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Quality Indicators in Peripheral Arterial Occlusive Disease Treatment: A Systematic Review

This systematic review aimed to identify evidence based quality indicators for invasive revascularisation of symptomatic peripheral arterial occlusive disease (PAOD).

Risk factors for mortality after endovascular repair for blunt thoracic aortic injury

Journal of Vascular Surgery - September 13, 2019 - 00:00
Despite high use of endovascular repair, blunt thoracic aortic injury (BTAI) leads to significant mortality. We sought to identify risk factors and create a predictive model for mortality after thoracic endovascular aortic repair (TEVAR) based on available preoperative clinical data.

Carotid endarterectomy after systemic thrombolysis in a stroke population

Journal of Vascular Surgery - September 13, 2019 - 00:00
Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, and even fewer studies have included a control group. The aim of this study was to evaluate the overall outcome of patients undergoing CEA after IVT and to compare them with contemporary patients with CEA after simple stroke (non-IVT group).

The Vascular Quality Initiative 30-day stroke/death risk score calculator after transfemoral carotid artery stenting

Journal of Vascular Surgery - September 13, 2019 - 00:00
Carotid artery stenting (CAS) was introduced as an alternative carotid revascularization procedure in patients deemed to be at high risk for carotid endarterectomy. Although techniques and selection criteria for patients have dramatically improved, CAS continues to have higher risk of stroke and death in comparison to carotid endarterectomy. Several risk factors are known to be associated with worse outcomes. Whereas knowledge of these independent factors is helpful, clinical decision-making is further refined when these are considered in aggregate.

Gastroepiploic artery pseudoaneurysm: a rare cause of abdominal pain

ANZ Journal of Surgery - September 12, 2019 - 19:09
ANZ Journal of Surgery, EarlyView.

Near‐infrared spectroscopy in the diagnosis of testicular torsion: valuable modality or waste of valuable time? A systematic review

ANZ Journal of Surgery - September 12, 2019 - 03:33

Testicular torsion (TT) is a urological emergency that affects one in 4000 males younger than 25 years. Delays in the management of TT may result in testicular ischaemia, testicular necrosis, orchidectomy and infertility. This review assesses the validity of near‐infrared spectroscopy as a diagnostic tool in the assessment and diagnosis of TT.


Abstract Background

Testicular torsion (TT) is a urological emergency that affects one in 4000 males younger than 25 years. Delays in the management of TT may result in testicular ischaemia, testicular necrosis, orchidectomy and infertility. This review assesses the validity of near‐infrared spectroscopy (NIRS) as a diagnostic tool in the assessment and diagnosis of TT.

Methods

A systematic search of Cochrane Database of Systematic Reviews, EMBASE, Google Scholar, PubMed, Scopus and Web of Science databases was performed in January 2019 using specific search terms. Selected studies were ranked and evaluated using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines and the Quality Assessment of Diagnostic Accuracy Studies‐2 tool.

Results

A total of nine studies that included 253 subjects (88 animals and 165 humans) with a mean sample size of 28.1 (standard deviation 40.8) subjects were included. The mean difference in testicular tissue oxygen saturation between torsed and non‐torsed testes (Δ%StO2) were 45%, 42% (±5%), 26% and 5–18% in four animal studies and 2.0%, 3.0%, 6.7%, 6.8% and 23.0% in five human studies. The tissue oxygen saturation difference between contralateral healthy testes (controls) ranged from 1% to 10% in the five studies that alluded to this.

Conclusion

The current body of evidence does not support the use of NIRS in the work‐up of TT. Well‐designed clinical trials with large patient samples are required to determine whether NIRS may have some future role as a diagnostic modality in TT.

Clinical state of the paediatric acute scrotum in south‐eastern Victoria

ANZ Journal of Surgery - September 11, 2019 - 20:04

This is a prospective study investigating delays in assessment and treatment of acute scrotal pain in children. We identify potential delays from the time of onset of the pain to seeking medical advice at different healthcare providers


Abstract Background

Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay.

Methods

We conducted a prospective study (April 2017–November 2018) of paediatric patients (<18 years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes.

Results

A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo‐orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11 years (4 months–16 years). Fifty‐seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0–135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67–24.5) h; via GP to paediatric ED was 2.58 (0.75–25.5) h; via local ED to paediatric ED was 2.25 (1–7.75) h; and directly to paediatric ED was 0.45 (0–1.42) h.

Conclusion

Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base.

Clinical predictors of small solitary hepatitis B virus‐related hepatocellular carcinoma microinvasion

ANZ Journal of Surgery - September 11, 2019 - 20:03
Abstract Background

Microinvasion serves as a reliable indicator of poor prognosis after hepatectomy or transplantation for hepatocellular carcinoma (HCC). However, microinvasion is difficult to detect with current imaging modalities and is usually diagnosed histopathologically. The aim of this study is to identify the preoperative clinical predictors of microinvasion of small solitary hepatitis B virus (HBV)‐related HCC.

Methods

From January 2000 to December 2009, 110 patients with HBV‐related small primary solitary HCC (tumour diameter ≤3.0 cm) who underwent hepatectomy at Chinese PLA General Hospital were enrolled. The independent predictors of microinvasion, such as microvascular invasion and microscopic satellite nodules, were analysed. The prognosis of patients with microinvasion was compared with that of patients without microinvasion.

Results

Of the 110 patients, 31 (28.2%) exhibited microinvasion. Among them, 16 (51.6%) had microvascular invasion with microscopic satellite nodules, five (16.1%) had microscopic satellite nodules without microvascular invasion and 10 (32.3%) had microvascular invasion without microscopic satellite nodules. Two independent predictors of microinvasion were identified: serum alpha‐fetoprotein >20 ng/mL and a viral load of >104 copies/mL. Patients without microinvasion exhibited a significantly better prognostic outcome compared with those with microinvasion.

Conclusion

Regarding HBV‐related small HCC, patients presenting with alpha‐fetoprotein levels >20 ng/mL and a high viral load (HBV‐DNA >104 copies/mL) are at substantial risk for microinvasion.

Corrigendum to ‘Trends in Major Lower Limb Amputations Related to Peripheral Arterial Disease in Hungary. A Nationwide Study (2004–2012).’[European Journal of Vascular & Endovascular Surgery 50/1 (2015) 78–85]

The authors regret that in their previous paper titled ‘Trends in major lower limb amputations related to peripheral arterial disease in Hungary. A nationwide study (2004–2012).' that appeared in EJVES (Vol. 50, no. 1, pp. 78–85, Jul 2015). A minor numerical error was found in Table 2, where standardized incidences were given. The standardization was accidently performed using a wrong reference population (counts for two age groups were interchanged). The correct numbers in Table 2, following recalculation, are:

Expanded Petticoat technique to promote the reduction of contrasted false lumen volume in patients with chronic type B aortic dissection

Journal of Vascular Surgery - September 11, 2019 - 00:00
This study examined the outcomes of our novel concept of expanded provisional extension to induce complete attachment strategy (Petticoat) for safety, durability, and remodeling of chronic type B dissections.

Urgent retrograde two-stage hybrid repair of a complicated blunt traumatic aortic injury

Journal of Vascular Surgery - September 11, 2019 - 00:00
Blunt traumatic aortic injury (BTAI) is a rare but life-threatening emergency that is usually caused by sudden acceleration/deceleration injuries in vehicular accidents. We describe our initial experience of a retrograde two-stage hybrid treatment approach for the emergent management of a 63-year-old motorcyclist who presented with a complicated BTAI with malperfusion syndrome. To our best knowledge, this uncommon BTAI case with fatal distal malperfusion saved by an urgent retrograde two-stage hybrid procedure has been reported rarely.

Ten‐year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

ANZ Journal of Surgery - September 10, 2019 - 05:00
Abstract Background

We aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life‐threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre.

Methods

A retrospective study of prospectively collected data was performed over a 14‐year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre‐MTP group (2002–2006), an MTP‐I group (2006–2010) and an MTP‐II group (2010–2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused.

Results

A total of 168 patients were included: 54 pre‐MTP patients were compared to 47 MTP‐I and 67 MTP‐II patients. In the MTP‐II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP‐I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay.

Conclusion

Introduction of an MTP‐II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real‐life medical care in a level 1 civilian trauma centre.

Long-term outcomes comparing endovascular and open abdominal aortic aneurysm repair in octogenarians

Journal of Vascular Surgery - September 10, 2019 - 00:00
Patients older than 80 years have significantly lower early mortality with endovascular aneurysm repair (EVAR) compared with open repair for abdominal aortic aneurysms (AAAs), but long-term results remain poorly studied. We analyzed the results of both emergent and elective AAA repair in patients aged 80 years or older who had at least 5 years of follow-up.

Development of drug-coated balloon for the treatment of multiple peripheral artery segments

Journal of Vascular Surgery - September 10, 2019 - 00:00
Peripheral artery disease is the second most common cardiovascular disease. It can often occur in complex form when there is a presence of long, diffuse, and multiple lesions. Current treatments use either single long drug-coated balloons (DCBs) or multiple DCBs; however, treatment success is limited. The purpose of this study was to investigate the preclinical feasibility of our multiple-release Tailored Medical Devices DCB (MR-TMD-DCB) to treat multiple arterial segments using a single DCB.

Concomitant ipsilateral carotid endarterectomy and stenting is an effective treatment for tandem carotid artery lesions

Journal of Vascular Surgery - September 10, 2019 - 00:00
Data regarding the treatment of tandem carotid artery lesions at the bifurcation and ipsilateral, proximal common carotid artery (CCA) are limited. It has been suggested that concomitant treatment with carotid endarterectomy (CEA) and proximal ipsilateral carotid artery stenting confers a high risk of stroke and death. The objective of this study was to evaluate the technique and outcomes of this hybrid procedure at a single institution.

Risk score for nonhome discharge after lower extremity bypass

Journal of Vascular Surgery - September 10, 2019 - 00:00
Patients undergoing lower extremity bypass (LEB) for peripheral artery disease require intensive health care resource utilization including rehabilitation and skilled nursing facilities. However, few studies have evaluated factors that lead to nonhome discharge (NHD) in this population of patients. This study sought to predict NHD by preoperative risk factors in patients undergoing LEB for peripheral artery disease using a novel risk score.

Outcomes of atherectomy for lower extremity ischemia in an office endovascular center

Journal of Vascular Surgery - September 10, 2019 - 00:00
To evaluate the safety and effectiveness of infrainguinal artery revascularization via atherectomy supplemented with other endovascular techniques in an office endovascular center (OEC) setting.

Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions

Journal of Vascular Surgery - September 10, 2019 - 00:00
Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival.

Clinicopathological factors associated with positive circumferential margins in rectal cancers

ANZ Journal of Surgery - September 9, 2019 - 18:51

The incidence of advanced T3/T4 rectal cancers with positive circumferential resection margins after surgery in Western Sydney is significantly higher than recent national estimates. This may be exacerbated by failure to treat eligible patients with appropriate neoadjuvant therapy.


Abstract Background

Positive circumferential resections are associated with local disease recurrence and reduced survival in rectal cancer. We studied a cohort of consecutive rectal cancer resections to assess for clinicopathological differences and survival in patients with positive and negative circumferential margins.

Methods

Rectal cancers were identified from a retrospective histopathology database of colorectal resections performed at five western Sydney hospitals from 2010 to 2016. Univariate and multivariate analysis with binary logistic regression were performed on histopathology data matched with survival times from the New South Wales Registry of Births Deaths and Marriages.

Results

A total of 502 rectal cancer patients were identified including 66 (13.1%) with involved circumferential margins. Patients with positive and negative circumferential margins had a similar distribution of age, gender and use of neoadjuvant radiotherapy. Tumours with involved circumferential margin comprised 98.5% T3 and T4 disease of which 51.5% received neoadjuvant radiotherapy. These were significantly associated with metastatic disease, increasing tumour size, circumferential and perforated tumours on univariate analysis. Multivariate analysis identified abdomino‐perineal resection (odds ratio (OR) 3.35; P = 0.003), en‐bloc multivisceral resection (OR 2.56; P = 0.032), T4 stage (OR 6.99; P < 0.001), perineural (OR 5.61; P < 0.001) and vascular invasion (OR 2.46; P = 0.022) as independent risk factors. Five‐year survival was significantly worse for patients with involved circumferential margins (26% versus 69%; P < 0.001).

Conclusion

Circumferential margin status reflects not only technical success but also aggressive disease phenotypes which require adjuvant therapy. Further work is needed to determine whether omission of radiotherapy has had an effect on long‐term outcomes in some of our at‐risk patients.

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