Aortic aneurysms, a significant cause of mortality, particularly in individuals aged 55 years and older, have witnessed a transformative shift in treatment strategies with the advent of endovascular surgery. Cydar-EV is an innovative image fusion technology that can augment preoperative planning and surgical guidance of endovascular aneurysm repair (EVAR). The ARIA trial aims to evaluate the efficacy of using Cydar-EV with EVAR procedures to reduce operating time while enhancing procedural precision, patient outcomes, and cost-effectiveness. This paper describes the statistical analysis plan for the study. The ARIA trial, a phase III, multi-centre, open-label, two-armed, parallel groups randomised controlled surgical trial, seeks to recruit 340 patients diagnosed with abdominal or thoraco-abdominal aortic aneurysms. Participants are randomly assigned to receive either standard endovascular repair or an endovascular repair assisted by Cydar-EV for planning and surgical guidance. Primary and secondary outcomes are assessed at baseline, 4–12 weeks, and 52 weeks. The primary outcome measure is procedure duration at baseline, while additional secondary outcomes are recorded at various time points and include indicators for technical effectiveness, patient outcomes, procedure efficiency, and cost-effectiveness. We plan to analyse the patient outcome data according to the treatment they received regardless of initial allocation. The statistical analysis plan outlines methods for handling missing data, covariates for adjusted analyses, and planned sensitivity analyses to ensure robust evaluation of treatment effects. The trial was registered with the ISRCTN register on 03/12/2021, number ISRCTN13832085.

AIM:The aim of this study was to determine if there is an association between statin-use and prosthetic mobility and long-term survival in patients receiving rehabilitation after major amputation for lower limb arterial disease. METHODS:A retrospective analysis of prospectively maintained data (2008-2020) from a centre for rehabilitation was performed. Patients were grouped by statin-use status and sub-grouped by the combination of statin and antithrombotic drugs (antiplatelets or anticoagulants). Outcomes were prosthetic mobility (SIGAM score, timed-up-go and 2-min walking distance) and long-term survival. Regression, Kaplan-Meier and Cox-proportional hazard analyses were performed to test associations adjusted to confounders. RESULTS:Of 771 patients, 499 (64.7%) were on a statin before amputation or prescribed a statin peri-operatively. Rate of statin-use was significantly lower among female (53.3%) compared to male (68.2%) patients, P < 0.001. Statin-use was associated with significantly better prosthetic independence (53.1% vs 44.1%, P = 0.017), timed-up-go (mean difference of 4 s, P = 0.04) and long-term survival HR 0.59 (0.48-0.72, P < 0.001). Significance persisted after adjusting for confounding factors and in subgroup analyses. The combination of statin with antiplatelet was associated with the most superior survival, HR 0.51 (0.40-0.65, P < 0.001). Sensitivity analysis (exclusion of non-users of prosthesis) showed that statin-use remained a significant indicator of longer survival, maximally when combined with antiplatelet use HR 0.52 (0.39-0.68, P < 0.001). CONCLUSIONS:Statin-use is associated with better mobility and long-term survival in rehabilitees after limb loss, particularly when used in combination with antiplatelets. Significantly lower rates of statin-use were observed in female patients. Further research is warranted on gender disparities in statin-use and causality in their association with improved mobility and survival.

Objective: This study aimed to assess the quality of patient information material regarding elective abdominal aortic aneurysm (AAA) repair on the internet using the Modi fi ed Ensuring Quality Information for Patients (MEQIP) tool. Methods: A qualitative assessment of internet based patient information was performed. The 12 most used search terms relating to AAA repair were identi fi ed using Google Trends, with the fi rst 10 pages of websites retrieved for each term searched. Duplicates were removed, and information for patients undergoing elective AAA were selected. Further exclusion criteria were marketing material, academic journals, videos, and nonEnglish language sites. The remaining websites were then MEQIP scored independently by two reviewers, producing a fi nal score by consensus. Results: A total of 1 297 websites were identi fi ed, with 235 (18.1%) eligible for analysis. The median MEQIP score was 18 (interquartile range [IQR] 14, 21) out of a possible 36. The highest score was 33. The 99th percentile MEQIP scoring websites scored > 27, with four of these six sites representing online copies of hospital patient information lea fl ets, however hospital sites overall had lower median MEQIP scores than most other institution types. MEQIP subdomain median scores were: content, 8 (IQR 6, 11); identi fi cation, 3 (IQR 1, 3); and structure, 7 (IQR 6, 9). Of the analysed websites, 77.9% originated from the USA (median score 17) and 12.8% originated in the UK (median score 22). Search engine ranking was related to website institution type but had no correlation with MEQIP. Conclusion: When assessed by the MEQIP tool, most websites regarding elective AAA repair are of questionable quality. This is in keeping with studies in other surgical and medical fi elds. Search engine ranking is not a reliable measure of quality of patient information material regarding elective AAA repair. Health practitioners should be aware of this issue as well as the whereabouts of high quality material to which patients can be directed.

Background Endovascular repair of aortic aneurysmal disease is established due to perceived advantages in patient survival, reduced postoperative complications, and shorter hospital lengths of stay. High spatial and contrast resolution 3D CT angiography images are used to plan the procedures and inform device selection and manufacture, but in standard care, the surgery is performed using image-guidance from 2D X-ray fluoroscopy with injection of nephrotoxic contrast material to visualise the blood vessels. This study aims to assess the benefit to patients, practitioners, and the health service of a novel image fusion medical device (Cydar EV), which allows this high-resolution 3D information to be available to operators at the time of surgery. Methods The trial is a multi-centre, open label, two-armed randomised controlled clinical trial of 340 patient, randomised 1:1 to either standard treatment in endovascular aneurysm repair or treatment using Cydar EV, a CE-marked medical device comprising of cloud computing, augmented intelligence, and computer vision. The primary outcome is procedural time, with secondary outcomes of procedural efficiency, technical effectiveness, patient outcomes, and cost-effectiveness. Patients with a clinical diagnosis of AAA or TAAA suitable for endovascular repair and able to provide written informed consent will be invited to participate. Discussion This trial is the first randomised controlled trial evaluating advanced image fusion technology in endovascular aortic surgery and is well placed to evaluate the effect of this technology on patient outcomes and cost to the NHS. Trial registration ISRCTN13832085. Dec. 3, 2021

Abstract Aim Patients with symptomatic peripheral artery disease (PAD) are highly co-morbid and thus may benefit from cardiovascular disease risk factors optimisation at the time of admission. This audit aimed at reviewing adherence to NICE guidelines for secondary prevention of cardiovascular disease amongst hospital in patients with critical limb-threatening ischaemia (CLTI) or intermittent claudication (IC). Method A retrospective review of all CLTI or IC inpatient admissions to a tertiary referral vascular surgery centre, over 9 months, was performed. We assessed adherence to five NICE recommendations for cardiovascular risk factor optimisation: 1) smoking cessation 2) lipid modification 3) antiplatelet therapy 4) blood pressure control 5) diabetes risk assessment, with target adherence of 100%. Results 97 admissions for PAD were recorded (CLTI n=87, 89.7%; IC n=10, 10.3%). The average age was 70.8±11.7 years, and 68.4% were male. Smoking cessation service was provided to 40.5% of eligible patients, lipid modification to 18.8%, blood pressure control to 29.5%, diabetes risk assessment to 21.1%, and antiplatelet therapy to 38.9%. Admissions longer than 10 days had a significantly higher rate of adherence (>10 days 35.5% vs ≤10 days 19.8%, p=0.017). Conclusions There are gaps in risk factor optimisation amongst PAD inpatients, with risk factors either not documented, or addressed appropriately. Shorter, elective hospital admissions were associated with worse risk factor optimisation. A dedicated review of risk factors should be offered to all PAD inpatients early during their admission. To achieve the best long-term adherence, multidisciplinary engagement of geriatrics, smoking cessation, diabetes, and primary care is essential.

We read with interest the paper from Lin et al.1 Lin X. Jiang S. Chen B. Deng Y. Yu B. Tang J. Endovascular radiofrequency ablation of nerves for treatment of Raynaud's phenomenon. Eur J Vasc Endovasc Surg. 2023; 66: 278-279 Abstract Full Text Full Text PDF Scopus (1) Google Scholar describing their experience with endovascular radiofrequency ablation in patients with Raynaud's phenomenon. Endovascular Radiofrequency Ablation of Nerves for Treatment of Raynaud's PhenomenonEuropean Journal of Vascular and Endovascular SurgeryVol. 66Issue 2PreviewRaynaud's phenomenon (RP) is a symptom caused by digital vascular compromise that affects 5% of the population.1 Surgical interventions are limited for patients with refractory RP because of post-operative complications such as compensatory sweating and Horner's syndrome following thoracic sympathectomy. Endovascular radiofrequency ablation (endo-RFA) is a minimally invasive technique that may interrupt afferent nerve activity and reduce sympathetic nerve activity.2 Full-Text PDF

OBJECTIVE:To evaluate the long term outcomes of individuals who attended for transthoracic echocardiograms (TTEs) or lower limb arterial duplex scans (LLADS) and were opportunistically screened for abdominal aortic aneurysms (AAA). METHODS:Follow up of a prospective single centre pilot cohort study conducted between December 2012 and September 2014 at a tertiary vascular centre in the United Kingdom. Men and Women aged 65 and over were invited to undergo AAA screening when attending hospital for TTE or LLADS. Screening was performed by ultrasonographic examination of the abdomen at the end of their planned scans. AAA was defined as an abdominal aorta outer wall to outer wall anteroposterior diameter of 30 mm or more. Patients were excluded if they had a known AAA or previous abdominal aorta intervention. Follow up outcomes were evaluated in December 2020. RESULTS:762 patients were enrolled in this study; 486 had TTE and 276 patients had LLADS. The overall incidence of AAA was 54 (7.1%) in the combined cohort, 25 (5.1%) in the TTE group, and 29 (10.5%) in the LLADS group. After a median 7.6 years, two of the 54 AAAs received intervention in the form of endovascular repair. Three others reached treatment threshold but were managed conservatively. The overall intervention rate was 3.7% of detected AAAs. Adjusted mortality rates in those with AAA vs. without was 64.8% and 36%, respectively (hazard ratio [HR] 2.02, p < .001). Diabetes (HR 1.35, p = .015) and older age (HR 1.18, p = .17) were the other factors associated with death. CONCLUSION:AAA is associated with a significantly increased mortality rate. Populations attending hospital for TTE or LLADS demonstrate a higher prevalence of AAA than population based screening; however, the proportion offered AAA intervention was low. Further research into opportunistic screening should target those more likely to undergo AAA repair, unless other interventions are demonstrated, to reduce the general increased mortality in AAA patients.

Objective Diagnosis/treatment algorithms for limb ischaemia rely solely on clinical signs and non-functional assessments. It has been shown previously that calf muscle oxygenation, measured by Blood Oxygenation Level Dependent MRI (BOLD MRI), correlates with the severity of limb ischaemia. This study aimed to develop BOLD for the foot and to determine calf/foot oxygenation after limb revascularisation. Methods T2* weighted single shot multi echo BOLD MRI of the foot and calf at 3.0T were carried out prior to and up to 14 days after revascularisation by angioplasty/stenting or bypass surgery. Gradient (Grad), measured on T2* curve, indicated muscle oxygenation. Changes in calf/foot oxygenation were correlated with limb outcomes. Results Forty eight patients (30 men, median age 73 [59 – 88] years) underwent pre-intervention foot BOLD scanning, with good interscan (p < .001) and interuser (p < .001) reproducibility for Grad. CLTI patients had lower foot Grad than claudicants (p < .001). Fifty six patients (36 men, median age of 71 [61 – 84] years) had angiograms captured for collateral vessel assessment. Sixty one patients (40 men, median age 68 [60 – 85] years) had pre and post intervention BOLD of the calf and foot. Patients with unsuccessful revascularisation had a lower fold change in calf Grad (p < .001) and foot Grad (p < .030). BOLD assessment of the calf (sensitivity 82.14% [64.14 – 92.12%], specificity 75% [46.77 – 91.11%], p < .001) was superior to the foot (n = 21, sensitivity 100% [79.61 – 100%], specificity 66.67% [30 – 94.08%], p = .005) for predicting unsuccessful revascularisation on follow up. Conclusion BOLD MRI is a reliable tool for assessing oxygenation in the calf and foot muscles of patients with limb ischaemia. Its role for identifying poorly oxygenated limbs after revascularisation merits further investigation. Diagnosis/treatment algorithms for limb ischaemia rely solely on clinical signs and non-functional assessments. It has been shown previously that calf muscle oxygenation, measured by Blood Oxygenation Level Dependent MRI (BOLD MRI), correlates with the severity of limb ischaemia. This study aimed to develop BOLD for the foot and to determine calf/foot oxygenation after limb revascularisation. T2* weighted single shot multi echo BOLD MRI of the foot and calf at 3.0T were carried out prior to and up to 14 days after revascularisation by angioplasty/stenting or bypass surgery. Gradient (Grad), measured on T2* curve, indicated muscle oxygenation. Changes in calf/foot oxygenation were correlated with limb outcomes. Forty eight patients (30 men, median age 73 [59 – 88] years) underwent pre-intervention foot BOLD scanning, with good interscan (p < .001) and interuser (p < .001) reproducibility for Grad. CLTI patients had lower foot Grad than claudicants (p < .001). Fifty six patients (36 men, median age of 71 [61 – 84] years) had angiograms captured for collateral vessel assessment. Sixty one patients (40 men, median age 68 [60 – 85] years) had pre and post intervention BOLD of the calf and foot. Patients with unsuccessful revascularisation had a lower fold change in calf Grad (p < .001) and foot Grad (p < .030). BOLD assessment of the calf (sensitivity 82.14% [64.14 – 92.12%], specificity 75% [46.77 – 91.11%], p < .001) was superior to the foot (n = 21, sensitivity 100% [79.61 – 100%], specificity 66.67% [30 – 94.08%], p = .005) for predicting unsuccessful revascularisation on follow up. BOLD MRI is a reliable tool for assessing oxygenation in the calf and foot muscles of patients with limb ischaemia. Its role for identifying poorly oxygenated limbs after revascularisation merits further investigation.

OBJECTIVE:Despite widespread use, long term outcomes for fenestrated endovascular aneurysm repair (FEVAR) are uncertain. This meta-analysis reports long term survival, freedom from re-intervention, target vessel patency, and one year sac regression after FEVAR. DATA SOURCES:Systematic review and meta-analysis to pool time to event data according to PRISMA guidelines. The study was registered with the international prospective register of systematic reviews (PROSPERO) (ID: CRD42023401468). REVIEW METHODS:Medline, Embase, and Cochrane databases were searched from 1992 - 2023; articles were independently screened by two authors. Publication of complete time to event data for any outcome of interest was an inclusion criterion. Raw Kaplan-Meier probabilities were directly extracted from published curves and pooled by random effects. Risk of bias was assessed using ROBINS I and certainty with GRADE. RESULTS:A total of 3 569 records were retrieved, 2 869 screened after duplicate removal, yielding 37 included studies (n = 4 371). The pooled mean age was 73.2 years (interquartile range [IQR] 72.2, 73.7) and 87.4% were male (95% confidence interval [CI] 85.8 - 88.9). Pooled Kaplan-Meier estimated probabilities of survival (n = 34 studies, n = 4 192 patients) at one, three, and five years were 91.6% (95% CI 90.2 - 92.9), 80.8% (95% CI 78.0 - 83.2), and 65.1% (95% CI 60.9 - 69.1). For freedom from re-intervention (n = 24, n = 3 211 patients) at one, three, and five years these were 90.2% (95% CI 87.3 - 92.7), 80.9% (95% CI 76.5 - 84.9), and 73.8% (95% CI 67.1 - 79.6). For target vessel patency (n = 13, n = 5805 target vessels) at one, three, and five years, these were 96.6% (95% CI 94.9 - 98.0), 94.5% (95% CI 91.7 - 96.7), and 93.1% (95% CI 89.3 - 96.0). Pooled estimate of sac regression (n = 8, n = 560) at one year was 40.2% (95% CI 28.9 - 52.7). Risk of bias was judged as moderate in 11 studies and low for the remaining 26. CONCLUSION:There are moderate to low certainty data supporting reasonable long term outcome estimates following fenestrated endovascular aneurysm repair. Beyond five years there is a lack of data in the literature.

Objectives: The aim of this study was to compare outcomes of major lower limb amputation (MLA) in patients with and without cancer and with cancer patients receiving palliation over amputation for their unsalvageable limb. Methods: Cancer patients who underwent a major amputation or palliation between 2013 and 2018 were included. Comparison groups were cancer-MLA (active/managed cancers), non-cancer MLA (historic cancer or no cancer history) and cancer-palliation at presentation with unsalvageable limbs. Prospectively collected data was retrospectively analysed for outcomes including survival, postoperative complications, length of stay, suitability for rehabilitation and discharge destination. Results: 262 (cancer and non-cancer) patients underwent MLA and 18 patients with cancer received palliation. Of those amputated, 26 (9.9%) had active or managed cancer, of which 12 were diagnosed in the 6 months before MLA. Cancer-MLA patients presented with more acute ischaemia compared to non-cancer patients. Median survival was significantly different between the cancer-MLA (14.1 [9.5 -29.5, 95% CI] months), non-cancer MLA (57.7 [45 -73.6, 95% CI] months) and cancer-palliation (.6 [.4 -2.3, 95% CI] months) groups, P < .001. A significantly higher proportion of cancer-MLA patients (10/26, 38.5%) were deemed unsuitable for rehabilitation in post-operative assessment compared to non-cancer MLA (21/236, 8.9%) patients, P < .001. There was a variation in destinations of discharge, with a greater proportion of cancer-MLA patients (4/26, 15.4%) going to a nursing home compared to non-cancer MLA (10/236, 4.2%) patients, P = .016. Conclusion: Cancer is prevalent among vascular amputees, with a large proportion being occult diagnoses. Cancer is associated with poorer outcomes following amputation, but survival remains significantly better compared to palliation in cancer patients presenting with unsalvageable limbs.

OBJECTIVE:This study aimed to construct a decision aid to estimate the likelihood of independence with a prosthesis following rehabilitation for limb loss secondary to advanced ischaemia (acute or chronic limb threatening ischaemia) or diabetic foot disease (DFD). A secondary aim was to determine whether prosthetic independence is a surrogate marker of long term survival.METHODS:A retrospective cohort study of a prospectively maintained database of unilateral amputations due to ischaemia or DFD entering rehabilitation between 2007 and 2020 was performed. Predictors of independent prosthetic mobility (IPM) were used in construction of the IPM prediction model, which underwent bootstrap internal and criterion validation through correlation with predictors of other measures of function: Timed Up and Go (TUG) and two minute walk test. Kaplan-Meier and Cox regression analyses were performed to address the secondary aim.RESULTS:Of the 771 patients included, only 49.9% of amputees achieved IPM. Independent negative predictors of IPM were age > 75 years, female sex, higher amputation level, active malignancy, cerebrovascular disease, end stage renal disease, and cognitive impairment. The model yielded high discrimination (C statistic 0.778), and internal validation was demonstrated with bootstrapping (C statistic 0.778), confirming no over optimism. There was a strong correlation between IPM, TUG, and two minute distance and their predictors, confirming strong criterion validity. The IPM group had a median survival of 93.7 (80.7, 105) months, whereas the non-IPM group fared worse with a median survival of 56.6 (48.5, 66.7) months (p < .001).CONCLUSION:An internally validated decision aid for estimating the likelihood of independence with a prosthesis after major amputation was constructed. A strong association between female sex and poorer prosthetic mobility was observed. Prosthetic function was shown to be a surrogate marker of long term survival. Future research will involve external validation studies to confirm the generalisability of the decision aid in clinical practice.

Objective A need exists for a marker of therapeutic failure after endovascular aneurysm repair (EVAR) given concerns of late device related complications. The utility of post-EVAR aneurysm sac size change in informing risk prediction models of endograft failure was studied. Methods The ENGAGE EVAR registry was retrospectively analysed. Post-operative sac size change was modelled for patients with reference to observed endograft complications (composite outcome of type 1 or type 3 endoleak, rupture preventing re-intervention, or secondary rupture). Kaplan–Meier analysis was performed to establish the event free probability of EVAR endograft complications associated with sac size change. Joint Bayesian modelling with K-fold cross validation was used to produce risk predictions of EVAR endograft complications. Results Of 1 151 patients included for analysis (median follow up 4.1 years; interquartile range 2.9, 4.7), 60% had sac regression, 30% had a stable sac, and 10% had sac expansion after EVAR. The five year event free probability of suffering an endograft complication was 92% (95% confidence interval [CI] 90 – 94), 84% (95% CI 78 – 90), and 45% (95% CI 35 – 58) for the sac regression, stable sac, and sac expansion groups, respectively. Informed by changing aneurysm diameter after EVAR, a joint Bayesian modelling technique could predict the risk of an endograft complication at five years with very good discrimination and precision (area under the curve 0.90, prediction error 0.065). Conclusion Sac size change after EVAR is a promising dynamic marker of EVAR durability. Joint Bayesian modelling informed by post-EVAR sac size change provides a novel approach in obtaining risk predictions of endograft related complications. A need exists for a marker of therapeutic failure after endovascular aneurysm repair (EVAR) given concerns of late device related complications. The utility of post-EVAR aneurysm sac size change in informing risk prediction models of endograft failure was studied. The ENGAGE EVAR registry was retrospectively analysed. Post-operative sac size change was modelled for patients with reference to observed endograft complications (composite outcome of type 1 or type 3 endoleak, rupture preventing re-intervention, or secondary rupture). Kaplan–Meier analysis was performed to establish the event free probability of EVAR endograft complications associated with sac size change. Joint Bayesian modelling with K-fold cross validation was used to produce risk predictions of EVAR endograft complications. Of 1 151 patients included for analysis (median follow up 4.1 years; interquartile range 2.9, 4.7), 60% had sac regression, 30% had a stable sac, and 10% had sac expansion after EVAR. The five year event free probability of suffering an endograft complication was 92% (95% confidence interval [CI] 90 – 94), 84% (95% CI 78 – 90), and 45% (95% CI 35 – 58) for the sac regression, stable sac, and sac expansion groups, respectively. Informed by changing aneurysm diameter after EVAR, a joint Bayesian modelling technique could predict the risk of an endograft complication at five years with very good discrimination and precision (area under the curve 0.90, prediction error 0.065). Sac size change after EVAR is a promising dynamic marker of EVAR durability. Joint Bayesian modelling informed by post-EVAR sac size change provides a novel approach in obtaining risk predictions of endograft related complications.

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.

The timing of carotid endarterectomy (CEA) for symptomatic ipsilateral carotid artery stenosis has evolved in practice over time. Key landmark trials outlined the benefit of performing CEA in the recently symptomatic carotid artery stenosis, defined as revascularisation within 6 months of the index neurological event. Further evidence and sub-analysis demonstrate that performing CEA within 2 weeks of symptoms has the maximal benefit in reducing stroke free survival and is associated with a safe perioperative complication profile. This has translated into guideline recommendations and widespread clinical practice. The case for performing urgent CEA (within 48 hours of index neurological event) over early CEA (within 2 weeks) has been put forward and studied. Data examining perioperative complications for urgent CEA are mostly derived from retrospective single series studies. A moderate balance exists in the literature for the safety and risk of urgent CEA. Although many studies present acceptable perioperative stroke and mortality rates associated with urgent CEA, evidence still exists that the perioperative complications may not be insignificant. This is particularly the case if the presenting neurology is a stroke, rather than a transient ischaemic attack (TIA) or amaurosis fugax. This should be contextualised in the practice of modern aggressive medical therapy with dual antiplatelets and statins, with evidence suggesting a reduction in recurrent ischaemic events prior to surgical intervention. Careful patient selection, presenting neurology and medical therapy is likely to be a key feature in considering urgent CEA versus early CEA.

Diabetic MedicineVolume 36, Issue 2 p. 257-258 Letter Screening for peripheral artery disease in people with diabetes: authors’ reply B. Vriens, B. Vriens Vascular Department, Colchester General Hospital, Colchester Hospital University NHS Foundation Trust, Colchester, UKSearch for more papers by this authorF. D'Abate, F. D'Abate St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorB. A. Ozdemir, B. A. Ozdemir orcid.org/0000-0002-0982-4482 Southmead Hospital, North Bristol NHS Trust, Bristol, UKSearch for more papers by this authorC. Fenner, C. Fenner St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorW. Maynard, W. Maynard St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorJ. Budge, J. Budge St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorD. Carradice, D. Carradice Academic Vascular Surgical Unit, Hull York Medical School, Hull, UKSearch for more papers by this authorR. J. Hinchliffe, R. J. Hinchliffe Bristol Centre for Surgical Research, University of Bristol, Bristol, UKSearch for more papers by this author B. Vriens, B. Vriens Vascular Department, Colchester General Hospital, Colchester Hospital University NHS Foundation Trust, Colchester, UKSearch for more papers by this authorF. D'Abate, F. D'Abate St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorB. A. Ozdemir, B. A. Ozdemir orcid.org/0000-0002-0982-4482 Southmead Hospital, North Bristol NHS Trust, Bristol, UKSearch for more papers by this authorC. Fenner, C. Fenner St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorW. Maynard, W. Maynard St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorJ. Budge, J. Budge St. George's Vascular Institute, St. George's Hospital, St. George's University NHS Foundation Trust, London, UKSearch for more papers by this authorD. Carradice, D. Carradice Academic Vascular Surgical Unit, Hull York Medical School, Hull, UKSearch for more papers by this authorR. J. Hinchliffe, R. J. Hinchliffe Bristol Centre for Surgical Research, University of Bristol, Bristol, UKSearch for more papers by this author First published: 22 September 2018 https://doi.org/10.1111/dme.13822Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume36, Issue2February 2019Pages 257-258 RelatedInformation

Objective: The study aimed to assess the cumulative radiation exposure from preoperative, periprocedural, and follow-up imaging to patients who underwent common endovascular deep venous interventions for acute and chronic central venous outflow obstructive diseases; namely, deep vein thrombosis (DVT) thrombolysis, unilateral chronic iliofemoral venous stenting, and inferior vena cava (IVC) reconstruction in a single center. Methods: Patients who had DVT thrombolysis of upper extremity (UE) DVT and lower extremity (LE) DVT, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction between May 1, 2012, and July 31, 2017, in a single unit were retrospectively reviewed. Demographic data, anatomic DVT, imaging, technical details of the index procedure, follow-up, and radiation exposure measured in dose-length product, dose-area product (DAP), and fluoroscopy time (FT) from related computed tomography scans and interventions were analyzed. Mann-Whitney U tests were performed to assess for significance of differences between subgroups. A P value of less than .05 was considered significant. Results: In total, 20 UE DVT thrombolysis, 91 LE DVT thrombolysis, 56 unilateral chronic iliofemoral venous stenting, and 39 endovascular IVC reconstruction patients were included in the study, with the following median ages: 39 years (range, 20-67 years), 44 years (range, 15-78 years), 45 years (range, 20-80 years), and 35 years (range, 18 -73 years), respectively. The median cumulative DAP for the index DVT thrombolysis was 9.2 Gycm(2) (range, 0.2-176.0 Gycm(2)) for LE DVT and 2.0 Gycm(2) (range, 0.1-11.7 Gycm(2)) for UE DVT (P<.0001). The median cumulative FT for the index thrombolysis was 981 seconds (range, 20-4890 seconds) and 837 seconds (range, 19-2895 seconds) for LE DVT and UE DVT, respectively (P=.18). For unilateral chronic iliofemoral venous stenting, the median cumulative DAP and FT were 32.4 Gycm(2) (range, 0.1-289.6 Gycm(2)) and 660 seconds (range, 246-4200 seconds), respectively. Meanwhile, the median cumulative DAP and FT for the endovascular IVC reconstruction were 60.8 Gycm(2) (range, 2.5-269.1 Gycm(2)) and 2846 seconds (range, 83611682 seconds), respectively. The median DAP for secondary procedures during follow-up was 6.6 Gycm(2) (range, 0.8 186.5 Gycm(2)), 1.9 Gycm(2) (range, 0.2-111.7 Gycm(2)), and 24.3 Gycm(2) (range, 0.2-157.5 Gycm(2)) for LE DVT thrombolysis, unilateral chronic iliofemoral venous stenting, and endovascular IVC reconstruction, respectively. Conclusions: Patient radiation exposure for endovascular deep venous interventions for central venous outflow obstruction measured in DAP and FT seemed to be less than and at most similar to anatomically comparable arterial interventions in the literature. However, these patients were usually much younger than those with arterial diseases and may need secondary interventions involving further radiation exposure in their lifetime.

Short stay endovascular aneurysm repair pathways (SS-EVAR) provide potential advantages to both healthcare providers and patients. However, these benefits must be carefully balanced against the inherent risks to patient safety and tariff penalties associated with unplanned readmissions.A literature review was performed using the databases MEDLINE, Embase and Cochrane Library up until March 2019. Search terms used included "endovascular aneurysm repair," "aneurysm repair," "EVAR," "abdominal aortic aneurysm," "day case," "short stay," "fast track," and "ambulatory."Nine relevant articles (including one prior review on the topic) were identified. This early data suggests that SS-EVAR is associated with good patient satisfaction and modest cost savings for healthcare providers. Patient selection, preoperative preparation and supported discharge with early follow-up are essential components of a SS-EVAR pathway. Increasingly, SS-EVAR tends to be delivered via bilateral percutaneous access and loco-regional anesthesia. Over 70% of patients enrolled onto SS-EVAR pathways successfully complete them. Long procedures with excessive blood loss are associated with pathway non-completion. All serious complications occur within 6 hours of the procedure and the mortality (0-1%), morbidity (8-58%) and readmission rates (0-6%) associated with SS-EVAR remains acceptably low. SS-EVAR pathways can be safely and effectively implemented in both teaching and non-teaching hospitals.Short-stay EVAR pathways are safe and acceptable to patients. With appropriate selection of motivated patients, successful expedited discharge can be achieved with limited readmissions, thus facilitating increased resource efficiency and cost savings for healthcare providers.

INTRODUCTION: Short stay endovascular aneurysm repair pathways (SS-EVAR) provide potential advantages to both healthcare providers and patients. However, these benefits must be carefully balanced against the inherent risks to patient safety and tariff penalties associated with unplanned readmissions. EVIDENCE ACQUISITION: A literature review was performed using the databases MEDLINE, Embase and Cochrane Library up until March 2019. Search terms used included "endovascular aneurysm repair," "aneurysm repair." "EVAR," "abdominal aortic aneurysm." "day case," "short stay," "fast track," and "ambulatory." EVIDENCE SYNTHESIS: Nine relevant articles (including one prior review on the topic) were identified. This early data suggests that SS-EVAR is associated with good patient satisfaction and modest cost savings for healthcare providers. Patient selection, preoperative preparation and supported discharge with early follow-up are essential components of a SS-EVAR pathway. Increasingly, SS-EVAR tends to be delivered via bilateral percutaneous access and loco-regional anesthesia. Over 70% of patients enrolled onto SS-EVAR pathways successfully complete them. Long procedures with excessive blood loss are associated with pathway non-completion. All serious complications occur within 6 hours of the procedure and the mortality (0-1%), morbidity (8-58%) and readmission rates (0-6%) associated with SS-EVAR remains acceptably low. SS-EVAR pathways can be safely and effectively implemented in both teaching and non-teaching hospitals. CONCLUSIONS: Short-stay EVAR pathways are safe and acceptable to patients. With appropriate selection of motivated patients, successful expedited discharge can be achieved with limited readmissions, thus facilitating increased resource efficiency and cost savings for healthcare providers.