147], p=0.011). Conclusion: Late type IA endoleak after EVAR can be treated safely with a fenestrated stent-graft; preoperative maximum aneurysm diameter is associated with an increased risk of later aneurysm sac growth. Close follow-up is mandatory in this subgroup of patients given the high reintervention rate. Clinical Impact Type IA endoleak following endovascular aneurysm repair (EVAR) can be treated using a fenestrated stent-graft (FEVAR). Treatment options include the addition of a fenestrated cuff alone or complete relining of the previous graft with either a 3-component device or a unibody bifurcated FEVAR. Regardless of the device configuration the treatment appears to be safe but remains associated with high rates of reintervention and aneurysm growth. Although no significant differences have been observed in long-term outcomes, a complete relining with a bifurcated FEVAR may be preferred as a first-line approach, as it offers the advantage of addressing occult associated Type III endoleaks and reducing the risk of component disconnection.

Background Standardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim of the Transfer of Thoracic Aortic Vascular Emergencies to Regional Specialist INstitutes Group study was to establish an interdisciplinary consensus on the interhospital transfer of patients with AAS to specialist high-volume aortic centres. Methods Consensus on the key aspects of interhospital transfer of patients with AAS was established using the Delphi method, in line with Conducting and Reporting of Delphi Studies guidelines. A national patient charity for aortic dissection was involved in the design of the Delphi study. Vascular and cardiothoracic surgeons, emergency physicians, interventional radiologists, cardiologists, intensivists and anaesthetists in the United Kingdom were invited to participate via their respective professional societies. Results Three consecutive rounds of an electronic Delphi survey were completed by 212, 101 and 58 respondents, respectively. Using predefined consensus criteria, 60 out of 117 (51%) statements from the survey were included in the consensus statement. The study concluded that patients can be taken directly to a specialist aortic centre if they have typical symptoms of AAS on the background of known aortic disease or previous aortic intervention. Accepted patients should be transferred in a category 2 ambulance (response time <18 min), ideally accompanied by transfer-trained personnel or Adult Critical Care Transfer Services. A clear plan should be agreed in case of a cardiac arrest occurring during the transfer. Patients should reach the aortic centre within 4 hours of the initial referral from their local hospital. Conclusions This consensus statement is the first set of national interdisciplinary recommendations on the interhospital transfer of patients with AAS. Its implementation is likely to contribute to safer and more standardised emergency referral pathways to regional high-volume specialist aortic units.

Background: Autologous saphenous vein is the preferred conduit for below-the-knee bypasses in patients with critical limb-threatening ischemia. Alternative graft must be considered for patients without (autologous saphenous vein). The aim of this article is to evaluate the mid-term performance of arterial allograft (AA) and venous allograft (VA) used as alternative conduits. Methods: This retrospective study included patients with critical limb-threatening ischemia, with or without a history of homolateral femoropopliteal bypass, and no autologous veins were available who underwent infrainguinal arterial reconstructions using VA or AA from 2008 to 2018. Patients undergoing revision operations for infected bypasses were excluded. Primary patency (PP), primary assisted patency, secondary patency, major amputation, and death from any cause were the endpoints. For each event, a set of analyses were performed. Results: Overall, 111 patients (63 VAs and 48 AAs) were included, with 108 having below-theknee bypass. The median follow-up time was 27.8 months (15.6-37.4). The difference in PP between the 2 allograft types was significant (P = 0.049), with 65.9% (43.7-81.0), 44.1% (24.2-62.3), and 44.1% (24.2-62.3) in the AA group, respectively, at 6, 12, and 18 months, whereas 55.6% (40.0-68.6), 46.0% (30.6-60.2), and 33.2% (18.2-49.0) in the VA group. The choice of an AA over a VA was an independent factor associated with patency (for PP: hazard ratio [HR] = 0.43 [0.24-0.75], P = 0.003); primary assisted patency: HR = 0.52 (0.30-0.89], P = 0.018; and secondary patency: HR = 0.49 (0.27-0.88), P = 0.016. The allograft type did not affect either the incidence of major amputation or death from any cause (respectively, HR = 1.20 [0.49-2.93], and 0.88 [0.37-2.14]). Conclusions: The nature of the allograft appears to influence the patency of infrainguinal reconstruction, but not the course of the disease. Performant alternative grafts answering infectious issues are needed.

BACKGROUND To evaluate results of the invasive repair in the management of acute aortic dissection (AoD) in France. METHODS Patients admitted to hospital with acute AoD from 2012 to 2018 were identified. Patient demographics, severity score at admission, treatment strategy and in-hospital mortality were described. For patients undergoing intervention, perioperative complications rate was reported. A secondary analysis evaluating patients' outcome as regards of the annual caseload per center was conducted. RESULTS Overall, 14,706 patients with acute AoD were identified (male 64%, mean age 67, median modified Elixhauser score 5). The overall incidence increased during the study period (from 3.8 in 2012 to 4.4/100,000 in 2018) associated with a North-South gradient (respectively 3.6 vs. 4.7/100,000) and a winter peak; 45.5% (N.=6697) of patients received medical treatment alone. Among those with invasive repair, 6276 (78.3%) were defined as type A AoD (TAAD), whereas type B AoD (TBAD) accounted for 1733 patients (21.7%), of whom 1632 (94%) had TEVAR and 101 (6%) had other arterial procedures; 30-day mortality was respectively 18.9% in TAAD and 9.5% for TBAD. In high-volume centers (i.e. >20 AoD/year), a lower 3-month mortality of 22.3% was noted compared to 31.4% in the low-volume centres (P<0.001); 47% of patients reported ≥1 early major complication. TEVAR exhibited less complication (P<0.001) compared to other arterial reconstructions in TBAD. CONCLUSIONS The incidence of acute AoD increased in France over the period of the study and was associated with stable postoperative early mortality. Early postoperative mortality is significantly reduced in high-volume centers.

Abstract OBJECTIVES Understanding morphology and how this relates to treatment strategy is critical for achieving remodelling in aortic dissection. A controllable and reproducible large animal model is required for investigating new therapeutic devices and interventions. METHODS Our experimental protocol involved the development of surgically created type B aortic dissection (TBAD) and endovascular reintervention-induced TBAD porcine models. The sample was randomly divided into 2 groups: 1 underwent a secondary tear creation (STC) procedure and the other underwent a false lumen extension (FLE) procedure. Anatomical features were observed at 1 and 3 months, and 2 animals in each group were euthanized at 3 months after the procedures. The aorta and main branches were harvested en bloc, cross-sectioned and prepared for histological examination. RESULTS All surgically created TBAD models were successfully generated, and no unintended complications occurred. The endovascular reintervention-induced TBAD model was successfully created in 11 of 12 animals, with 6 in the STC group and 5 in the FLE group. In the STC group, the intraoperative mean diameter of the new secondary tear was 7.23 mm, and a slight increase was observed at first 30 days (P = 0.0026). In the FLE group, the intraoperative new propagation length was (235.80 ± 84.94) mm. The FL propagation length at the 1-month follow-up was significantly longer than that measured intraoperatively (P = 0.0362). Histological evaluation demonstrated that the elastic fibres in the media layer of the aortic wall were disrupted and appeared to be significantly stretched on the adventitial side of the false lumen. CONCLUSIONS Our endovascular reintervention is a reliable, minimally invasive approach for producing specific TBAD models with different morphologies.

OBJECTIVES:The goal of this study was to describe the learning curve of an operator trained in an aortic centre during the first years of performing fenestrated/branched endovascular aortic repairs independently. METHODS:Patients electively treated with fenestrated/branched stent grafts from January 2013 to March 2020 were included retrospectively. Groups were defined according to the treating operator: experienced operator (group 1), early-career operator (group 2) or both during a 14-month surgical companionship period (group 3). The early-career operator's learning curve was assessed using a cumulative sum analysis. A composite criterion including technical failure, death and/or any major adverse event was evaluated in a logistic regression model. RESULTS:Overall, 437 patients (93% male; median 69 (63, 77) years old) were included (group 1: n = 240; group 2: n = 173; group 3: n = 24). There were significantly more extended thoraco-abdominal aneurysms (extent I, II, III and V) in group 1 compared to group 2 [n = 68 (28%) vs 19 (11%), P<0.001]. The technical success rate was 94% (P=0.874). The 30-day mortality and/or major adverse event rates in juxta-/pararenal aneurysms or extent IV thoraco-abdominal aneurysms were 8.1% in group 1 and 9.7% in group 2 (P = 0.612), whereas they were 10% (group 1) and 0 (group 2) for extended thoraco-abdominal aneurysms (P=0.339). The adjusted cumulative sum analysis highlighted satisfactory results from the beginning of the experience. The operator's experience was not predictive of the composite criterion [adjusted OR 0.77; 95% (0.42, 1.40); P=0.40]. CONCLUSIONS:This study demonstrated favourable outcomes in patients treated with a fenestrated/branched aortic stent graft performed by an early-career operator trained in a high-volume centre from the beginning of independent practice.

The purpose of this narrative review was to detail and discuss the underlying principles and benefits of preoperative interventions addressing risk factors for perioperative adverse events in open aortic surgery (OAS). The term “complex aortic disease” encompasses juxta/pararenal aortic and thoraco-abdominal aneurysms, chronic aortic dissection and occlusive aorto-iliac pathology. Although endovascular surgery has been increasingly favored, OAS remains a durable option, but by necessity involves extensive surgical approaches and aortic cross-clamping and requires a trained multidisciplinary team. The physiological stress of OAS in a fragile and comorbid patient group mandates thoughtful preoperative risk assessment and the implementation of measures dedicated to improving outcomes. Cardiac and pulmonary complications are one of the most frequent adverse events following major OAS and their incidences are correlated to the patient’s functional status and previous comorbidities. Prehabilitation should be considered in patients with risk factors for pulmonary complications including advanced age, previous chronic obstructive pulmonary disease, and congestive heart failure with the aid of pulmonary function tests. It should also be combined with other measures to improve postoperative course and be included in the more general concept of enhanced recovery after surgery (ERAS). Although the current level of evidence regarding the effectiveness of ERAS in the setting of OAS remains low, an increasing body of literature has promoted its implementation in other specialties. Consequently, vascular teams should commit to improving the current evidence through studies to make ERAS the standard of care for OAS.

Objective: We evaluated whether a combination of intraoperative contrast-enhanced cone beam computed tomography (ceCBCT) and postoperative contrast-enhanced ultrasound (CEUS) after infrarenal endovascular abdominal aortic aneurysm repair (EVAR) could reduce late stent graft-related complications and, consequently, reintervention. Methods: All consecutive patients who had received infrarenal bifurcated stent grafts in our hybrid room (IGS 730; GE Healthcare, Ile-de-France, France) during two discrete periods were included in the present study. From November 2012 to September 2013, two-dimensional completion angiography was performed after each EVAR, followed by computed tomography angiography (CTA) before discharge (group 1). From October 2013 to January 2015, intraoperative ceCBCT was performed, followed by CEUS within the first postoperative days (group 2). Comparative analyses of the outcomes were performed. The primary endpoint was late stent graft-related complications, a composite factor incorporating aneurysm-related death, type I or III endoleaks, kink or occlusion of the iliac limb, and aortic sac enlargement after the first 30 postoperative days. The secondary endpoint was all stent graft-related reinterventions. All-cause and aneurysm-related deaths were also recorded. Results: Overall, 100 consecutive patients (50 each in groups 1 and 2) were enrolled, with a median follow-up of 60 months (interquartile range, 41-69 months). At 60 months after the index procedure, the freedom from late stent graft-related complications in each group was 61.6% (95% confidence interval [CI], 47.0%-80.6%) for group 1 and 81.7% (95% CI, 70.1%-95.2%) for group 2 (P = .033). The use of intraoperative ceCBCT was independently associated with a reduced rate of late stent graft-related complications on multivariate analysis (hazard ratio, 0.39; 95% CI, 0.16-0.95; P = .038) but did not appear to significantly protect against stent graft-related reinterventions (hazard ratio, 0.53; 95% CI, 0.20-1.39; P = .198) or all-cause death (P = .47). Conclusions: To the best of our knowledge, the present study is the first to report the influence of routine ceCBCT on late outcomes after EVAR. The use of ceCBCT shows the potential for reducing late stent graft-related complications associated.

Objective: In the present study, we reviewed the results of secondary iliac branch device (IBD) implantation for patients with a type Ib endoleak after prior fenestrated and/or branched (F/B) or infrarenal endovascular aortic aneurysm repair (EVAR) using either brachial access or an "up-and-over" transfemoral technique. Methods: We performed a retrospective, single-center analysis between January 2016 and October 2021 of consecutive patients who had undergone IBD to correct a type Ib endoleak after prior EVAR or F/B-EVAR. The groups were defined by arterial access, which was either brachial (group 1) or transfemoral (group 2). All implanted IBDs had been manufactured by Cook Medical, Inc (Bloomington, IN). The demographics, anatomic features, technical success, and 30-day major adverse events were recorded in accordance with the current Society for Vascular Surgery standards. The survival curves using the Kaplan-Meier method were calculated. Branch instability was a composite end point of any internal iliac artery (IIA) branch-related complication or reintervention indicated to treat endoleak, kink, disconnection, stenosis, occlusion, or rupture. Results: Overall, 28 patients (93% male; median age, 74 years), who had received 32 IBDs, were included, with 14 patients in each group. The prior endovascular aortic repairs included 23 cases of EVAR and 5 cases of F/B-EVAR, with an interval from the initial repair of 58 months (interquartile range [IQR], 48-70 months). The median pre-IBD maximal aneurysm diameter was 63.5mm(IQR, 59.0-78.0 mm). The baseline characteristics were similar between the two groups, except for pulmonary status. All procedures were performed in a hybrid operative room. The median total operating time, fluoroscopy time, and dose area product was 120 minutes (IQR, 86-167 minutes), 23 minutes (IQR, 15-32 minutes), and 54 Gy(.)cm(2) (IQR, 40-62 Gy(.)cm(2)), respectively. The total operating time was shorter for group 2 ( P =.006). The technical success rate was 100%, and no early deaths occurred. One 30-day major adverse event, medically treated colonic ischemia, had occurred in one patient in group 2. Aortic-related secondary interventions had been required for seven patients (five in group 1 and two in group 2), including three cases of surgical explantation. The median follow-up was 31 months (IQR, 24-42 months) and 6 months (IQR, 3-10 months) for groups 1 and 2, respectively. For group 1, the 2-year freedom from aortic-related secondary intervention and IIA branch instability was 84.6% (IQR, 67.1%-100%) and 92.3% (IQR, 78.9%-100%), respectively. For group 2, the 6-month freedom from aortic-related secondary intervention and IIA branch instability was 87.5% (IQR, 67.3%-100%) and 91.7% (IQR, 77.3%-100%), respectively. Conclusions: The results from the present study have shown that secondary implantation of an IBD to correct a distal type I endoleak from a previous aortic stent graft is safe with a high technical success rate. The "up-and-over" technique can be considered an alternative to brachial access for patients with suitable anatomy.

Objective The aim of this study was to determine the association between fluoroquinolones (FQs) use, the risk of de novo aortic aneurysm or dissection (AAD), and the prognosis of patients with pre-existing AAD. Materials and methods We searched PubMed, EMBASE, CENTRAL, Scopus, and Web of Science on 31 March 2022. Observational studies that evaluated the association of FQs with AAD risk in the general population or FQs with the prognosis of patients with preexisting AAD and presented adjusted effect estimates were included. Two reviewers assessed study eligibility, extracted data, and assessed the risk of bias and certainty of evidence using GRADE. Results Of the 13 included studies, 11 focused on the association of FQs with de novo AAD incidence, and only one study investigated the association of FQs with the patient with AAD prognosis. FQ use was associated with an increased risk of de novo AAD within 30 days (RR: 1.42; 95% CI: 1.11–1.81; very low certainty) and 60 days (RR: 1.44; 95% CI: 1.26–1.64; low certainty). Specifically, the association was significant when compared with amoxicillin, azithromycin, doxycycline, or no antibiotic use. Furthermore, patients with preexisting AAD exposure to FQ had an increased risk of all-cause mortality (RR: 1.61; 95% CI: 1.50–1.73; moderate certainty) and aortic-specific mortality (RR: 1.80; 95% CI: 1.50–2.15; moderate certainty), compared to the non-exposed FQ group within a 60-day risk period. Conclusion FQs were associated with an increased incidence of AAD in the general population and a higher risk of adverse outcomes in patients with preexisting AAD. Nevertheless, the results may be affected by unmeasured confounding factors. This should be considered by physicians contemplating using FQs in patients with aortic dilation and those at high risk of AAD. Systematic Review Registration [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021230171].

Abstract Introduction A number of factors have reportedly been associated with venous leg ulceration (VLU) however many of these remain disputed. UK Biobank (UKB) is an electronic dataset that provides in-depth detail on the lives of its participants. The aim of this research is to utilise UKB to understand factors associated with VLU. Methods Participants in the UKB with historical or active venous ulceration were identified and an age, sex and comorbidity matched control group was formed. A multivariate logistic regression was used to explore factors associated with VLU with significant factors expressed through odds ratios (OR). Mortality was investigated using a Kaplan Meier plot and log-rank test. Data analysis was preformed using R Studio Version 1.2.5033 and Python 3.8.10. Results Factors associated with VLU included; male gender, older age, deprivation (OR 1.27), obesity (OR 1.40), current smoking (OR 1.21), immoderate alcohol intake (OR 1.32), previous deep vein thrombosis (OR 3.07), depression and loneliness (OR 1.21). Biochemical factors associated with VLU included low haemoglobin concentrations (OR 1.50), low circulating lymphocyte percentages (OR 1.57), raised glycated haemoglobin (HbA1c) (OR 2.92), raised c-reactive protein (OR 1.41), raised cystatin C (OR 1.11) and low Vitamin D levels (OR 1.52). At a median follow up of 11.5 years, the mortality in VLU participants was 28%; significantly higher than in controls (P < 0.001). Conclusion Participants with VLU are comorbid with poorer physical, social and psychological wellbeing.

Variations in pedal circulation in congenital talipes equinovarus (CTEV) are well documented. There is a reported risk of vascular injury to the posterior tibial artery (PTA) during operative procedures for CTEV, potentially leading to necrosis and amputation. The aim of this systematic review was to identify the most common anomalies in arterial pedal circulation in CTEV and to determine the relevance of these to clinical practice. The systematic review was registered on PROSPERO and was carried out according to Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines by two independent reviewers. Studies that examined pedal circulation in idiopathic CTEV were included. Articles that studied nonidiopathic CTEV and those not published in English were excluded. Data extracted included patient demographics, imaging modalities, and findings. A total of 14 articles satisfied the inclusion criteria, including 192 patients (279 clubfeet), aged 0–13.5 years, at various stages in their treatment. Imaging modalities included arteriography ( n = 5), duplex ultrasound ( n = 5), magnetic resonance angiography ( n = 2), and direct visualization intraoperatively ( n = 2). The dorsalis pedis was most frequently reported as absent (21.5%), and the anterior tibial artery (ATA) was most frequently reported as hypoplastic (18.3%). Where reported ( n = 36 feet), 61% of patients were noted to have a dominant supply from the PTA. The most common variation in pedal circulation in CTEV is diminished supply from ATA and dorsalis pedis, although there are documented anomalies in all of the vessels supplying the foot. We therefore recommend routine Doppler ultrasound imaging prior to operative intervention in CTEV.

Objective: To provide an updated estimate of the global prevalence of CVD and to comprehensively evaluate risk factors associated with this condition. Background: CVD is an important cause of morbidity internationally, but the global burden of this condition is poorly characterized. The burden of CVD must be better characterized to optimize service provision and permit workforce planning to care for patients with different stages of CVD. Methods: A systematic search in Ovid MEDLINE and Embase (1946-2019) identified 1271 articles. Full-text, English language articles reporting on the epidemiology of CVD in a general adult population were included. Data extraction was performed by 2 independent reviewers, in accordance with a preregistered protocol (PROSPERO: CRD42019153656). STATA and Review Manager were used for quantitative analysis. A crude, unadjusted pooled prevalence was calculated for each Clinical (C) stage in the Clinical, Etiologic, Anatomic, Pathophysiologic classification and across different geographical regions. Qualitative analysis was performed to evaluate associated risk factors in CVD. Results: Thirty-two articles across 6 continents were identified. Nineteen studies were included in the overall pooled prevalence for each Clinical (C) stage; pooled estimates were: CO s: 9%, Cl: 26%, C2: 19%, C3: 8%, C4: 4%, C5: 1%, C6: 0.42%. The prevalence of C2 disease was highest in Western Europe and lowest in the Middle East and Africa. Commonly reported risk factors for CVD included: female sex (OR 2.26, 95% confidence intervals 2.16-2.36, P < 0.001), increasing age, obesity, prolonged standing, positive family history, parity, and Caucasian ethnicity. There was significant heterogeneity across the included studies. Conclusions: CVD affects a significant proportion of the population globally; however, there is significant heterogeneity in existing epidemiological studies.

OBJECTIVE:Proximal type 1 endoleak after endovascular abdominal aortic aneurysmal repair (EVAR) remains challenging to solve with no existing consensus. This work aims to compare two different surgical strategies to remedy type IA endoleak: endograft explantation (EXP) and aortic reconstruction or relining by custom made fenestrated EVAR (F-EVAR). METHODS:A retrospective single centre analysis between 2009 and 2018 was conducted including patients treated for type IA endoleak after EVAR with either EXP or F-EVAR. The choice of surgical technique was based on morphological factors (F-EVAR eligibility), sac growth rate, emergency presentation and/or patient symptoms. Technical success, morbidity, secondary interventions, 30 day mortality, and long term survival according to Kaplan-Meier were determined for each group and compared. RESULTS:Fifty-nine patients (91% male, mean age 79 years) underwent either EXP (n = 26) or F-EVAR (n = 33) during the study period. The two groups were equivalent in terms of comorbidity and age at the time of procedure. The median time from initial EVAR was 60.4 months (34-85 months), with no difference between groups. The maximum aneurysm diameter was greater in the EXP group compared with the F-EVAR group, 86 mm (65-100) and 70 mm (60-80), respectively (p = .008). Thirty day secondary intervention (EXP: 11.5% vs. F-EVAR: 9.1%) and mortality (EXP: 3.8% vs. F-EVAR: 3.3%) rates did not differ between groups, while major adverse events at 30 days, defined by the current SVS guidelines, were lower in the F-EVAR group (2.4% vs. 13.6%; p = .016). One year survival rates were similar between the groups (EXP: 84.0% vs. F-EVAR: 86.6%). CONCLUSION:Open explantation and endovascular management with a fenestrated device for type IA endoleak after EVAR can be achieved in high volume centres with satisfactory results. F-EVAR is associated with decreased early morbidity. Open explantation is a relevant option because of acceptable outcomes and the limited applicability of F-EVAR.

Objectives A short-stay endovascular aneurysm repair (SS-EVAR) pathway for infrarenal abdominal aortic aneurysms offers the potential to improve service efficiency and patient satisfaction by reducing the hospital length of stay. This study aimed to determine whether the implementation of a novel set of patient selection criteria for a theoretical SS-EVAR pathway could facilitate an expansion of the proportion of suitable patients, whilst maintaining patient safety and limiting unplanned emergency readmissions. Methods Two SS-EVAR selection criteria (low and high risk) were generated based upon patient pre-operative comorbidities. The low risk criteria essentially selected fit and healthy individuals, whereas the high risk criteria included patients with a range of comorbidities that could still theoretically enable enrolment onto a SS-EVAR pathway. A retrospective analysis, whereby both criteria were applied to all elective EVARs recorded in the National Vascular Registry between 2013 and 2016 at a single tertiary vascular unit was performed. Rates and timings of postoperative complications, reinterventions and unplanned readmissions for patients meeting each criteria were assessed. Results In total, 188 patients were included (92% male, mean age 75.4 ± 7.2 years). Twenty-nine patients (15%) met the low risk criteria. Two (7%) of these experienced an inpatient complication which were both detected within 24 h of operation (including one who required reintervention), and no patients in this group had an unplanned readmission within 30 days. One-hundred and ten patients (59%) met our high risk criteria and 19 (17%) experienced an inpatient complication, with 4 (4%) of these occurring beyond 24 h post-EVAR (three urinary problems and one acute on chronic kidney injury). Six (6%) of these patients required a reintervention; however, all of these complications were detected within 24 h. Two (2%) high risk cohort patients required unplanned readmission within 30 days for a femoral pseudoaneurysm and musculoskeletal back pain. Conclusions With high risk patient selection criteria and appropriate post-operative safeguards, up to 60% of infrarenal abdominal aortic aneurysms patients could be safely enrolled onto a next-day discharge SS-EVAR pathway with minimal readmissions, thus allowing more effective resource utilisation.

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.