Background Stent graft migration is a well-recognized complication of endovascular aneurysm repair (EVAR) that can predispose patients to type I endoleaks, renal artery compromise, and secondary interventions, particularly in cases with hostile neck anatomy, which poses a significant technical challenge for graft fixation. The GORE Excluder Conformable AAA Endoprosthesis (CLEVAR) is specifically designed to address these challenges by accommodating neck lengths as short as 10 mm, diameters down to 16 mm, and angulations up to 90°. This study aimed to evaluate the early stability and safety of the CLEVAR in patients with hostile neck anatomy by assessing its migration behavior within the first postoperative year. Methodology This retrospective, single-center study analyzed consecutive patients who underwent repair of hostile neck abdominal aortic aneurysms with the CLEVAR device between January 2019 and December 2022, focusing on early (≤1 year) postoperative stability. Eligible patients completed both three-month and one-year postoperative CT angiography. Migration was assessed by measuring the distance between the proximal stent edge and the bilateral renal arteries at both time points, with the difference representing stent movement. Descriptive statistics were calculated, normality was tested using the Shapiro-Wilk method, and comparisons were performed with nonparametric Wilcoxon signed-rank tests. Results A total of 25 patients were included. The mean stent migration across the cohort was 1.29 mm (SD 1.36 mm), with a median of 0.85 mm and a maximum migration of 6.0 mm. Both right and left renal reference points showed similar results (mean 1.17 mm and 1.40 mm, respectively), with no statistically significant difference between sides (p = 0.4261). Migration distributions were non-normally distributed and positively skewed. Analysis confirmed that stent displacement was statistically greater than zero (p < 0.00000001), indicating measurable, albeit small, positional changes during the interval. Conclusions In this study, the CLEVAR device demonstrated stable proximal fixation in challenging hostile neck anatomies over the first postoperative year. Observed migration was minimal, symmetrical, and well below thresholds considered clinically significant. These findings suggest that CLEVAR provides reliable early stability in anatomically complex aneurysm necks, potentially reducing the risk of migration-associated complications. However, the small sample size, retrospective design, and one-year follow-up limit generalizability. Longer-term studies with larger cohorts are needed to confirm the durability of fixation and explore the relationship between late migration, endoleak incidence, and the need for reintervention.

Abstract Background The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all NHS healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations. Method Patients' data for emergency major lower limb amputations (MLLA) for critical limbthreatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare® and divided into the control pre-pandemic group (April 2018 to March 2020) and the pandemic group (April 2020 to March 2022). The statistical analysis was conducted using the IBM SPSS software [v28.0.1.1 (14)]. Results A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every one in five of these finally underwent an amputation. There was an increase in the absolute number of Above- and Below-Knee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (p-value <0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30-day mortality rate of 7.26% (n=26). Conclusion NHS vascular management groups should update themselves with evolving technologies to optimise the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Objectives Abdominal aortic aneurysms (AAAs) demonstrating hostile neck anatomy (HNA) are associated with increased perioperative risk and mortality. A number of these patients are not suitable for standard endovascular aneurysm repair (EVAR) and are high risk for open surgery. We present our experience with the first implantations in Scotland of a novel conformable aortic stent-graft designed to overcome some of the challenges of HNAs. Methods From May 2018 to March 2022, 24 consecutive patients with non-ruptured AAAs demonstrating HNAs (neck length < 15 mm, or angulation > 60°) were treated with GORE Excluder Conformable AAA endoprosthesis (CLEVAR) (CEXC Device, W.L. Gore and Associates, Flagstaff, AZ, USA) at a Scottish vascular centre. We assessed clinical outcomes and technical success of CLEVAR during deployment, primary admission and the post-operative period at 3- and 12-month clinical follow-up alongside CT angiography. Results Twenty-four patients (20 males, mean age 75.6) were included. Primary technical success of proximal seal zones and CLEVAR deployment (no type 1/3 endoleaks, no conversion to open repair, AAA excluded and patient leaving theatre alive) was achieved in 100% of patients. All patients were alive and clinically stable at 3- and 12-month follow-up. There were five patients requiring re-intervention; at the 3-month follow-up, one patient (4.2%) developed a type 1b endoleak requiring graft limb extension, one patient developed a right common femoral artery dissection requiring open repair and one patient required a limb extension of the right iliac limb due to risk of developing a type 1b endoleak. At the 12-month follow-up, two patients required embolization of type 2 endoleaks and no patients demonstrated type 1 or type 3 endoleaks. Conclusions: In-hospital and post-operative 3- and 12-month clinical and angiographic outcomes demonstrate safety and efficacy with CLEVARs in treating unruptured AAAs with HNA. Further research involving larger heterogenous sample sizes is warranted to determine long-term clinical outcomes.

Background: The COVID-19 pandemic has affected the healthcare systems worldwide since the dawn of 2020. In March 2020, the United Kingdom government announced the first national lockdown which severely disturbed all National Health Service (NHS) healthcare elective services. Our aim is to assess the long-term impact of COVID-19 related disruption of NHS elective services on emergency major lower limb amputations (MLLAs). Methods: Patients' data for emergency MLLA for critical limb -threatening ischemia and diabetic foot infections performed at Aberdeen Royal Infirmary was collected through Trakcare and divided into the control prepandemic group (April 2018 -March 2020) and the pandemic group (April 2020 -March 2022). The statistical analysis was conducted using the IBM SPSS software (v28.0.1.1 [14]). Results: A total of 358 patients underwent MLLA and 206 (57.5%) of these had diabetes mellitus. There was a 17% increase in the number of urgent referrals and every 1 in 5 of these finally underwent an amputation. There was an increase in the absolute number of Above- and BelowKnee amputations. There was a statistically significant increase by 33% in emergency MLLAs during the pandemic period (P < 0.05). A total of 165 postoperative deaths up to December 2022 were recorded with 30 -day mortality rate of 7.26% (n 1/4 26). Conclusions: NHS vascular management groups should update themselves with evolving technologies to optimize the care provided during future unprecedented times. Furthermore, more effective measures should also be implemented to avoid delayed presentations, which can potentially lead to higher rates of major limb amputations.

Inferior mesenteric artery (IMA) aneurysms represent the minority of visceral aneurysm presentations. A 57-year-old female was admitted with a symptomatic IMA aneurysm secondary to atherosclerotic disease. She was treated with open excision which revealed a contained ruptured of a true aneurysm. This case highlights the challenges of an accurate preoperative diagnosis of IMA aneurysm and the correct position of the recent guidelines on visceral aneurysms issued by the Society of Vascular Surgery (SVS).

This report describes a pilot health behaviour change (HBC) project established by NHS Grampian vascular service. Results are presented in the form of case studies and data. The intervention aimed to support patients with peripheral arterial disease (PAD) to change health behaviour/improve self-management. PAD is a common condition among people aged over 55 years, with significant health implications if not well managed. PAD is caused by narrowing of the arteries, leading to poor blood flow causing pain and cramp mainly in the calf (intermittent claudication). Without proper blood flow, patients with PAD are at high risk of developing serious health problems, including heart attack, stroke, and amputation. Costs associated with PAD are substantial and largely avoidable with effective behaviour change. Smoking is the principle risk factor in the development of PAD. Other modifiable risk factors include obesity and sedentary lifestyle. Service evaluation data was collected at Aberdeen Royal Infirmary with 30 patients attending the vascular outpatient clinic. Patients received a tailored HBC intervention. Post-intervention, fewer participants smoked (67 per cent at baseline, 30 per cent follow-up); average daily step count increased by 1677 steps; average 5kg weight reduction at six month follow-up. Qualitative feedback highlighted increased self-esteem and improved strategies to help cope with PAD.

Purpose of the research: This pilot study reports the feasibility of a future randomized controlled trial (RCT) investigating the effect of supported self-management through low-intensity psychological intervention in patients with peripheral arterial disease (PAD) resulting in claudication. The study protocol, measurement instrument, data collection, and analysis were evaluated. Clinical outcome measures include depression and anxiety scores, smoking cessation, activity (step count), weight, and quality of life. Both Quantitative and Qualitative data were collected to evaluate participant experience and the clinical impact of a supported self-management intervention delivered in a routine clinical setting. Methods: Participants received an initial one to one assessment with a health psychologist. Demographic data and baseline clinical outcome measures were recorded. These included Hospital Anxiety and Depression Scale score (HADS), health-related quality of life questionnaire (EQ-5D-3 L), number of cigarettes smoked daily, weight/BMI, and daily step count. Participants each received an activity tracker to record daily step count and were followed up weekly to provide psychological input, including goal setting, overcoming barriers, and preventing relapse. Quantitative data collectionwas scheduled at baseline, 3 and 6 months (final follow-up). At the final follow-up, participants provided qualitative feedback reflecting upon their experience of the intervention and its impact. Descriptive statistical analysis and simple paired samples t-test were employed in data evaluation. Results: The sample size was small (n = 30). Twenty-three participants were followed up to 6 months. Depression scores improved with statistical significance from baseline to 6-month follow-up. Eight participants stopped smoking (47% reduction); a further 9 greatly reduced their intake. A borderline statistically significant increase of daily step count was achieved between baseline and 6-month followup. In addition, positive weight loss trends were observed in a predominantly obese or overweight cohort. The qualitative feedback highlighted participants understood and embraced the information delivered regarding the importance of health behavior change. Participants were able to link tailored action plans with what mattered to them with the help of the Health Psychologist. Conclusion: This study embraces the contemporary ideology of enabling self-management of long-term conditions to improve clinical outcomes. As a pilot study, we have shown that an expanded, randomized controlled trial is both safe and feasible. A positive trend in clinical outcomes suggests this patient group may benefit from supported self-management through low-intensity psychological intervention, where other forms of early intervention have historically faltered. (C) 2021 Society for Vascular Nursing. Published by Elsevier Inc. All rights reserved.

Anatomical variation may result in unexpected complications after fenestrated endovascular aneurysm repair (FEVAR). We report a 78-year-old gentleman who was admitted for elective FEVAR procedure for a juxtarenal abdominal aortic aneurysm. Three days post-operatively, he deteriorated clinically. Computed tomography (CT) angiogram showed small bowel ischaemia and a replaced right hepatic artery originating from superior mesenteric artery. A necrotic gallbladder found during laparotomy required cholecystectomy following small bowel resection that required a relook for anastomosis and drainage of bile collection. He had prolonged ICU stay requiring treatment for multiple organ dysfunction then spent 4 weeks in hospital. Following multidisciplinary team approach in management of his complications during post-operative phase, he recovered well enough for rehabilitation and discharge home. Surveillance CT aorta at 1 month and 6 months post FEVAR showed satisfactory FEVAR appearance with no endoleak.

Isolated internal iliac artery aneurysm is a rare condition with limited evidence in the literature to support management strategy. Repair has traditionally been associated with significant morbidity. However advances in endovascular technique offer the potential for new treatment options. We report our experience of using an off-label device for endovascular repair of an isolated internal iliac artery aneurysm.

Background:The recently described "Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB)" technique challenges the role of open surgical bypass in the treatment of aorto-iliac occlusive disease.Complications and mortality after aortobi-femoral bypass have remained stable over the last three decades despite declining caseloads but there are few contemporary outcomes to enable direct comparison.We present 10 years of consecutive patients treated with aorto-bi-femoral bypass at a single tertiary centre.Methods: A retrospective review was performed of prospectively maintained operating theatre logbooks.Notes were reviewed to ascertain the indication for surgery in addition to demographic data.Cross-sectional pre-operative imaging was reviewed to determine the extent of the disease according to the TASC-II classification.Primary endpoints were graft patency and survival.Secondary endpoints were reinterventions, immediate and delayed complications.Results: Between 2004 and 2015, 185 patients (61% male) with peripheral vascular disease (51% Fontaine Class 2b, 25% Class 3, 21% Class 4) were treated.The median age was 62 years (range 37-82).58% were current smokers, 41% ex-smokers.26% had undergone previous attempts at treatment (42/49 by endovascular means).Lesion morphology characterised by CT angiography included 1 TASC-II A, 9 TASC-II B, 25 TASC-II C and 97 TASC-II D lesions.Median follow up was 67 months.Thirty-day mortality was 4.3%.There were 28 major complications (15%), including 7 early limb occlusions requiring reintervention.Patency was 94% at 1 year, 88% at 3 years, 82% at 5 years and 79% at 10 years.In 31% of cases the limbs of the graft were landed distal to the common femoral artery.To date there have been 9 cases of graft infection, 5 requiring explantation.Survival was 94%, 81% and 64% at 1, 5 and 10 years respectively.Conclusions: Open surgery cannot compete with low 30-day morbidity and mortality rates reported with endovascular techniques.However, patency in our series exceeds much of the historical literature for this procedure despite the graft landing distal to the common femoral artery in one third of patients.Comparing our data to the available 1 and 2-year CERAB patency rates, our rates exceed endovascular patency by over 5% at both 1 and 3 years.Secondary patency for CERAB can be obtained but longer-term follow-up for endovascular techniques have yet to be reported.The "Gold Standard" remains a subject for debate.

EVAR has revolutionized the care of patients with aortic abdominal aneurysms and efforts to evolve the technique continue, with aim of improving patient experience and outcomes.We aimed to collect objective data related to using percutaneous access in EVAR operations in our unit in Aberdeen Royal Infirmary, with particular focus on post-operative complications.We found that nearly all patients (11 out of 12) who underwent percutaneous EVAR or FEVAR in Aberdeen Royal Infirmary since the introduction of the technique did so without experiencing any post-operative wound complications.This case series reflects the success and benefits of the use of percutaneous EVAR in our unit and also contributes to current evidence base for the use of the technique in selected patient groups.

Endovascular procedures are becoming more complex and intricate as technology evolves. This is very favourable for patients, who can have mora advanced procedures performed with minimal morbidity and mortality. However these advances come at the cost of increased radiation dosage to the operating surgeon, interventionist and angiosuite team. We present a review article of the current problems facing the interventional team and of possible solutions.

Background and Aims: Thoracic Endovascular Repair (TEVAR) is the preferred option for managing aneurysm disease of the Descending Thoracic Aorta (DTAA) and complications of acute Thoracic Aortic Dissection (TAD).We describe our early Northeast Scotland 5-year experience of TEVAR.Methods: Retrospective analysis of all emergency and elective TEVAR from January 2012 -July 2017 was performed.Patient demographics, presentation, imaging, operative details, survival status and surveillance CTA status were recorded.Technical success was defined as exclusion of the DTAA without Type 1 endoleak or conversion to open repair or sealing of the proximal entry in acute dissection.Results: We identified 10 (M: F ratio of 4:1, mean age of 67 years old; standard deviation 17 years) with a technical success of 100%.7(70%) cases were performed as emergency (3 symptomatic dissection, 1 rupture dissection, 1 rupture aneurysm, 1 aortic transection, 1 rupture penetrating aortic ulcer).Postoperative SCI was not observed.1 (10%) patient had prophylactic spinal cerebrovascular fluid (CSF) drainage.3 (30%) patient had coverage of the left subclavian artery (LSA).Mean follow-up was 12 months.30-daymortality was zero, mortality at follow up was 10% (n=1).In hospital, post-operative morbidity was 30%.Endoleak was noted in 2 (20%) patients at follow up. Conclusion:This study demonstrates the relatively high incidence of unscheduled admission and treatment for this pathology and encouraging early results.Prophylactic measure for SCI remains a topic for debate.

patient was worked up with diagnostic angiography and intravascular ultrasound5,6 (IVUS) to accurately confirm luminal diameter of the parent artery. Subsequent transfemoral stenting of the hepatic artery was performed with a 5mmx5cm Gore Viabahn endoprosthesis with excellent result on completion angiography and subsequent followup CT scanning. Care was taken to ensure continued perfusion of an early hepatic artery branch. The patient remains alive and well with normal liver function one year post-procedure (Figure 1A-1C).

EVAR continues to evolve. A certain proportion of recipients meet criteria for early discharge after surgery, making day case EVAR a possibility. We present our experience with a minimally-invasive arterial closure device prior to instituting a day-case EVAR programme.

Hybrid proceduresEndovascular and surgical procedures were first combined and conducted in the 1970s. 4Hybrid procedures have been reported to have primary success rates ranging from 93% to 100%. 2,5,6Outcomes of hybrid endovascular procedures are comparable to pure surgical interventions.Hybrid procedures have patency rates of 60 to 90 percent and are associated with lower morbidity and mortality and shorter hospital and intensive care stay. 1,2,5,6However there are reports suggesting higher morbidity rates in hybrid endovascular procedures when compared to pure endovascular interventions. 2 The number of patients who received revascularisation using hybrid procedures has increased in the last 10 years and accounts for 5 to 20 percent of cases per year. 2,7brid procedures in lower limb ischemia Hybrid procedures can be divided into three groups: a. Open vascular surgery and endovascular intervention distal to the site of open reconstruction b.Open vascular repair and endovascular procedure proximal to the site of open surgery.c.Open vascular surgery and endovascular procedures both at the distal and proximal sites of open procedures.9

We present a large contemporary series of patients presenting with unreconstructable critical limb ischaemia and requiring amputation. As well as being an insight into the challenges faced with the implementation of a quality improvement framework, We also feel the results will better inform the practising vascular surgeon and patients about the risks of limb loss in the 21st century.