COVID-ASSOCIATED ACUTE LIMB ISCHEMIA DURING THE DELTA SURGE AND THE EFFECT OF VACCINES.
Bowen Xie MD, et al.
DOI: https//doi.org/10.1016/j.jvs. 2022.12.002.
As we sigh a breath of relief since the Covid-19 pandemic is coming to an end the world over, we are coming across a number of studies from various centres around the world, particularly about its effect on the vascular system. This retrospective single-centre study analysed patient data treated between March 2020 and December 2021 for Acute Limb Ischaemia (ALI) and recent (<14 days) covid infection or who developed ALI during hospitalization for the covid-19 patients. Patients were grouped by year as well as by pre and post-Delta variant emergence in 2021 based on WHO guidelines. Demographics, imaging, interventions and outcomes were evaluated and a control cohort of ALI patients requiring surgical interventions for a 2 yr period prior to the pandemic was used as a comparison group. Primary outcomes studied included In-hospital mortality and amputation-free survival rate. About 40 limbs with ALI were identified among 36 patients with COVID during the Delta surge, the rate of Covid associated ALI almost doubled during the Delta surge, interventions (open/Endo vs primary amputation) was performed on 31 limbs in 28 patients and systemic anti-coagulation in the remaining eight pts. Post-operative mortality was 48% with an overall mortality of 50%, significant amputation rates following interventions was higher than the pre-pandemic group (25% vs3%), Thirty -day amputation free survival was significantly lower in the covid group and also had a higher incidence of re-thrombosis was seen in the covid group with an increase in re-intervention (21% vs0%).
The authors conclude that covid-19 Delta variant-induced ALI was more resistant to standard therapy and occurred almost exclusively in non-vaccinated patients (92%) stressing the importance of vaccination in prevention.
SYSTEMATIC REVIEW OF GROIN INCISION SURGICAL SITE INFECTION PREVENTIVE MEASURES IN VASCULAR SURGERY.
Justin Robbins M.D, James Courtney BS, BME, Anil Hingorani MD,
DOI: https://doi.org/10.1016/j.jvs. 2023.01.209.
Groin surgical site infections (SSI) following open revascularization contributes to increased morbidity, increased hospital stay and mortality as well in some patients. This paper analyses various prophylactic measures and makes recommendations to prevent this complication. This paper is a systematic review of 33 studies which were selected out of 1371 potential studies on this topic. The primary outcome of interest is how the rate of SSI was affected by each preventive technique;
The recommendations included 1) the use of prophylactic flaps (sartorius etc) in high-risk surgical patients (Grade. 2c) 2.) Use of transverse incisions for open arterial exposures (Grade 2c) 3. Closed incision negative pressure wound therapy (Grade 2B). However, no recommendations were given for using Topical antibiotics and adhesive wound Drapes. The highly effective technique of meticulous dissection and tissue handling, ligation of lymphatics in the wound along with effective hemostasis and thorough asepsis and the role of prophylactic antibiotics should go with this. This study suffers from a lack of effective data and the need for more multi-centre studies.
RELATIONSHIP BETWEEN WIFI (WOUND, ISCHEAMIA, FOOT INFECTION) STAGE AND QUALITY OF LIFE AT REVASCULARIZATION IN THE BEST-CLI (BEST ENDOVASCULAR VERSUS BEST SURGICAL THERAPY IN PATIENTS WITH CHRONIC LIMB-THREATENING ISCHEAMIA) TRIAL.
Jeffrey J Siracuse MD, Vincent Rose MD, Mathew. T. Menard et al…
DOI: https://doi.org/1016/j.jvs. 2022.11.050.
This paper analyses the relationship between the quality of life in terms of the both physical and mental status of CLTI patients and the WIFI stage. The study used the dataset of the BEST-CLI trial and queried for HRQOL assessment at patient enrollment which included 1) Vascular Quality of Life. 2) 12 Item short form survey (SF-12).3) EQ-5D. A total of 1568 patients with complete WIFI data were analysed; Patients with WIFI stage 4 were more often men, current smokers, had bad ESRD, Diabetes, were not ambulatory independently and had higher median morbidity scores. On multivariate analysis, WIFI stage 4 compared with stages 1-3 was associated with lower SF-12 mental component scores and short form six dimension R2 utility index scores. The WIFI stage was not independently associated with baseline vascular quality of life, SF-12 physical component scale or EQ-5D assessments. The paper concludes that advanced WIFI stage 4 was independently associated with poor quality of life because of these patients’ mental rather than physical health, highlighting the tremendous mental burden borne by these patients.
OUTCOMES OF PERCUTANEOUS INTERVENTIONS IN PATIENTS WITH TAKAYASU’S ARTERITIS.
George Joseph, DM et al., CMC, Vellore, India.
https://doi.org/10.1016/j.jacc. 2022.10.024. Journal of the American college of cardiology.
This study evaluates the role of percutaneous interventions (PI) in the management of stenosis/occlusive or aneurysmal lesions in Takayasu’s arteritis (TAK) patients, even though guidelines recommend against it. This is a retrospective study of PI procedures done in a single institute from 1996-2022. A total of 942 patients underwent PI to treat 2450 arterial lesions (2365 stenosis or occlusions, 85 aneurysms or dissections) in 630 subclavian or axillary, 586 renal, 463 aortic, 333 carotids, 188 mesenteric, 116 iliac, 71 coronaries and 63 other arteries. 3,805 PI were performed i.e around 1.55 PIs per person. Early success was achieved in 2,262 (92.3%) and late success in 1460 pts (84.5%) with an average follow-up of 39 months. Sometimes repeated PI increased the chances of late success. There was a 36% success rate with POBA however Cutting balloon angioplasty (CBA) had a high 19% complication rate with dissections, rupture and pseudo-aneurysm formation. A total of 472 complications occurred in 415 lesions (17%). In this study, 101 patients underwent 118 open surgical procedures as well. Aortic PI had the best results, carotids fared badly so were subclavian lesions >8 cm in length. The authors conclude that PI can be safely and effectively done in patients with TAK. Very interesting and thought-provoking article as well.
RANDOMIZED CLINICAL TRIAL OF SUPERVISED EXERCISE THERAPY VS ENDOVASCULAR REVASCULARIZATION FOR INTERMITTENT CLAUDICATION CAUSED BY ILIAC ARTERY OBSTRUCTION-THE SUPER STUDY.
Mark J. W. Koelemay et al., University of Amsterdam, Eur J Vasc Endovasc Surg (2022) 63,421-429.
https://doi.org/10.1016/j.ejvs. 2021.09.042.
This multicentre RCT analysed patients with intermittent claudication (IC) caused by Iliac artery obstruction and who were treated with either supervised exercise therapy (SET) or endovascular revascularization (ER). The primary endpoints were Maximum walking distance (MWD) on a treadmill and disease-specific quality of life (VascuQol) after 1 year, any additional interventions over a mean follow-up of 5.5 years were recorded. The study period was between November 2010 and May 2015,114 patients were allotted to SET, and 126 to ER, the trial, however, was concluded prematurely when 240 patients were enrolled, the study was also flawed in that were many cross-overs to ER and poor compliance to SET by some. However the study like the CLEVER study (where patients also received Cilastazol) demonstrated no significant differences in clinical outcomes and supports current guidelines to start SET in patients with mild IC and to accept a 30% failure rate in these patients who should be discussed beforehand with the patients, thus avoiding unnecessary ER in these patients.
