ANZ Journal of SurgeryVolume 91, Issue 7-8 p. E523-E525 IMAGES FOR SURGEONS Catheter entrapment in the aortic sac during Onyx embolization for type II endoleak Russell W. Jamieson MChir, FRCSEd, Russell W. Jamieson MChir, FRCSEd orcid.org/0000-0001-6004-4214 Edinburgh Vascular Surgical Service, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Conceptualization, ​Investigation, Writing - original draft, Writing - review & editingSearch for more papers by this authorOlivia M. B. McBride MChir, FRCSEd, Olivia M. B. McBride MChir, FRCSEd Edinburgh Vascular Surgical Service, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Writing - original draft, Writing - review & editingSearch for more papers by this authorNeil M. Masson FRCR, Neil M. Masson FRCR Department of Interventional Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Writing - original draft, Writing - review & editingSearch for more papers by this author Russell W. Jamieson MChir, FRCSEd, Russell W. Jamieson MChir, FRCSEd orcid.org/0000-0001-6004-4214 Edinburgh Vascular Surgical Service, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Conceptualization, ​Investigation, Writing - original draft, Writing - review & editingSearch for more papers by this authorOlivia M. B. McBride MChir, FRCSEd, Olivia M. B. McBride MChir, FRCSEd Edinburgh Vascular Surgical Service, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Writing - original draft, Writing - review & editingSearch for more papers by this authorNeil M. Masson FRCR, Neil M. Masson FRCR Department of Interventional Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK Contribution: Writing - original draft, Writing - review & editingSearch for more papers by this author First published: 15 December 2020 https://doi.org/10.1111/ans.16492Read 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 onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume91, Issue7-8July/August 2021Pages E523-E525 RelatedInformation

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.

Background: Endovascular abdominal aortic aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive than open surgery, but may be associated with important complications. Patients receiving EVAR require long-term surveillance to detect abnormalities and direct treatments. Computed tomography angiography (CTA) has been the most common imaging modality adopted for EVAR surveillance, but it is associated with repeated radiation exposure and the risk of contrast-related nephropathy. Colour duplex ultrasound (CDU) and, more recently, contrast-enhanced ultrasound (CEU) have been suggested as possible, safer, alternatives to CTA. Objectives: To assess the clinical effectiveness and cost-effectiveness of imaging strategies, using either CDU or CEU alone or in conjunction with plain radiography, compared with CTA for EVAR surveillance. Data sources: Major electronic databases were searched, including MEDLINE, EMBASE, Science Citation Index, Scopus’ Articles-in-Press, Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database from 1996 onwards. We also searched for relevant ongoing studies and conference proceedings. The final searches were undertaken in September 2016. Methods: We conducted a systematic review of randomised controlled trials and cohort studies of patients with AAAs who were receiving surveillance using CTA, CDU and CEU with or without plain radiography. Three reviewers were involved in the study selection, data extraction and risk-of-bias assessment. We developed a Markov model based on five surveillance strategies: (1) annual CTA; (2) annual CDU; (3) annual CEU; (4) CDU together with CTA at 1 year, followed by CDU on an annual basis; and (5) CEU together with CTA at 1 year, followed by CEU on an annual basis. All of these strategies also considered plain radiography on an annual basis. Results: We identified two non-randomised comparative studies and 25 cohort studies of interventions, and nine systematic reviews of diagnostic accuracy. Overall, the proportion of patients who required reintervention ranged from 1.1% (mean follow-up of 24 months) to 23.8% (mean follow-up of 32 months). Reintervention was mainly required for patients with thrombosis and types I–III endoleaks. All-cause mortality ranged from 2.7% (mean follow-up of 24 months) to 42% (mean follow-up of 54.8 months). Aneurysm-related mortality occurred in < 1% of the participants. Strategies based on early and mid-term CTA and/or CDU and long-term CDU surveillance were broadly comparable with those based on a combination of CTA and CDU throughout the follow-up period in terms of clinical complications, reinterventions and mortality. The economic evaluation showed that a CDU-based strategy generated lower expected costs and higher quality-adjusted life-year (QALYs) than a CTA-based strategy and has a 63% probability of being cost-effective at a £30,000 willingness-to-pay-per-QALY threshold. A CEU-based strategy generated more QALYs, but at higher costs, and became cost-effective only for high-risk patient groups. Limitations: Most studies were rated as being at a high or moderate risk of bias. No studies compared CDU with CEU. Substantial clinical heterogeneity precluded a formal synthesis of results. The economic model was hindered by a lack of suitable data. Conclusions: Current surveillance practice is very heterogeneous. CDU may be a safe and cost-effective alternative to CTA, with CTA being reserved for abnormal/inconclusive CDU cases. Future work: Research is needed to validate the safety of modified, more-targeted surveillance protocols based on the use of CDU and CEU. The role of radiography for surveillance after EVAR requires clarification. Study registration: This study is registered as PROSPERO CRD42016036475. Funding: The National Institute for Health Research Health Technology Assessment programme.

ANZ Journal of SurgeryVolume 89, Issue 4 p. 425-426 IMAGES FOR SURGEONS Suprascapular artery pseudoaneurysm Rachel Falconer MBChB, MRCS, Rachel Falconer MBChB, MRCS orcid.org/0000-0002-4621-4085 Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this authorEuan N. Munro MD, FRCSEng, FRCSEd Gen, Euan N. Munro MD, FRCSEng, FRCSEd Gen Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this authorRussell W. Jamieson MChir, FRCS (Ed), Russell W. Jamieson MChir, FRCS (Ed) Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this author Rachel Falconer MBChB, MRCS, Rachel Falconer MBChB, MRCS orcid.org/0000-0002-4621-4085 Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this authorEuan N. Munro MD, FRCSEng, FRCSEd Gen, Euan N. Munro MD, FRCSEng, FRCSEd Gen Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this authorRussell W. Jamieson MChir, FRCS (Ed), Russell W. Jamieson MChir, FRCS (Ed) Department of Vascular Surgery, Aberdeen Royal Infirmary, Aberdeen, UKSearch for more papers by this author First published: 11 July 2017 https://doi.org/10.1111/ans.14102Read 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. Volume89, Issue4April 2019Pages 425-426 RelatedInformation

OBJECTIVE:Endoleak remains the Achilles heel of endovascular aneurysm repair and the exclusion of Type II endoleaks, in particular, remains challenging. This systematic review presents the evidence for ethylene-vinyl-alcohol-copolymer liquid embolic agent as a monotherapy in the treatment of endoleaks. METHODS:A systematic literature search was performed for all studies reporting the use of liquid embolic agent as a sole agent in the treatment of endoleaks. Patient numbers, clinical details (endoleak type, route of delivery) and outcome in terms of survival, technical and clinical success with freedom from endoleak together with follow-up period were examined. RESULTS:Only 12 articles reporting the use of liquid embolic as the sole treatment modality for endoleaks in 174 patients were identified. All but 21 patients had a Type II endoleak. Transarterial embolization was attempted in 73% of patients with 48 patients having direct sac puncture. Technical success was high at 96%, but in patients with adequate imaging, the clinical success rate dropped to 79%. Complications were sparsely reported and follow-up ranged from 0 to 75 months. CONCLUSIONS:This review highlights the lack of data regarding the use of liquid embolic agent as a monotherapy with only 4 studies including more than 10 patients. Data from the largest series suggests a learning curve exists and no study reports on cost effectiveness. Technical success does not always translate into clinical success and with the largest series only reporting median 4-month follow-up no claims regarding durability can be made. In problematic Type II endoleaks, however, liquid embolic agent is a welcome addition to the treatment armamentarium.

Endovascular technology now permits total endovascular thoracoabdominal aortic aneurysm (TAAA) repair with high volume centres reporting encouraging results. The long-term durability of such stent grafts is unknown, leading to concerns regarding their use in younger patients. This study reports contemporary outcomes of open repair in young patients.

BACKGROUND:The last decade has seen the evolution of vascular surgery from a sub-specialty of general surgery to that of an independent, stand-alone specialty. The introduction of a vascular-only curriculum is anticipated to require significant change from the current provision for vascular surgical training to allow vascular trainees to acquire the specialist skills in elective, emergency, and endovascular surgery to provide endovascular services in the future. AIM:To provide an insight into current vascular training in Scotland and Northern Ireland. METHOD:Specialty trainees in general surgery, with a sub-specialty interest in vascular in Scotland and Northern Ireland were asked to carry out a voluntary online survey between May 2012 and July 2012. RESULTS:22 specialty trainees/specialist registrars who have declared a sub-specialty interest in vascular surgery were identified and polled. 20 trainees completed the survey. 13 trainees still participated in general surgical on-call rotas. Formal teaching opportunities were readily available but only 10 trainees could attend regularly. All trainees worked in units offering endovascular treatment for aneurysm and occlusive disease, but few had dedicated training sessions in endovascular skills. All endovascular simulation-based training was industry sponsored. The majority of trainees report a good overall training experience and are keen to see the implementation of a vascular-specific curriculum. 15 trainees had undertaken a dedicated period of research towards a higher degree, with only 50% based on a vascular topic. CONCLUSION:The majority of trainees reported a positive training experience with Scotland and Northern Ireland having great potential as vascular training deaneries. The survey identifies specific areas that could be improved by the development of the new curriculum in vascular surgery to provide excellent vascular training in Scotland and Northern Ireland.

ANZ Journal of SurgeryVolume 86, Issue 7-8 p. 613-614 IMAGES FOR SURGEONS Popliteal pseudoaneurysm secondary to multiple hereditary exostoses Russell W. Jamieson MChir, FRCS, Russell W. Jamieson MChir, FRCS Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorFungai Dengu BMedSci, MBChB, Fungai Dengu BMedSci, MBChB Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorDaniel E. Porter MD, FRCSEd (Tr&Orth), Daniel E. Porter MD, FRCSEd (Tr&Orth) Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorDavid R. Lewis MD, FRACS (Vasc), David R. Lewis MD, FRACS (Vasc) Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this author Russell W. Jamieson MChir, FRCS, Russell W. Jamieson MChir, FRCS Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorFungai Dengu BMedSci, MBChB, Fungai Dengu BMedSci, MBChB Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorDaniel E. Porter MD, FRCSEd (Tr&Orth), Daniel E. Porter MD, FRCSEd (Tr&Orth) Department of Orthopaedics and Trauma, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this authorDavid R. Lewis MD, FRACS (Vasc), David R. Lewis MD, FRACS (Vasc) Edinburgh Vascular Surgical Services, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UKSearch for more papers by this author First published: 27 June 2014 https://doi.org/10.1111/ans.12733Citations: 2Read 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 onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume86, Issue7-8July-August 2016Pages 613-614 RelatedInformation

Aortic arch anatomy is variable, 70% of the population has the most common variant; a right innominate, left carotid and left subclavian origin from the arch.1Adachi B. Hasebe K. Igakubu K.D. Das Arteriensystem der Japaner. Vol 1. Maruzen Co, Kyoto1928: 85-92Google Scholar Here we display a three-dimensional vessel reconstruction of the computed tomogram (CT) angiogram of a 74-year-old man with a distal aortic arch aneurysm. This was complicated by variant aortic arch anatomy with an Adachi type C configuration featuring a separate left vertebral artery arising from the arch (A/Cover and B). A separate origin for the left vertebral is a relatively uncommon variant with an estimated prevalence ranging between 0.68% and 7.41%.2Bhatia K. Ghabriel M.N. Henneberg M. Anatomical variations in the branches of the human aortic arch: a recent study of a South Australian population.Folia Morphol (Warsz). 2005; 64: 217-223PubMed Google Scholar Open repair of thoracic aortic aneurysms is surgically challenging and is associated with significant morbidity and mortality. Endovascular stent graft exclusion offers a less invasive approach but relies on good proximal and distal graft sealing zones. To obtain satisfactory proximal seal, hybrid endovascular repair with open extra-anatomic bypass procedures or vessel reimplantation may permit coverage of the great vessel origins by the stent graft. In the present case, the origins of the left subclavian and left carotid arteries were covered to obtain an adequate proximal seal. An extra-anatomic right-to-left carotid-carotid bypass was performed using 8-mm ring-supported polytetrafluoroethylene (Gore Medical, Flagstaff, Ariz), and the left vertebral was reimplanted onto the left common carotid artery with ligation of the proximal left common carotid and vertebral arteries. Subsequent endovascular aneurysm exclusion using a 34- by 127-mm thoracic aortic stent graft (Cook Medical, Inc, Bloomington, Ind) was uncomplicated. Postoperative three-dimensional CT vessel reconstruction images demonstrate the final anatomy (C and D). At immediate and 12- month follow-up, no neurologic compromise was evident, the left arm remained well perfused, and imaging showed no evidence of endoleak or migration.

Endovascular technology can now support total endovascular thoracoabdominal aortic aneurysm repair with branches maintaining visceral and renal perfusion thus avoiding the need for massive open surgery. High‐volume centres have reported encouraging results. We report our Australasian experience of 10 cases including the first‐in‐man ‘off‐the‐shelf’ graft.

Aortic aneurysms, the majority of which affect the infrarenal abdominal portion of the aorta, are responsible for 1–2% of all deaths in men aged over 65 years in the Western world. The disease most commonly represents a multifactorial degenerative process involving both genetic and environmental risk factors and is characterized pathologically by a reduction in elastic lamellae within the aortic wall. The natural history of the condition is one of progressive enlargement with an associated increase risk of aneurysm rupture. Although aneurysm rupture remains a catastrophic event, with an overall mortality of approximately 80%, the majority of patients are asymptomatic. Asymptomatic aneurysms are usually diagnosed as an incidental finding and management relies on an assessment of the risks of future aneurysm rupture weighed against the risks associated with elective surgical repair. Aneurysm repair may be accomplished by traditional open surgery or minimally invasive endovascular repair. Although the latter confers a short-and medium-term survival advantage in selected patients, long-term follow-up data suggest this benefit may not persist. Thoracoabdominal aortic aneurysm disease is considerably more complex, with intervention, even in specialist centres, associated with significant morbidity and mortality. Best medical management of aortic aneurysm disease requires control of blood pressure, smoking cessation together with aspirin and statin therapy. Screening has been introduced in an effort to identify a largely silent killer although with better medical management the overall prevalence may be in decline.

Background: Aortic graft infection is a rare, but grave, complication in vascular surgery. Graft removal together with extra-anatomical bypass or in situ graft replacement is usually advocated, but these procedures are associated with significant morbidity and mortality.Methods and Results: Two cases of aortic graft infection in high-risk surgical candidates managed by open debridement and omental wrapping with graft preservation are described. Both remain well at 3 years without any adjunctive procedures.Conclusion: Debridement and omental wrapping may offer an alternative to graft removal and revascularization in selected patients. This relatively low-risk procedure may allow long-term survival.

BACKGROUND:Steatotic livers are increasingly common in the donor population. Cold storage of steatotic livers exacerbates ischemia-reperfuson injury and risks primary nonfunction and recipient death. Normothermic preservation avoids prolonged cooling of the organ and may be well suited to the preservation and resuscitation of damaged livers. By ex vivo normothermic perfusion, it may be possible to preserve and improve steatotic livers, so that transplantation is a viable option.METHODS:In a porcine model, streptozotocin was used to induce a hyperglycemic, ketotic state that, together with a high fat diet, resulted in mild hepatic steatosis at 5 weeks. A blood-based oxygenated ex vivo normothermic preservation system was then used to compare extended preservation of normal and mildly steatotic porcine livers at physiological pressures and flows. Serial liver biopsies were stained with Oil Red O, a specialist triglyceride stain, and were analyzed using custom-designed image analysis to quantify the degree of lipid deposition.RESULTS:Steatotic livers were capable of correcting the perfusate base excess and maintaining factor V and bile production and showed markers of liver injury comparable with normal livers. Steatotic livers had a significantly higher urea production and required no glucose support. Preliminary results suggest that prolonged normothermic perfusion results in a reduction in steatosis.CONCLUSIONS:This study suggests that steatotic livers can be successfully preserved using normothermic preservation for prolonged periods and that normothermic preservation facilitates a reduction in hepatic steatosis. Further studies are now needed including transplantation of steatotic livers after normothermic preservation.

Acute aortic occlusion caused by a saddle embolus is a rare vascular emergency. Associated sudden paraplegia secondary to spinal cord ischemia is even more uncommon. Aspergillus surgical site infection is typically linked to cardiac surgery but is exceptional. Here we present a case that combines all of these factors. A 67-year-old man presented with sudden paraplegia from acute aortic occlusion with a saddle embolus from Aspergillus niger aortitis 4 months after aortic valve replacement and aortoplasty. We believe this to be the second reported case of Aspergillus niger aortitis and the first presenting as aortic occlusion with paraplegia. (J Vase Surg 2011;54:1472-4.)

Organ transplantation is one of the medical success stories of the 20(th) century. Transplantation is, however, a victim of its own success with demand for organs far exceeding supply. The ischemia/reperfusion injury associated with organ transplantation is complex with interlinking cellular pathways and cascades. With increasing use of marginal organs and better understanding of the consequences of ischemia/reperfusion, enhanced organ preservation is required. Traditional static cold preservation cannot prevent ischemia/reperfusion injury, the low temperature itself is damaging and viability testing is limited. Donor preconditioning techniques to enhance organ preservation in advance of retrieval are starting to show convergence on several key pathways (HO-1 and cell apoptosis). Microdialysis and bioimpedence techniques may allow viability assessment during cold storage. Hypothermic machine perfusion has a role to play, particularly in preservation of kidneys from non-heartbeating donors although results of clinical trials are awaited. Normothermic preservation offers benefits over cold storage ( at least experimentally) by avoiding damage induced by low temperature, minimising ischemia/reperfusion injury and allowing resuscitation of damaged organs. Normothermic preservation is likely to increase as the average quality of donor organs declines and clinical trials are needed. In the long term, normothermic preservation may be used, not just to resuscitate organs, but facilitate organ immunomodulation.

Although organ preservation has relied upon hypothermia throughout the history of clinical transplantation, increasing reliance on suboptimal organs has recently focused attention on novel techniques that avoid the cumulative effects of preexisting organ damage and cold preservation. Normothermic preservation provides oxygen delivery at physiologic or near-physiologic temperature and allows maintenance of normal cellular metabolism. There is increasing evidence, mainly from experimental models, that this technique reduces preservation-related organ damage and that it has potential application particularly in the transplantation of marginal donor organs. The technical challenges and logistic constraints of what is an intrinsically more complex method have prevented introduction of normothermic preservation other than very limited clinical trials. However, the potential advantages of this technique are considerable, and it is likely that the technical problems will be overcome, allowing more widespread application into clinical practice.

PBS140 offers good cold preservation in renal transplantation and now, crucially, has been shown to promote immediate function following warm ischemia. For a new cold preservation solution to compete with UW solution, improved efficacy and lower price may not be enough. Reducing rates of delayed graft function in organs from non-heart-beating and marginal donors might be the key.