Stuart Suttie

Immediately Postoperative B-Type Natriuretic Peptide and Its Predictive Value

BACKGROUND Major vascular surgery involves a high risk of major cardiovascular morbidity and mortality. A method of predicting perioperative myocardial events is required. Preoperative B-type natriuretic peptide (BNP) has been evaluated for this purpose. The aims of this study were to determine the postoperative course of BNP levels and correlate these levels with the outcome. METHODS The present study included 45 patients undergoing major vascular surgery. These patients further underwent serial venous blood sampling for troponin-T and BNP and serial electrocardiograms, pre- and postoperatively (immediately postoperatively and at days 1 through 4). RESULTS Of the 45 patients, seven suffered myocardial damage, as defined by troponin-T. An immediate postoperative BNP (cutoff, 171 pg/mL) was better able to predict cardiac damage (p = 0.027) than BNP levels preoperatively (cutoff, 281 pg/mL, p = 0.042) and on day 1 postoperatively (cutoff, 182 pg/mL, p = 0.032). Only the preoperative BNP levels showed an effect on survival. Patients with a preoperative BNP >281 pg/mL had a mean survival of 12.7 months, as compared with 17.6 months for patients with a BNP <281 pg/mL, p = 0.044. CONCLUSION Preoperative BNP is an accurate determinant of postoperative cardiac morbidity and all cause survival, with BNP in the immediate postoperative period being an even more accurate predictor of cardiac events. An immediate postoperative BNP might help risk stratify patients for the next 72 hours in the perioperative period (and maybe longer).

Use of a Javid™ shunt in the management of axillary artery injury as a complication of fracture of the surgical neck of the humerus: a case report

IntroductionAxillary artery injury is a rare but severe complication of fractures of the surgical neck of the humerus.Case presentationWe present a case of axillary artery pseudoaneurysm secondary to such a fracture, in a 82-year-old white woman, presenting 10 weeks after the initial injury, successfully treated with subclavian to brachial reversed vein bypass together with simultaneous open reduction and internal fixation of the fracture. We discuss the use of a Javid™ shunt during combined upper limb revascularisation and open reduction and internal fixation of the fractured humerus.ConclusionThis case highlights the usefulness of a Javid™ shunt, over other forms of vascular shunts, in prompt restoration of blood flow to effect limb salvage. It can be considered as a temporary measure whilst awaiting definitive revascularisation which can be performed following fracture fixation.

Outcome from abdominal aortic aneurysms in Scotland, 1991–2006

This study assessed the impact of sex, presentation and treatment on outcome from abdominal aortic aneurysm (AAA) in Scotland.

Natural history of upper limb arterio-venous fistulae for chronic hemodialysis

Purpose Arterio-venous fistulae (AVF) for hemodialysis are prone to problems, ultimately leading to failure of the fistulae. Our aim was to determine the site and time to first stenosis and time to and factors influencing AVF failure for radio-cephalic (RC), brachio-cephalic (BC), and transposed brachio-basilic (BB) AVF. Methods Retrospective analysis of native AVF constructed within a single vascular unit between January 2002–December 2008. Patients followed up to the end points of death, AVF failure or end of study period. Data collected included: age, sex, AVF type, time and site of first stenosis and time to failure. The relationship between fistula type, stenosis, and failure were examined. Results In total, 398 native AVF were included in the study (91 RC, 208 BC, and 99 BB), with a mean age of 66 years. A total of 215 (54%) AVF developed a flow limiting stenosis, and over time 151 (40%) AVF failed. Stenoses developed significantly earlier in RC AVF (median 113 days) compared to BC (median 277 days), compared to BB (median days 414), P=.029. There was no statistically significant difference in time to failure (RC median 1344 days; BC median 1576 days; BB median 1159 days), P=.673. The presence of stenosis was the only variable found to have a significant impact on AVF failure in multivariate analysis. Conclusions Type of upper limb fistula did not impact on failure rates. Flow limiting stenoses impacted on fistula failure.

Necrotizing Soft Tissue Infections in Intravenous Drug Users: A Vascular Surgical Emergency

OBJECTIVE To assess the short and long-term outcomes of necrotizing soft tissue infection (NSTI) in intravenous drug users (IVDU) in a regional vascular centre. METHODS This was a retrospective analysis of all IVDUs with NSTI admitted to the regional vascular surgical unit between January 2009 and July 2014. Clinical outcome measures were interval between admission and surgery, length of ITU/HDU and hospital stays, post-operative complications, in hospital and one year mortality. RESULTS 25 patients were admitted. The median age was 39 years (range 30-53 years) with a female to male ratio of 1:3.3. The median interval between admission and surgery was 23 hours (range 2-195 hours), however, this was significantly less when the admitting specialty was directly to vascular surgery (median 4 hours, range 2-7) compared with other specialties (median 38 hours, range 7-195 hours). Ten patients required HDU/ITU care with a median duration of 4 days (range 1-12 days). Five patients (20%) required amputation, of whom two (40%) had a prosthetic limb fitted. There was one in hospital death (4%). Another patient died while awaiting limb fitting 4 months post discharge, giving a 1 year mortality of 8%. CONCLUSIONS NSTI in IVDUs carries high risk of amputation with a very low rate of limb fitting. Intervention is significantly delayed when the admitting specialty is not vascular surgery, and half of these patients require HDU/ITU care, with significant morbidity and mortality. Early diagnosis and referral to vascular surgery is crucial in management of these patients.

Spiral Laminar Flow: a Survey of a Three-Dimensional Arterial Flow Pattern in a Group of Volunteers

OBJECTIVE Spiral laminar flow was suggested as potentially the predominant arterial blood flow pattern many years ago. Computational fluid dynamics and flow rig testing have suggested there are advantages to spiral laminar flow. The aim of this study was to identify whether spiral laminar is the predominant flow pattern in a cohort of volunteers. METHODS This study included 42 volunteers (mean age 66.8 years). Eleven arterial sites were examined, comprising bilateral examination of the common carotid artery, internal carotid artery, external carotid artery, common femoral artery, superficial femoral artery, and the infra renal aorta. The presence or absence of spiral laminar flow, the peak systolic velocity, and the rotational velocity were assessed by colour Duplex scanning. RESULTS The incidence of spiral laminar flow ranged from 81% in the internal carotid artery to 90% in the common carotid artery and the infra renal aorta. Overall, in 58% of all right-sided arteries the rotation was clockwise and 42% anticlockwise. In all left-sided arteries these numbers were reversed. Analysis on the basis of volunteer rather than examination site showed that 41/42 (97%) had more sites with spiral laminar flow than without. Only one volunteer had more sites exhibiting non-spiral laminar flow. CONCLUSION Spiral laminar flow was the predominant flow pattern in the study population. This observation raises questions and suggests a need for further studies concerning the form and function of the left ventricle, the geometry of the arterial system, and the function of the arterial wall.

A rare cause of massive haematuria: Internal iliac artery-ureteric fistula.

Ureteric fistula into the arterial tree is a well-recognised, but uncommon condition. The involvement of internal iliac artery is rare. We present a rare case of fistulous communication and subsequent infection of an internal iliac artery aneurysm and ureter secondary to insertion of ureteric stent following endovascular exclusion of the aneurysm and its management. Nephrostogram identified the fistula not seen on computerised tomography. This case highlights the awareness of such pathology allowing for prompt recognition of the condition and importance of appropriate imaging.

The United Kingdom and Ireland experience of the Haemodialysis Reliable Outflow graft for vascular access

Objectives: To describe the UK and Ireland experience of the Haemodialysis Reliable Outflow graft in complex vascular access. Design: Observational, multi-centre case series. Methods: Data from any patient undergoing Haemodialysis Reliable Outflow graft were collected from eight UK and one Irish centre. Any Haemodialysis Reliable Outflow procedure between July 2013 and May 2016 was included. Demographics, primary and secondary patency rates, and complications were analysed. Results: A total of 52 patients underwent Haemodialysis Reliable Outflow graft insertion. Median age was 55 (20–86) years, 24 (46%) were male and 66% were Caucasian. Median follow-up was 290 (10–966) days and patient survival was 41/52 (79%). In total, 48 procedures were in the upper limb with 39 using the brachial artery as inflow (75%). The internal jugular vein and subclavian vein were most frequently used as access for outflow insertion. Primary patency rates at 6, 12, and 24 months were 51.2% (95% confidence interval, 38.8%–67.4%), 40.9% (95% confidence interval, 28.7%–58.2%), and 33.4% (95% confidence interval, 21.3%–52.5%), respectively. Secondary patency rates at 6, 12, and 24 months were 84.8% (95% confidence interval, 75%–95.9%), 76.5% (95% confidence interval, 64.5%–90.6%), and 70.6% (95% confidence interval, 56%–88.9%), respectively. There were 65 surgical and 49 radiological interventions resulting in 2.30 interventions per year to retain patency. Complications included four infections and two episodes of steal syndrome. Conclusion: The Haemodialysis Reliable Outflow graft provides acceptable 12-month secondary patency rates and acceptable complication rates in a UK and Ireland multi-centre series of complex access patients. Haemodialysis Reliable Outflow should be considered in patients with central pathology as a potential alternative to lower limb grafts and long-term central venous catheters.

Improved arterial exposure and ergonomics with use of elasticated retractors in vascular surgery

Traditional self-retaining retraction devices do not always provide adequate exposure and, on occasion, hamper economy of movement during vascular surgical procedures. We report the novel use of elasticated retractors to improve surgical exposure for vascular access procedures that may be transferable to other vascular surgical procedures.

Infrainguinal aneurysms in a tertiary setting: A study of outcomes

the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: Twelve cohort studies involving 1512 patients were included. The majority of these were treated endovascularly (1168 patients).DR was associated with improved wound healing (Odds Ratio, OR 0.39, p<0.001) and limb salvage rates (OR 0.20, p<0.001) compared to IR, however this effect was lost on certain sensitivity analyses. DR had no effect on reintervention rates (OR 0.44, p1⁄40.27) or subsequent mortality (OR 0.83, p1⁄40.37). Overall study quality was low. Conclusions: DR appears superior in terms of wound healing and limb salvage. There was no evidence that the approach was less safe than IR. Vascular units performing infrapopliteal revascularisation should consider DR whenever feasible.