Introduction Despite strong recommendations by the National Kidney Foundation (NKF) for the creation of radiocephalic arteriovenous fistula (RC AVF), most volume centres are reluctant due to contradictory complication rates and sustained patency. Factors influencing outcomes warrant attention, emphasising the importance of tailored approaches. Multicentre studies are recommended for broader validation of these findings. Therefore, the current study aimed to evaluate the outcome of RC AVF in our setup and to identify factors that influence its outcome. Method The prospective observational study was conducted at the Department of Vascular Surgery, Combined Military Hospital Lahore, over a year (October 2022-September 2023), and included 315 patients with RC AVF. Data were collected for demographic variables, comorbidities and fistula patency. The patients were further categorised into three subgroups on the basis of the location of RC AVF: snuff box, distal at the wrist, and proximal in the forearm. Follow-up evaluations were performed at one, six, and 12 weeks postoperatively. Statistical analysis was conducted using SPSS (IBM SPSS Statistics for Windows, IBM Corp., Version 22, Armonk, NY). The result shows that there was male predominance (75.2%). Results The mean age was 51.71 ± 14.94 years. Diabetes mellitus (40.6%) and hypertension (36.8%) were the most prevalent comorbidities. Distal radiocephalic arteriovenous fistula (DRC AVF) at the wrist was the most common access type (47.3%). Complications occurred in 9.2% of patients. Primary patency rates were 98.7% at one week, 92.1% at six weeks, and 90.5% at 12 weeks. Conclusion Radiocephalic fistula demonstrates favourable outcomes in our high-volume centre, with low complication rates and sustained patency. Factors influencing outcomes warrant attention, emphasising the importance of tailored approaches. Multicentre studies are recommended for broader validation of these findings.

Objective: To evaluate the spectrum of varicose veins and superficial venous reflux among candidates who were being evaluated for medical fitness. Study Design: Cross sectional study. Place and Duration of Study: Department of Vascular Surgery Combined Militay Hospital, Lahore Pakistan, from Jun to Sep 2021. Methodology: One hundred and one males underwent assessment of lower limbs varicose veins as a part of medical examination for recruitment. Along with demographic assessment, they were examined for varicose veins followed by hand held Doppler and ultrasound Doppler assessment for varicosities and reflux at sapheno femoral and sapheno popliteal junction. Reflux more than 0.5 seconds was considered noteworthy. Results: A total of 101 male candidates were included in the our study. The mean age of candidates was 19.9+1.75 years. The majority of patient were with C2 disease according to Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification 61(66.3%). Reflux at sapheno femoral junction detected by duplex scan was seen in 15(14.85%) of the candidates out of which 11(10.89%) had C2 disease. Chi-square test yielded a statistically significant relationship between the distribution of varicose vein along the length of saphenous vein and the grade of varicose vein according to CEAP classification (p<0.001). Conclusion: There was a statistically significant relationship between the size of varicosity according to CEAP classification and saphenofemoral junction competency, and the distribution of varicose veins along the length of the saphenous vein with the grade of varicose vein according to CEAP classification.

Objective: To assess the patterns and severity of peripheral vascular diseases (PVD) in a Pakistani population, using CT angiography. Study Design: Prospective longitudinal study. Place and Duration of Study: Department of Vascular Surgery, Combined Military Hospital, Rawalpindi Pakistan, from Aug to Dec 2023. Methodology: A total of 81 adult patients with clinically suspected lower limb PVD were included. Participants underwent a first routine clinical assessment, arterial Doppler, and then lower limb CTA if required to confirm the diagnosis. Patient characteristics, including demographic data and co-morbid conditions, were recorded. The arterial tree was divided into aorto-illiac, femoro-popliteal, and infra-popliteal segments, and the lesions were graded using the TASC-II classification. Results: The study included 62 males (76.5%) and 19 females (23.5%), with a mean age of 62.91±8.99 years. Hypertension (66.7%), diabetes (59.3%), and ischemic heart disease (51.9%) were common comorbidities. Smoking was reported in 49.4% of patients. The most affected segments were the femoro-popliteal arteries (55.6%), followed by the aorto-illiac (45.7%) and the infra-popliteal arteries (34.6%). Multiple segment involvement was noted in 34.6% of cases. Circumferential calcification was observed in 67.9% of patients. Diabetes was significantly less associated with infra-popliteal disease (p=0.035). Conclusion: There is a significant burden of PVD in the Pakistani population, particularly among males and individuals with comorbid conditions such as hypertension, diabetes, and ischemic heart disease. There is a predominance of femoro-popliteal involvement and an advanced nature of atherosclerosis, indicated by prevalent calcification and prevalent type D TASC II disease pattern in different arterial regions.

Objectives:to evaluate the potential of CT angiography in defining the severity of aorto-iliac and peripheral arterial disease and to quantify the percentage of correct findings in anticipating clinically relevant stenosis. Study Design: A Cross sectional study Place and Duration of the Study: General and vascular surgeon DHQ Hospital Batkhela and duration of the study was six months from jan 2024 to june 2024 Methodology: 50 patients suspected of having aorto-iliac and peripheral arterial diseases retrospectively. The results of diagnostic evaluation were compared against standard digital subtraction angiography as a gold standard. The degree of stenosis, the type of plaque and presence and grade of collaterals were measured in this study. To each variable, a test of significance was made using p-value; measure of variance was assessed using standard deviation (SD). Furthermore patients who underwent previous vascular interventional treatment were also excluded from the study. Results: Of 50 patients, 38 (76% of cases) were found to have clinically relevant stenosis (> 50%) by the use of CT angiography. There was a relative symmetry of the lesion:48 ‘Right’ (SD ±10); 49 ‘Left’. Collateral formation was confirmed in the present study in 22 patients (44%). CTA stenosis measurement yielded 90% sensitivity for diagnosis when compared with conventional angiography; p < 0.01. The sensitivity and specificity of CTA were 92% and 87% respectively. Conclusions: CT angiography procedures are quick and safe and provide accurate sensitivity and specificity results in differentiating aorto-iliac and peripheral arterial diseases. Because it can show arterial lesions, and collateral vessels, it can assist in treatment planning and may decrease the need for interventional actions. Keywords: Aorto-iliac PAOD, peripheral arterial disease, computer tomography angiography, stenosis

Objective: In patients with symptomatic and asymptomatic carotid artery stenosis, this retrospective observational study compared the clinical outcomes and side effects of carotid endarterectomy (CEA) with carotid artery stenting (CAS). The study took patient-specific risk variables into account and concentrated on major adverse cardiovascular events (MACE), such as myocardial infarction (MI), stroke, readmission, and death. Material and Method: This was a retrospective observational study carried out at Vascular Surgery Department and Interventional Radiology department of two tertiary care hospitals in Rawalpindi, from Jan 2022 to March 2023. With a 30-day follow-up, 60 patients from two Pakistani tertiary care centres underwent either carotid end arterectomy and carotid artery stenting were included. Patient having asymptomatic and symptomatic carotid disease were selected for the procedure. The impact of risk factors on procedural success and development of major adverse cardiovascular events (MACE) was examined in the study. Data regarding 30-day postoperative parameters of the procedure were collected and evaluated. p< 0.05 is considered significant. Results: The majority of patients in our series were males 46(77%) compared to 14(23%) females in the study. There were no intraoperative mortalities in our patients. The mortality rate of CAS alone was 1(1.66%). Four patients developed complications. Three in CAS group and 1 in CEA group. Comorbidities were present in 46(77%). Conclusion: Compared to CEA, CAS is linked to a greater risk of stroke or mortality in patients with symptomatic carotid stenosis within 30 days of treatment. Patients' unique characteristics, age, comorbidities, and previous surgical experiences should guide the choice of treatment.

Objective: To explore the feasibility of assessment of operative skills of FCPS vascular surgery trainees based on video recordings of the surgical procedures with a view to introduce it in the curriculum. Methods: This qualitative study was carried out from 9th April 2021 - 15th July 2021 at Shifa Tameer e Millat University, Islamabad, Pakistan. It is a qualitative study based on constructivist grounded theory. Semi structured interviews of 16 participants, including five vascular surgical trainees, six vascular surgical consultants/supervisors/examiners, and five medical educationists were conducted, recorded and transcribed. Open and axial coding method was employed to identify recurring themes. Results: Six themes could be identified. (1) There was consensus among participants on deficiency in current assessment of surgical skills. (2) Most participants believed that this is a useful method, although four out of 16 participants believed that current methods were sufficient. (3) There was a unanimous opinion that its purpose should be initially formative assessment and later for summative assessment. (4) It was suggested that it is practical with logistic support; it can be made part of trainee's record to be reviewed later; maybe by independent observers. (5) Participants believed that the logistic issue in term of equipment and trained manpower will be a challenge in implementing this mode of assessment. Other barriers included medicolegal and ethical issue and acceptability by the stake holders. (6) Participants also suggested remedies for the barriers. Conclusion: Video review of surgical procedures can improve assessment of operative skills of trainees provided it is used as formative tool initially with a need to overcome logistics, medicolegal and cultural barriers.

Objective: to evaluate the knowledge and practice of diabetic patients in terms of the diabetic foot and correlate it with the severity of diabetic foot and limb loss. Study Design: Cross-sectional study Place and Duration of Study: Department of Vascular Surgery, Combined military hospital, Lahore Pakistan, from Jan 2020 to Jan 2021. Methodology: Data was recorded in terms of demographics, knowledge and practice of control of blood sugars and foot care of the patients. SINDBAD scoring was used to assess the severity of diabetic foot and compare it with their knowledge and practice and ultimately as an outcome of their limb salvage. Results: Most patients 171(88.6%) already had a diabetic foot ulcer. Hypertension alone 72(37.3%) was the most common comorbid condition. A large percentage of patients, 108(63%), ultimately ended up with a limb amputation. A higher age and longer duration of diabetes were associated with an adverse outcome of diabetic foot disease. According to the SINDBAD scoring, the assessment of the foot showed the majority 142(73.6%), had lost protective sensation, with the ulcer being greater than 1cm2 in a large number 147(76.2%) of feet. Conclusion: While steps are made for patient awareness related to diabetes and its complications, there is a need to address the decreased applicability of this knowledge by the patients, especially with regard to diabetic foot disease.

Artificial intelligence (AI) has taken the world by storm and has even been referred to as the “new electricity”. 1 It powers voice assistants like Apple’s Siri and Google’s Alexa to “understand” and respond to voice commands. Recom-mendation systems in Facebook, Netflix, YouTube, and other social media platforms also use AI algorithms. AI systems are machine and software systems designed to perform functions requiring human intelligence, like face recognition, understanding language, decisionmaking, etc. It analyses large amounts of data and selflearning. 2 One of the most interesting advancements in AI is the development and success of Large Language Models (LLM). These algorithms and software are trained to generate human-like language. Currently, the most popular amongst them is Chat GPT (Chat Generative Pre-trained Transformer), developed by Open AI©. While this was initially designed to have enhanced chat capabilities, it was quickly realized that it could do much more. It mesmerized young students, scholars, and researchers in various fields.

Objectives:To assess the quality of medical call writing in multiple tertiary care hospitals based on a variety of parameters.METHODS:The cross-sectional study was conducted in 8 tertiary care hospitals across Pakistan from May 27 to June 27, 2021, and comprised residents and consultants aged 25-60 years regardless of gender and specialty. Data was collected using questionnaires related to demographic and professional characteristics, quality of calls received, quality of calls sent, and opinion regarding improvements to the existing system. Data ws analysed using SPSS 22.RESULTS:Of the105 participants, 65(62%) were residents and 40(38%) were consultants. General surgery team received referrals most frequently 26(24.7%). History of the patient along with relevant examination findings were mentioned in 4(3%) and 6(5%), respectively (p=0.6 vs p=0.5). The timeline was mentioned by 10(9.5%), (p=0.09), and it was inconsistent with the clinical relevancy in 13(12.3%) cases (p=0.5). The working diagnosis for which the patient was admitted in a particular service was mentioned in 35(33.3%) of the generated calls (p=0.01).CONCLUSIONS:The call referral system deserved more attention in order to improve communication among the physicians. Analysis of the quality of referral letters should be part of initial and continuing medical education.

Objective : To assess the outcomes in managing patients with chronic kidney disease (CKD) requiring vascular access before and after, a formal vascular surgery fellowship program (VSFP) was introduced in a tertiary care hospital in Punjab. Study Design : Pilot quasi-experimental study. Place and Duration of Study: Department of Vascular Surgery and Nephrology at Combined Military Hospital (CMH) ,Lahore Pakistan, from Feb to Oct 2020. Methodology: Patients meeting the inclusion criteria of ages between 20 to 70 years, either gender and undergoing dialysis due to chronic renal failure were recruited in the study. Data was collected at the initial phase when a VSFP was absent and later when it was present. Outcome variables were current dialysis access, waiting time for permanent dialysis access and failure rate about the duration of chronic renal failure. Results: A total of 226 patients were recruited in the study. In both pre-vascular surgery fellowship program time (pre-VSFPT) and post-vascular surgery fellowship program time (post-VSFPT), the predominant functional dialysis access at the time of the interview was arterio-venous fistula (AVF). However, they were much higher in the post-VSFPT, i.e., 46(54.1%) as compared to 96 (68.1%) (p= 0.069). In addition, in pre-VSFPT, 24 (28.2%) patients had a “Never Created” AVF status at the time of the interview as compared to 21(14.9%) in post-VSFPT, which was statistically significant. Conclusion: The establishment of a fellowship program not only benefits the trainee but it improves patient care significantly. This study highlights the improvement in all the benchmarks of the formation

This study was conducted at the Department of Vascular Surgery at Combined Military Hospital Lahore from December 2019to June 2020. The mortality of patients on the waiting list for vascular access in our institution three months afterimplementing strict policies for elective surgeries (30th March 2020 to 29th June 2020) was compared with the preceding threemonths. The mortality of patients in the pre-COVID-19 periods on the waiting list for HD was 11 (7.9%) in the pre-COVID-19 period, while this increased to 5 (12.5%) in the post-COVID-19 period. COVID-19 related suspension of vascular access services negatively influences CKD patients waiting for permanent vascular access.

OBJECTIVE The aim of the study was to measure the relationship between the type of vascular access and HRQOL in patients undergoing dialysis in a tertiary care hospital STUDY DESIGN Cross-sectional study PLACE AND DURATION OF STUDY Department of Vascular Surgery and Nephrology from January 2021 till June 2021 PATIENTS AND METHODS Data was collected by dialysis center nurse and duty doctors on patients meeting the inclusion criteria . It was a short form survey 36 ( SF -36 ) questionnaire which included health related quality if life in terms of physical symptoms, social functions and access related complications in last 4 weeks on a score of 0 to 3 .Higher scores means poorer quality of life. RESULTS A total of 80 patients were recruited in the study. A total of 80 patients participated in the study. Male predominance was observed ( n = 59, 73.8 % ). Mean age was 53 +/− 13.9 . 2. Mean HRQOL score in AVF 3.8 +/− 4.8 which was the lowest followed by tunnelled dialysis catheter ( TDC) 9.7 +/−4.5 and non tunnelled double lumen catheter( NTDC ) 11.8 +/−9.1 . CONCLUSION The HRQOL assessment in ESRD patients can inform the medical personnel of the effectiveness of treatment interventions, it also plays an important role in improving patient's care, assessing patient's needs, setting treatment goals and monitoring disease progression.

Aim: To evaluate the pattern of surgical emergencies and surgical care provided during COIVD 19 pandemic. Study design: Cross-sectional Study Place and duration of study: Department of Surgery, CMH, Lahore from 15th March - 15 June 2020. Methodology: Data was collected retrospectively, of all the patients who were admitted in department of surgery over the duration of 3 months. Demographic variables, diagnosis, work up related to COVID-19, specialty of admission and surgical vs conservative management was recorded. Results: A total of 312 patients were included. Majority were male 216(69.2%). Most of the patients 191(61.2%) were admitted via clinic, predominantly in month of May 148(41%). COVID-19 PCR was done on 210 patients (67.3%), chest x-ray was done on 271(87.9%), HRCT chest was done on 113 patients (29.20%). Although general surgery was the busiest service line with a total patient admission of 89(43.1%), Orthopedic surgery top the operative interventions list with 85.1% of admissions underwent operative management. Conclusion: The current local guidelines about patient flow and management of patients in COVID crisis are practical and can be implemented. In the wake of the later waves of COVID 19 hospitals should prepare to divert their resources to high volume specialties like General and orthopedic surgery. Simple, but important procedures like arteriovenous fistula creation should only be stopped it there is shortage of manpower. MeSH words: Audit, COVID- 19, General Surgery, Pakistan, Vascular Surgery

Objective: to determine the outcome of arteriovenous fistula in the elderly compared to the younger age group and its association with mortality so that the best approach to hemodialysis access can be defined. Study Design: Prospective longitudinal study Place and Duration of Study: Department of Vascular Surgery, CMH, Lahore Pakistan, from Jan 2020 to Aug 2021. Methodology: All the Patients who presented to access the Surgical Clinic were categorized into three groups according to their age. Outcome variables like fistula maturation, complications and mortality were compared according to age groups. Result: A total of 184 patients were recruited. We found that in the age group >70 years, there was male predominance (12, 54.5%), three-quarters of them were on hemodialysis at the time of access surgery, only half of them were functional at one year of follow-up, and 6 (27.3%) were not alive at the time of contact. In addition, the pseudo aneurysm was the most common complication in this group, which was the most dreadful of all access-related complications and further put the already frail at risk. Conclusion: No single optimal approach can be expected to meet the needs of all, and an extensive patient-centred case-based discussion is required for each patient in the hope that optimal dialysis access can be created. Age cannot be defined as an independent risk factor for access creation.

Objective: to analyze the outcomes of arteriovenous fistula (AVF) constructed in our setup. Study Design: Retrospective observational study. Place and Duration of Study: Combined Military Hospital, Lahore, from Mar 2019 to Mar 2020. Methodology: Our study included all the patients who had their arteriovenous fistula (AVF) made during the study period. Data was collected via telephone calls, to inquire about the status of AV fistula after one year of AV fistula construction surgery. Results: Out of 130 study participants, 97 were successfully contacted. Mean age of patients was 54 .39 ± 12.75 years. Majority were male patients (71.1%) and had their first dialysis via temporary dialysis access catheter. Most of the patients (74.7%) had functional AVF. 35 (36.1%) patients were not alive at the time of contact. In 9 (9.2%) patients, AV fistula failed with the most common cause being thrombosis (77.7%). Conclusion: Current study is one of the pioneer in Pakistan where we have started to audit our performance as the dedicated access surgeons. It is high time for us to evaluate our performance so that better outcome can be offered to the dialysis dependent patients.

Aim: To assess the compliance and difficulties faced by health care providers with variants of mask, eye protection and face shields. Methodology: This cross sectional study took place from 2nd April 2020 till 30th April 2020. All participants meeting inclusion criteria filled online questionnaire regarding type of mask, eye protection and face shields they use in their outpatient clinics, ward rounds and while performing surgical procedures, which is their favorite feature of these, which of the characteristic of particular equipment, how often they readjust the mask and how long do they wear it daily on an average. Results: A total of 196 participants were recruited in the study. The frequency of mask readjustment was most frequent by house officers 35(48.6%). Five (10.4%) of the consultants and 1(1.7%) of the medical students do not wear mask at all. In present study, the highest compliance was with N95 mask with filter 68(33.6%) 31(14.8%) wear goggles, 33(16.3%) wear face shield. The most comfortable characteristic of mask was chosen to be elastic ear loops 72(36.5%) voted by most of the house officers 27(37.5%) in which 40% wear it daily for 8 to 2 hours straight. Goggles leads to troublesome fogging interfering to an extent of limiting their performance and efficacy p <0.001. Luckily, 9(0.4%) came out to be positive in our research (p 0.47). Conclusion: The choice of PPE should be based on the nature of interactions with patients and the modes of transmission but sadly it is seen to be much impacted by the discomfort faced by our front line worriers while wearing it that will adversely affect themselves the most.

Objective: To assess the knowledge, attitude and practices (KAP) of Pakistani doctors in the early period of COVID-19 Pandemic. Methodology: This KAP survey was conducted from 29th March to 6th April 2020. The questionnaires were disseminated using Google Forms, which utilized electronic consent. Physicians and surgeons of frontline involved in the care of COVID-19 patients including house officers, postgraduate trainees of all specialties, and consultants were included in study. Results: Out of 112 participants, 52.7% were female. Mean age was 29.93 +/- 7.3 years. There were 46 (41.3%) house officer. Twenty five (22.3%) participants were daily exposed to COVID-19. Residents who had maximum exposure on a daily basis, none had access of full personal protective equipment. Only 13.4% had correct knowledge about time of maximum disease transmission and 70% health care workers had greatest concern about their family's health. Conclusion: There was poor level of knowledge and worrisome practice and discrepancies in the perceptions about COVID-19 among our study participants.

Objective: This prospective, pilot randomized double-blind study aimed to compare the effects of buffered and non-buffered xylocaine solutions on injection pain and anesthesia effectiveness in patients undergoing arteriovenous fistula surgery. Material and methods: A total of 100 adult patients meeting inclusion criteria undergoing arteriovenous fistula surgery were included in the study. They were split into two groups at random. The control group received 1% xylocaine dissolved in 5 ml distilled water, while the intervention group received sodium bicarbonate mixed with 1% xylocaine solution as a local anesthetic. The patients were asked to rate the pain of first and subsequent injections on a visual analog scale (VAS). Besides, the need for extra analgesia was investigated. The mean and standard deviation of the data was determined. Results: During both the first and subsequent injections, the alkalinized local anesthetic group showed substantially lower VAS scores. In the alkalinized local anesthetic group, anesthesia satisfaction was also more than three times higher. Furthermore, the non-alkalinized group's mean analgesic requirement was higher than the intervention group. Conclusion: Our findings support the effectiveness of the alkalinized local anesthetic solution in minimizing injection pain and increasing anesthesia duration and overall patient's surgical experience in terms of anesthesia satisfaction score.

Introduction: Since the outbreak of the Ebola virus, its design has constantly been evolving to serve the purpose of protection without hampering the efficiency. In a study conducted in 2019, before the advent of COVID 19, it was found that performing precarious laboratory or clinical works while wearing PPE involved various restrictions compared to the same work without PPE. The objective of this study is to identify the influence of personal protective equipment on physiological parameters and the individual wellbeing of healthy workers. Methods: This Pilot Quasi-experimental study was performed on 12 volunteers fitting the inclusion criteria. Candidates were seated comfortably and their baseline resting pulse rate, respiratory rate, oxygen saturation via pulse oximeter, blood pressure, and End-tidal CO2 were recorded via a portable monitor. All candidates were asked to wear a KN95 mask along with a 3 ply mask over it and wear anti-fog goggles. All the above-mentioned parameters were recorded again after five minutes of comfortable sitting and ten minutes of brisk walk. Result: Significant difference is found between resting EtCO2 and after wearing of PPE (P = 0 .044). After a brief exercise, the further rise in EtCO2 is also significant (P = 0.002). There is no significant rise in pulse after wearing PPE (P = 0.092) but on exertion after wearing PPE, the rise in pulse is statistically significant (P = 0.002). The rest of the variables, such as the rise in respiratory rate, blood pressure, and fall in oxygen saturation rise has no statistical significance. Conclusion: Personal protective equipment has proven to rise in end-tidal carbon dioxide and tachycardia, which can lead to headache, dizziness, and respiratory discomfort. All of the factors can hamper the health care workers' performance and can adversely affect their efficiency. Keywords: covid-19, end tidal CO2, personal protective equipment, physiological

Objective: To analyze errors in primary treatment of vascular injuries and delayed presentations of missed vascular injuries as a surrogate indicator of need for improved vascular surgical training of upcoming general surgeons. Materials and methods: This retrospective observational study was carried out at vascular surgery department of two tertiary care hospitals of Armed Forces from Jan 2012 to June 2017. Hospital records of all patients with vascular trauma were analyzed for presence of pitfalls in primary treatment and delayed presentation of missed vascular injuries which resulted in redo surgeries or adverse outcomes. Results: Out of 256 patients with vascular injury sequel 41 had either a problem in primary treatment or presented with delayed complications of missed injuries. The omissions can be divided into: missed injuries (24/41), technical errors in initial repair (12/24), reperfusion of mangled Extremity (3/41) and non availability of a surgeon capable of undertaking vascular repair. The commonest operative fault was failure to debride the vessel adequately and vascular repair under tension. The commonest primary assessment problem was failure to timely appreciate hard signs of vascular injury. Conclusion: With better training and emphasizing the need of thorough clinical examination outcome of vascular trauma can be improved.