Phillip Puckridge

Neutrophil-lymphocyte ratio as a prognostic marker of outcome in infrapopliteal percutaneous interventions for critical limb ischemia

BACKGROUND Endovascular intervention has become a frequently used treatment of critical limb ischemia (CLI) in recent times. The recent Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial consensus recommended endovascular treatment as a first-line treatment in patients who have a life expectancy that was limited to <2 years. Despite these recommendations, there still remains limited data available to clinicians when seeking to risk stratify patients who present with CLI. The neutrophil-lymphocyte ratio (NLR) has been suggested to be a marker for predicting mortality and patency. This study aimed to investigate the use of the NLR as a prognostic marker for primary patency and mortality after an infrapopliteal endovascular intervention in patients with CLI. METHODS All patients who underwent tibial angioplasty for CLI were retrospectively analyzed. Demographics, degrees of stenosis, vessel patency rates, mortality, and comorbidities were recorded. NLRs were calculated from preoperative blood samples. Primary end points were all-cause mortality, primary patency, and amputation-free survival (AFS) within the follow-up period of 12 months. Multivariate Cox proportional hazard models were used to identify independent predictors. Overall survival, AFS, and the probability of a vessel remaining patent were evaluated by standard Kaplan-Meier survival curves and groups compared by the log-rank test. RESULTS Eighty-three patients were monitored for 12 months. Ninety limbs were identified, with 104 procedural events and 127 vessels undergoing successful angioplasty. The technical success rate was 86%, and patency at 1 year was 19%. Survival at 1 year was 76% and AFS was 61%. Patients with a NLR ≥5.25 had an increased risk of death (hazard ratio, 1.97; 95% confidence interval, 1.08-3.62; P = .03) compared with those with a NLR of <5.25. Furthermore, those with lymphocytes counts of <1.5 × 10(9)/L had higher mortality (hazard ratio, 1.88; 95% confidence interval, 1.02-3.70; P = .045) than those with lymphocyte counts >1.5 × 10(9)/L. CONCLUSIONS The NLR and absolute lymphocyte counts are potentially valuable prognostic indicators for risk stratification of patients presenting with CLI undergoing infrapopliteal angioplasty.

Severe bilateral renal artery stenosis after transluminal radiofrequency ablation of renal sympathetic nerve plexus

Percutaneous renal sympathetic denervation is an evolving therapy for resistant hypertension. Evidence to date demonstrates a reduction of blood pressure in the short term to medium term. Reported complications relate to problems with vascular access vessels and dissection of the renal artery. Renal artery stenosis has not been described in the literature. We present a patient with hypertensive crisis, flash pulmonary edema, and deterioration of renal function, secondary to bilateral renal artery stenosis, 9 months after renal sympathetic radiofrequency ablation denervation.

PERIOPERATIVE HIGH-DOSE OXYGEN THERAPY IN VASCULAR SURGERY

Background:  Patients undergoing infrainguinal bypass surgery have reduced baseline tissue oxygen tension and high rates of wound infections. The hypoxaemia worsens during surgery, potentially reducing the ability to combat bacterial lodgement. We investigated whether high‐dose perioperative oxygen administration to patients undergoing infrainguinal arterial surgery results in increased tissue oxygenation.

A 3-year follow-up study of inpatients with lower limb ulcers: evidence of an obesity paradox?

Objectives To determine whether body composition is related to long-term outcomes amongst vascular inpatients with lower limb ulcers. Design Prospective study with 3 years follow-up. Materials and methods Body mass index (BMI), fat, and fat-free mass were measured and associations with readmission to hospital (number, cause, length of stay) and all-cause mortality were explored. Results Thirty patients (22 men, 8 women) participated in the study. Ten patients (33%) had a BMI ≥ 30 kg/m2. 18/20 (90%) patients with a BMI < 30 kg/m2 and 9/10 (90%) patients with a BMI ≥ 30 kg/m2 were admitted to hospital in the 3 years of follow-up. Patients with a BMI < 30 kg/m2 were admitted more frequently, earlier and for longer compared to those with BMI ≥ 30 kg/m2 but these did not reach statistical significance. The 3 year mortality rate for patients with BMI ≥ 30 kg/m2 was 20% (n = 2/10) compared to 70% (n = 14/20) with a BMI < 30 kg/m2, P = 0.019. Conclusion This preliminary study suggests that higher BMI may have a protective effect against mortality in vascular patients with lower limb ulcers. These findings contradict the universal acceptance that obesity leads to poor health outcomes. Further work is required to confirm these findings and explore some of the potential mechanisms for this effect.

The use of ultrasound to assist deployment of the StarClose vascular closure device in arterial access sites.

Access site complication rates remain relatively high following interventional procedures and have not been shown to be reduced by the use of vascular closure devices. This report describes an ultrasound-assisted technique of deploying one type of vascular closure device, the StarClose (Abbott Vascular, Illinois, USA). This technique has significantly reduced failure rates and complication rates since its introduction. The technique is relatively simple but requires familiarity with the use of ultrasound and the StarClose device.

A pilot study of the development and implementation of a ‘best practice’ patient information booklet for patients with chronic venous insufficiency

Objective Chronic venous insufficiency (CVI) is a chronic condition that has a significant impact on the individual. For the effective, long-term management of CVI, it is important that patients are educated on the patho-physiology of the condition and strategies that can minimize the related complications. Therefore, the aim of this study was to develop and pilot a ‘best practice’ information booklet for CVI and to assess the impact of this booklet on CVI-related knowledge and quality of life (QOL). Method A ‘best practice’ CVI booklet was developed based on the best available evidence from the literature. Participants with a formal diagnosis of CVI with a clinical, aetiological, anatomical and pathological elements (CEAP) classification of 3–6 were recruited from vascular outpatient clinics at a tertiary hospital. Each participant was given and explained the CVI booklet and asked to undertake the recommended activities at home over the next six-month period. Measurements were taken at baseline, one month and six months postbooklet implementation via the previously validated Health Education Impact and the CVI Questionnaires. Results Twenty-six participants, aged 38–90 years (mean 71.8 ± 12.9 years) initially participated in the study, with 20 participants remaining at the six-month time point (77% completion rate). At the end of one month, there had been a significant improvement in doing at least one activity to improve CVI (P = 0.010), monitoring CVI (P = 0.045), having effective ways to prevent CVI symptoms (P = 0.045), knowing CVI triggers (P = 0.005), ability to travel by car and bus (P = 0.05), undertaking social activities (P = 0.030) and feeling less embarrassed about the legs (P = 0.025). At trial end (6 months), there was a significant improvement in doing at least one activity to improve CVI (P = 0.003), knowing CVI triggers (P = 0.016), having effective ways of preventing CVI symptoms (P = 0.008), worrying about the CVI (P = 0.030), feeling hopeless because of CVI problems (P = 0.007), leg and ankle pain (P = 0.038), ability to do domestic duties (P = 0.017), feeling nervous and tense (P = 0.026), and feeling less embarrassed about the legs (P = 0.008). Although other domains improved in the study, none of these improvements were statistically significant. Conclusion Although a small pilot study, the outcomes demonstrate that the implementation of a ‘best practice’ CVI information booklet into a patients management routine can improve both CVI-related knowledge and QOL.

Nutritional issues in older adults with wounds in a clinical setting

Background The ability for patients to access and consume sufficient quantities of nutrients to meet recommendations for wound management is vital if decline in nutritional status during hospital admission is to be prevented. This study aims to investigate menu quality, consumption patterns, and changes in nutritional status for inpatients with wounds. Methods Wound healing recommendations were compared against the nutrient content of the inpatient menu. Individual intakes were compared to estimated requirements: energy using the Schofield equation; protein using wound healing recommendations; vitamin A, C, and zinc using the recommended daily intake (RDI). Results The inpatient menu did not provide sufficient energy or zinc to meet the estimated average requirement while the ordering practices of participants allowed all RDI to be achieved except for zinc. Actual intake fell below recommendations: 62%, 41%, 55%, and 79% of patients not meeting energy, minimum protein requirements, vitamin A or zinc RDI respectively. A nonsignificant trend for weight loss, particularly fat mass, was observed over time. Conclusion Inpatients with wounds are at risk of being unable to consume sufficient quantities of nutrients important for healing and prevention of decline in nutritional status. This is despite the menu seemingly providing sufficient nutrients. More attention to education, encouragement, and supplementation are recommended.

Type 3 endoleak following endovascular abdominal aortic aneurysm repair

Endovascular aneurysm repair (EVAR) is a frequently used method for aneurysm repair, with benefits including lower early morbidity and mortality, earlier discharge from hospital and less blood loss. Patients with EVAR may however have a higher re-intervention rate than conventional open surgery due to complications that are specific to EVAR. Endoleaks are one such complication, causing ongoing blood flow within an aneurysmal sac. Type 1 endoleaks develop from poor apposition between one or more attachment sites of the graft and native vessel causing a high-pressure leak into the aortic sac; type 2, the commonest type of endoleak, is caused by retrograde flow of blood from small tributaries into the sac and is generally considered benign. Type 3 endoleaks, a high-risk and high-pressure leak, is caused by separation of or a defect in graft components, and type 4 endoleaks are due to graft porosity and usually spontaneously settle. Type 1 and 3 endoleaks are uncommon but may lead to aneurysm rupture and need to be investigated and treated with urgency. An 85-year-old man presented with a 7-cm infrarenal abdominal aortic aneurysm extending to the aortic bifurcation and underwent EVAR using a Cook Zenith graft. At the end of the procedure, no endoleak was identified. Surveillance ultrasound 3 months post-procedure demonstrated a type 2 endoleak felt to arise from the inferior mesenteric artery. This was observed for 18 months, over which time the aortic sac increased in size to 8.1 cm, confirmed with computed tomography angiography (CTA). Due to sac size increasing, coil embolization of the endoleak was performed via the superior mesenteric artery through the arc of Riolan. There was no residual endoleak visualized at the end of the procedure (Fig. 1). Over the next 5 months, surveillance demonstrated that the aneurysm sac size continued to increase to 9 cm. An ultrasound and CTA (Fig. 2) failed to demonstrate a definite endoleak, but the ultrasound demonstrated an anechoic area around the graft suggestive of fresh blood within the sac. After radiological investigation failed to reveal a cause, it was decided to proceed with open surgical exploration to find and treat the presumed endoleak. Laparotomy was performed and the aortic sac was opened without clamping; fluid under high pressure among old thrombus was immediately encountered within the sac. Upon careful removal of the degenerating thrombus without touching the endograft, bleeding was noted coming from four pin-prick sized holes of the right limb of the stent graft, consistent with a type 3 endoleak from a defect in the fabric (Fig. 3). The holes were associated with the Prolene sutures (Ethicon, Somerville, NJ, USA) that attach the stents to the graft fabric. After initial haemostasis was obtained with compression and Surgicell application, the