• Can compassionate leadership of senior hospital leaders help retain trainee doctors?

  McCarthy, Mark (2024-07-02)

  Background: High burnout and low retention rates among trainee doctors threaten the future viability of the UK medical workforce. This study empirically examined factors that can sustain trainee doctors. Method: A total of 323 trainee doctors from 25 National Health Service (NHS) Trusts in England and Wales completed an online survey on their training and employment experiences. A mixed method approach was employed. Results: Structural equation modelling revealed that perceived compassionate leadership of hospital senior leaders (CLSL) (i.e., doctors in senior clinical and management positions, and senior managers) is directly and negatively associated with trainee doctors' burnout and intention to quit. We propose the associations may be indirectly strengthened through two mediating pathways: increased psychological contract fulfilment (PCF) of training/organisational support and reduced worry about the state of the NHS; however, only the former is supported. The model can explain a substantial 37% of the variance in reported burnout and 28% of intention to quit among trainee doctors. Being a Foundation Year (FY) trainee was significantly associated with poor PCF and burnout. Rich qualitative data further elaborated on their experiences in terms of senior leaders' awareness of their training/working experiences, listening to and acting on. Conclusions: Active and demonstrable CLSL plays a vital role in trainee doctors' retention. It has both direct (through support) and indirect effects through improving trainee doctors' PCF to reduce burnout and intention to quit. This seems particularly valuable among FY doctors. Implications for the development and management of the medical workforce are discussed.
• Management of common femoral artery occlusive disease: the current gap in the evidence and future perspectives

  Messeder, Sarah; Musto, Liam; Saratzis, Athanasios (2024-06-18)

  The common femoral artery (CFA) is the most common site affected by peripheral artery disease. Due its various anatomical and morphological features, common femoral endarterectomy has long since been the preferred treatment option. However, there are complications associated with common femoral endarterectomy including, but not limited to, surgical site infections, hematoma formation, bleeding, and nerve injury. Unfortunately, this has been further complicated by the ageing population and increasing epidemic of obesity and diabetes mellitus. Within vascular surgery, there has been a rise in use of endovascular techniques for peripheral artery disease. Endovascular repair of the CFA is safe and feasible. One clear advantage is that they can be performed under local or regional anesthesia, thus reducing morbidity. This narrative review seeks to describe the current gap in the evidence and future perspectives in the management of common femoral artery occlusive disease.
• New horizons in peripheral artery disease

  Houghton, John; Saratzis, Athanasios; Sayers, Rob D (2024-06-01)

  Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
• Endovascular versus surgical treatment for all comer patients with prosthetic bypass graft occlusion: the multicentre ENSUPRO study

  Saratzis, Athanasios (2024-05)

  Objective: Bypass surgery plays a key role in complex lower limb lesions. However, there is a lack of evidence regarding the management of symptomatic prosthetic bypass graft (PBG) occlusion. This study aimed to report outcomes following open, hybrid, or endovascular management of patients presenting with symptomatic PBG occlusion. Methods: A multicentre, retrospective cohort study was conducted, including patients presenting with PBG occlusion between January 2014 and December 2021 from 18 centres. It assessed the comparative value of treatment strategies, including (1) recanalisation of native vessels, (2) endovascular treatment of the failed PBG, (3) hybrid treatment, and (4) open surgery. The primary outcome measure was amputation free survival (AFS, time to major amputation and or death), whereas all cause mortality, major amputation, PBG re-occlusion, target lesion revascularisation (TLR), and Rutherford category (RC) improvement during follow up were considered as secondary endpoints. Results: Of 260 patients with occluded PBGs, 108 (41.5%) were treated endovascularly (24 [22.2%] by recanalisation of native vessels and 84 [77.7%] by PBG re-opening), 57 (21.9%) underwent hybrid revascularisation, and 58 (22.3%) had surgery. In addition, 27 (10.4%) were treated conservatively and 10 (3.8%) received systemic thrombolysis. With a median follow up of 1.4 (0.6 - 3.0) years, AFS was 95.5%, 76.4%, 45.5%, and 37.1%, respectively in Groups 1 - 4 (p = .007). Older age and non-endovascular treatment (HR 1.05 and 1.70; p < .01 for both) were independent predictors of poor AFS. Endovascular treatment was associated with lower rates of major amputation (p = .04), PBG re-occlusion (p < .001), and TLR (p = .037), and higher RC improvements (p < .001), whereas all cause mortality was comparable between treatment groups (p = .21). Conclusion: Endovascular treatment is associated with higher rates of AFS and RC improvement and lower rates of PBG re-occlusion and TLR in patients with PBG occlusion.
• Chronic nicotine exposure is associated with electrophysiological and sympathetic remodeling in the intact rabbit heart

  Ng, Andre (2023-11-23)

  Nicotine is the primary addictive component in tobacco products. Through its actions on the heart and autonomic nervous system, nicotine exposure is associated with electrophysiological changes and increased arrhythmia susceptibility. However, the underlying mechanisms are unclear. To address this, we treated rabbits with transdermal nicotine (NIC, 21 mg/day) or control (CT) patches for 28 days prior to performing dual optical mapping of transmembrane potential (RH237) and intracellular Ca 2+ (Rhod-2 AM) in isolated hearts with intact sympathetic innervation. Sympathetic nerve stimulation (SNS) was performed at the 1 st - 3 rd thoracic vertebrae, and β-adrenergic responsiveness was additionally evaluated as changes in heart rate (HR) following norepinephrine (NE) perfusion. Baseline ex vivo HR and SNS stimulation threshold were increased in NIC vs. CT ( P = 0.004 and P = 0.003 respectively). Action potential duration alternans emerged at longer pacing cycle lengths (PCL) in NIC vs. CT at baseline ( P = 0.002) and during SNS ( P = 0.0003), with similar results obtained for Ca 2+ transient alternans. SNS reduced the PCL at which alternans emerged in CT but not NIC hearts. NIC exposed hearts also tended to have slower and reduced HR responses to NE perfusion. While fibrosis was unaltered, NIC hearts had lower sympathetic nerve density ( P = 0.03) but no difference in NE content vs. CT. These results suggest both sympathetic hypo-innervation of the myocardium and diminished β-adrenergic responsiveness with NIC. This autonomic remodeling may underlie the increased risk of arrhythmias associated with nicotine exposure, which may be further exacerbated with continued long-term usage. New & noteworthy: Here we show that chronic nicotine exposure was associated with increased heart rate, lower threshold for alternans and reduced sympathetic electrophysiological responses in the intact rabbit heart. We suggest that this was due to the sympathetic hypo-innervation of the myocardium and diminished β- adrenergic responsiveness observed following nicotine treatment. Though these differences did not result in increased arrhythmia propensity in our study, we hypothesize that prolonged nicotine exposure may exacerbate this pro-arrhythmic remodeling.
• Individual patient data meta-analysis of dynamic cerebral autoregulation and functional outcome after ischemic stroke

  Beishon, Lucy; Gkargkoula, Panagoula; Minhas, Jatinder S (2024-03-21)

  Background: The relationship between dynamic cerebral autoregulation (dCA) and functional outcome after acute ischemic stroke (AIS) is unclear. Previous studies are limited by small sample sizes and heterogeneity. Methods: We performed a 1-stage individual patient data meta-analysis to investigate associations between dCA and functional outcome after AIS. Participating centers were identified through a systematic search of the literature and direct invitation. We included centers with dCA data within 1 year of AIS in adults aged over 18 years, excluding intracerebral or subarachnoid hemorrhage. Data were obtained on phase, gain, coherence, and autoregulation index derived from transfer function analysis at low-frequency and very low-frequency bands. Cerebral blood velocity, arterial pressure, end-tidal carbon dioxide, heart rate, stroke severity and sub-type, and comorbidities were collected where available. Data were grouped into 4 time points after AIS: <24 hours, 24 to 72 hours, 4 to 7 days, and >3 months. The modified Rankin Scale assessed functional outcome at 3 months. Modified Rankin Scale was analyzed as both dichotomized (0 to 2 versus 3 to 6) and ordinal (modified Rankin Scale scores, 0-6) outcomes. Univariable and multivariable analyses were conducted to identify significant relationships between dCA parameters, comorbidities, and outcomes, for each time point using generalized linear (dichotomized outcome), or cumulative link (ordinal outcome) mixed models. The participating center was modeled as a random intercept to generate odds ratios with 95% CIs. Results: The sample included 384 individuals (35% women) from 7 centers, aged 66.3±13.7 years, with predominantly nonlacunar stroke (n=348, 69%). In the affected hemisphere, higher phase at very low-frequency predicted better outcome (dichotomized modified Rankin Scale) at <24 (crude odds ratios, 2.17 [95% CI, 1.47-3.19]; P<0.001) hours, 24-72 (crude odds ratios, 1.95 [95% CI, 1.21-3.13]; P=0.006) hours, and phase at low-frequency predicted outcome at 3 (crude odds ratios, 3.03 [95% CI, 1.10-8.33]; P=0.032) months. These results remained after covariate adjustment. Conclusions: Greater transfer function analysis-derived phase was associated with improved functional outcome at 3 months after AIS. dCA parameters in the early phase of AIS may help to predict functional outcome.
• Safety and effectiveness of the phoenix atherectomy device for endovascular treatment of common femoral and popliteal arteries: Results of the EN-MOBILE trial

  Saratzis, Athanasios

  Background: This study aimed to assess the peri- and postprocedural outcomes of atherectomy-assisted endovascular treatment of the common femoral (CFA) and popliteal arteries. Methods: Phoenix atherectomy was used for the treatment of 73 and 53 de novo CFA and popliteal artery lesions, respectively, in 122 consecutive patients. Safety endpoints encompassed perforation and peripheral embolization. Postprocedural endpoints included freedom from clinically driven target lesion revascularization (CD-TLR) and clinical success (an improvement of ⩾ 2 Rutherford category [RC]). In addition, 531 patients treated for popliteal artery stenosis or occlusion without atherectomy were used as a comparator group. Results: Procedural success (residual stenosis < 30% after treatment) was 99.2%. The need for bail-out stenting was 2 (2.7%) and 3 (5.7%) in CFA and popliteal artery lesions, respectively. Only one (1.4%) embolization occurred in the CFA, which was treated by catheter aspiration. No perforations occurred. After 1.50 (IQR = 1.17-2.20) years, CD-TLR occurred in seven (9.2%) and six (14.6%) patients with CFA and popliteal artery lesions, respectively, whereas clinical success was achieved in 62 (91.2%) and 31 (75.6%), respectively. Patients treated with atherectomy and DCB in the popliteal artery after matching for baseline RC, lesion calcification, length, and the presence of chronic total occlusion, exhibited higher freedom from CD-TLR compared to the nondebulking group (HR = 3.1; 95% CI = 1.1-8.5, p = 0.03). Conclusion: Atherectomy can be used safely and is associated with low rates of bail-out stenting in CFA and popliteal arteries. CD-TLR and clinical success rates are clinically acceptable. In addition, for the popliteal artery, atherectomy combined with DCB demonstrates lower CD-TLR rates compared to a DCB alone strategy. (German Clinical Trials Register: DRKS00016708).
• The "Woundosome" concept and Its impact on procedural outcomes in patients with chronic limb-threatening ischemia

  Davies, Robert (2024-03-25)
• Biomimetic Stents for Infra-inguinal Peripheral Arterial Disease: Systematic Review and Meta-Analysis

  Messender, Sarah; Pepper, Coral; Lopez-Pena, Gabriel; Saratzis, Athanasios (2023-11-04)

  Objective: Biomimetic stents are peripheral infra-inguinal self-expanding stents that mimic the anatomy of the vasculature and artery movement. They are indicated for use in infra-inguinal arteries. This research aimed to synthesise all current evidence on the use of biomimetic stents as adjuncts for endovascular treatment of infra-inguinal peripheral arterial disease (PAD), helping to guide clinical decision making. Data sources: MEDLINE, Embase, CINAHL and Cochrane databases. Review methods: Random effects meta-analysis following PRISMA guidelines (PROSPERO registration CRD42022385256). Study quality was assessed using the Joanna Briggs Institute critical appraisal tools checklist, and certainty assessment through the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Endpoints included primary patency, target lesion revascularisation, stent fracture, secondary patency, and mortality at 1 year. Results: In total, 37 studies were included in the meta-analysis (33 cohort studies, 2 case series, and 2 randomised controlled trials [RCTs]), representing 4 480 participants. Of these, 34 studies included data on Supera (81.5% of participants) and 3 studies reported data on BioMimics 3D (18.5% of participants) stents. The pooled primary patency rate of 33 studies at 1 year follow up was 81.4% (95% confidence interval [CI] 78.7 - 83.9%), and the pooled target lesion revascularisation rate of 18 studies at 1 year was 12.2% (95% CI 9.6 - 15.0%). The certainty of evidence outcome rating as qualified by GRADE was very low for both. Only one study reported a positive stent fracture rate at 1 year follow up of 0.4% with a certainty of evidence outcome of low. Conclusion: Using biomimetic stents for infra-inguinal PAD may be associated with acceptable 1 year primary patency and target lesion revascularisation rates, with near negligible 1 year stent fracture rate. Their use should be considered in those presenting with infra-inguinal PAD undergoing endovascular revascularisation. A RCT trial is necessary to determine their clinical and cost effectiveness.
• The effect of hypercapnia on the directional sensitivity of dynamic cerebral autoregulation and the influence of age and sex

  Clough, Rebecca; Beishon, Lucy; Robinson, Thompson; Davies, Aaron; Minhas, Jatinder S (2023-09-25)

  The cerebral circulation responds differently to increases in mean arterial pressure (MAP), compared to reductions in MAP. We tested the hypothesis that this directional sensitivity is reduced by hypercapnia. Retrospective analysis of 104 healthy subjects (46 male (44%), age range 19-74 years), with five minute recordings of middle cerebral blood velocity (MCAv, transcranial Doppler), non-invasive MAP (Finometer) and end-tidal CO2 (capnography) at rest, during both poikilocapnia and hypercapnia (5% CO2 breathing in air) produced MCAv step responses allowing estimation of the classical Autoregulation Index (ARIORIG), and corresponding values for both positive (ARI+D) and negative (ARI-D) changes in MAP. Hypercapnia led to marked reductions in ARIORIG, ARI+D and ARI-D (p < 0.0001, all cases). Females had a lower value of ARIORIG compared to males (p = 0.030) at poikilocapnia (4.44 ± 1.74 vs 4.74 ± 1.48) and hypercapnia (2.44 ± 1.93 vs 3.33 ± 1.61). The strength of directional sensitivity (ARI+D-ARI-D) was not influenced by hypercapnia (p = 0.46), sex (p = 0.76) or age (p = 0.61). During poikilocapnia, ARI+D decreased with age in females (p = 0.027), but not in males. Directional sensitivity was not affected by hypercapnia, suggesting that its origins are more likely to be inherent to the mechanics of vascular smooth muscle than to myogenic pathways.
• Intraoperative predictors of in-hospital mortality after open repair of ruptured abdominal aortic aneurysms

  Saratzis, Athanasios (2023-06-28)

  Background: Several models and scores have been released to predict early mortality in patients undergoing surgery for a ruptured abdominal aortic aneurysm (rAAA). These scores included above all preoperative factors and they could be useful to deny surgical repair. The aim of the study was to evaluate intraoperative predictors of in-hospital mortality in patients undergoing open surgical repair (OSR) for a rAAA. Methods: Between January 2007 and December 2020, 265 patients were admitted at our tertiary referral hospital for a rAAA. Two-hundred-twenty-two patients underwent OSR. Intra-operative factors were analyzed by means of univariate analysis (step 1). Associations of procedure variables with in-hospital mortality rates were sought based on a multivariate Cox regression analysis (step 2). Results: Overall, in-hospital mortality rate was 28.8% (64 cases). Multivariate Cox regression analysis reported that operation time >240 minutes (P=0.032, OR 2.155, CI 95% 1.068-4.349), and hemoperitoneum (P<0.001, OR 3.582, CI 95% 1.749-7.335) were negative predictive factors for in-hospital mortality. Patency of at least one hypogastric artery (P=0.010; OR 0.128, CI 95% 0.271-0.609), and infrarenal clamping (P=0.001; OR 0.157, CI 95% 0.052-0.483) had a protective role in reducing in-hospital mortality rate. Conclusions: Operation time >240 minutes, and hemoperitoneum affected in-hospital mortality in patients undergoing OSR for rAAA. Patency of at least one hypogastric artery, and infrarenal clamping had a protective role. Further studies are needed to validate these outcomes. A validated predictive model could be useful to help the physicians in communication with patients' relatives.
• Are portable ankle brachial pressure index measurement devices suitable for hypertension screening?

  Janus, Justyna; Nicholls, Jennifer; Pallett, Edward; Bown, Matthew; Chung, Emma (2023-03-21)

  Objective: In a large-scale population cardiovascular screening programme, peripheral artery disease (PAD) and hypertension would ideally be rapidly assessed using a single device. The ankle-brachial pressure index (ABPI) is calculated by comparing the ankle and brachial blood pressure (BP). However, it is currently unclear whether brachial BP measurements provided by automated PAD screening systems are sufficiently accurate for simultaneous hypertension screening. Methods: Two portable PAD screening devices, the MESI ABPI MD and Huntleigh's Dopplex ABIlity, were evaluated following the European Society of Hypertension International Protocol (ESH-IP) Revision 2010 using a mercury-free sphygmomanometer as a reference device. Results: On average, the MESI slightly underestimated brachial systolic blood pressure (BP) with a bias and standard deviation (SD) of -3.5 (SD: 3.3) mmHg and diastolic BP with a bias of -1.5 (SD: 2.3) mmHg. For systolic BP estimates, the Dopplex was more accurate than the MESI with a lower bias of -0.5 (SD: 4.2) mmHg but less precise. The MESI successfully fulfilled all the requirements of the ESH-IP for hypertension screening. The Dopplex device failed the ESH-IP due to the absence of DBP measurements. Conclusions: The MESI device appears to be suitable for simultaneous PAD and hypertension screening as part of a preventative care programme. Huntleigh's Dopplex ABIlity failed to pass the ESH-IP validation test. Further clinical trials are underway to assess the use of the MESI for simultaneous screening for hypertension and PAD in a population screening setting.
• Clinimetrics of performance-based functional outcome measures for vascular amputees: A systematic review

  Daynes, Enya; Houghton, John; Sayers, Robert; Pepper, Coral; Singh, Sally (2023-06-03)

  Background: Objective physical performance-based outcome measures (PerBOMs) are essential tools for the holistic management of people who have had an amputation due to vascular disease. These people are often non-ambulatory, however it is currently unclear which PerBOMs are high quality and appropriate for those who are either ambulatory or non-ambulatory. Research question: Which PerBOMs have appropriate clinimetric properties to be recommended for those who have had amputations due to vascular disease ('vascular amputee')? Data sources: MEDLINE, CINAHL, EMBASE, EMCARE, the Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus databases were searched for the terms: "physical performance" or "function", "clinimetric properties", "reliability", "validity", "amputee" and "peripheral vascular disease" or "diabetes". Review methods: A systematic review of PerBOMs for vascular amputees was performed following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and PRISMA guidelines. The quality of studies and individual PerBOMs was assessed using COSMIN risk of bias and good measurement properties. Overall PerBOM quality was evaluated with a modified GRADE rating. Key clinimetric properties evaluated were reliability, validity, predictive validity and responsiveness. Results: A total of 15,259 records were screened. Forty-eight studies (2650 participants) were included: 7 exclusively included vascular amputees only, 35 investigated validity, 20 studied predictive validity, 23 investigated reliability or internal consistency and 7 assessed responsiveness. Meta-analysis was neither possible nor appropriate for this systematic review in accordance with COSMIN guidelines, due to heterogeneity of the data. Thirty-four different PerBOMs were identified of which only 4 are suitable for non-ambulatory vascular amputees. The Amputee Mobility Predictor no Prosthesis (AMPnoPro) and Transfemoral Fitting Predictor (TFP) predict prosthesis use only. PerBOMs available for assessing physical performance are the One-Leg Balance Test (OLBT) and Basic Amputee Mobility Score (BAMS). Conclusion: At present, few PerBOMs can be recommended for vascular amputees. Only 4 are available for non-ambulatory individuals: AMPnoPro, TFP, OLBT and BAMS.
• Defining quality assessment in vascular surgery training: an expert Delphi process

  McCarthy, Mark (2023-02-13)

  Introduction: A robust and reproducible way of assessing training should optimise and standardise vascular surgical training. This study describes the methodology supporting the Vascular Surgery Specialty Advisory Committee regional quality assurance reports for vascular surgery training programmes in the UK. Methods: A Delphi consensus exercise was performed to establish the domains of training that most appropriately assess the quality of a vascular surgery training programme. A total of 54 stakeholders were invited to participate, including trainees, training programme directors and members of the vascular speciality advisory committee (SAC), vascular society executive and education committees. Results: A total of 39 stakeholders successfully completed the three-stage Delphi process over 15 weeks. The domains identified as most appropriate to assess the quality of a vascular training programme were: Joint Committee on Surgical Training (JCST) survey results, clinical experience, regional education programmes, radiology support, timetable, regional support for trainees, trainer support for trainees, opportunities for professional development, trainee-rated quality of consultant teaching and training, and trainee recommendation of the post. Conclusions: This study describes a method to identify and prioritise domains that are appropriate to assess the quality of a vascular training programme. The domains that were identified as appropriate to assess quality are transferable internationally and the Delphi methodology could be used by other training schemes to 'fine-tune' their own domains to review and optimise the quality of their own training programmes.
• Genetic risk score for intracranial aneurysms: Prediction of subarachnoid hemorrhage and role in clinical heterogeneity

  Bown, Matthew (2023-03)

  Background: Recently, common genetic risk factors for intracranial aneurysm (IA) and aneurysmal subarachnoid hemorrhage (ASAH) were found to explain a large amount of disease heritability and therefore have potential to be used for genetic risk prediction. We constructed a genetic risk score to (1) predict ASAH incidence and IA presence (combined set of unruptured IA and ASAH) and (2) assess its association with patient characteristics. Methods: A genetic risk score incorporating genetic association data for IA and 17 traits related to IA (so-called metaGRS) was created using 1161 IA cases and 407 392 controls from the UK Biobank population study. The metaGRS was validated in combination with risk factors blood pressure, sex, and smoking in 828 IA cases and 68 568 controls from the Nordic HUNT population study. Furthermore, we assessed association between the metaGRS and patient characteristics in a cohort of 5560 IA patients. Results: Per SD increase of metaGRS, the hazard ratio for ASAH incidence was 1.34 (95% CI, 1.20-1.51) and the odds ratio for IA presence 1.09 (95% CI, 1.01-1.18). Upon including the metaGRS on top of clinical risk factors, the concordance index to predict ASAH hazard increased from 0.63 (95% CI, 0.59-0.67) to 0.65 (95% CI, 0.62-0.69), while prediction of IA presence did not improve. The metaGRS was statistically significantly associated with age at ASAH (β=-4.82×10-3 per year [95% CI, -6.49×10-3 to -3.14×10-3]; P=1.82×10-8), and location of IA at the internal carotid artery (odds ratio=0.92 [95% CI, 0.86-0.98]; P=0.0041). Conclusions: The metaGRS was predictive of ASAH incidence, although with limited added value over clinical risk factors. The metaGRS was not predictive of IA presence. Therefore, we do not recommend using this metaGRS in daily clinical care. Genetic risk does partly explain the clinical heterogeneity of IA warranting prioritization of clinical heterogeneity in future genetic prediction studies of IA and ASAH.
• Acute kidney injury in patients with acute type B aortic dissection

  Katsogridakis, Emmanuel; Saratzis, Athanasios (2022-10-20)

  Objective: Acute kidney injury (AKI) is common in patients with aortic diseases; however, it has not been extensively studied in acute type B aortic dissection (TBAD). AKI is known to be associated with adverse kidney outcomes and premature death. This study investigated the incidence and impact of AKI in patients with acute TBAD. Methods: This was a retrospective study including data from two tertiary vascular centres in the UK. Case notes and electronic records were reviewed for consecutive patients presenting with acute symptomatic TBAD. Patients were managed according to a uniform clinical protocol; both patients who underwent surgery and those managed conservatively were included in this analysis. Serum creatinine values were used to calculate the number of patients who developed AKI, based on validated Kidney Disease Improving Global Outcomes definitions. Associations between incidence of AKI, death, and Major Adverse Kidney Events (MAKE; defined as death, dialysis and/or drop in estimated glomerular filtration rate > 25%) were explored. Results: Overall, 66 (42.6%) of 155 patients developed AKI within one week of presenting with TBAD. Of these, 23 patients (34.8%) had stage 1, 26 patients (39.4%) stage 2, and 17 patients (25.8%) stage 3 AKI. MAKE at 30 and 90 days occurred in 17 (11.0%) and 12 patients (7.7%), respectively. AKI was associated with significantly worse outcomes, with a 24.2% mortality rate in the AKI group compared with 7.8% among those with no AKI (p <.001); this association was also significant in adjusted analyses, both in patients who did and did not undergo surgery. Conclusion: AKI is very common among patients presenting with acute TBAD, even in clinically uncomplicated disease. There was a significant association with mortality and MAKE, whether patients underwent surgery or not. This warrants further investigation to better understand the underlying causes of the AKI and investigate management strategies which may improve outcomes.
• 50 Shades of 'Groundhog Day'

  Naylor, Ross (2022-08-23)

  Introduction: The 2017 European Society for Vascular Surgery (ESVS) guidelines on carotid and vertebral artery disease concluded that the evidence did not support a role for carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with asymptomatic carotid stenosis (ACS) in preventing cognitive impairment or dementia. What new data have emerged since 2017, and have they influenced the 2023 ESVS guidelines? Report: In a systematic review, 33/35 studies (94%) reported a "significant association" between ACS and cognitive impairment; 20 studies had 1-3 tests with significant cognitive impairment; 10 reported 4-6 tests with cognitive impairment; and three studies reported ≥7 tests with significant cognitive impairment. Baseline data from 1 000 patients with ACS in the second Carotid Revascularisation Endarterectomy versus Stenting Trial (CREST-2) reported that the overall Z score for cognition in patients with ACS was significantly lower than expected, especially for word list recall and word list learning. Another systematic review reported that (in the long term) 69% of patients with ACS undergoing CEA/CAS had no change in cognitive function. However, in another 25%, cognitive scores/domains were mostly unchanged, but 1-2 individual tests were significantly improved. In addition, 1 601 UK and Swedish patients with ACS were randomised in the first Asymptomatic Carotid Surgery Trial (ACST-1) to CEA or best medical therapy (BMT). There was no difference in 10 year rates of dementia (CEA 6.7% vs. 6.6% with BMT) or at 20 years (14.3% [CEA] vs. 15.5% [BMT]), suggesting that CEA did not prevent dementia vs. BMT (hazard ratio 0.98, 95% confidence interval 0.75-1.28; p = .89). Discussion: ACS is associated with significant cognitive impairment, but whether this supports a direct aetiological role, or a marker for something else, remains unknown. There is no evidence that CEA/CAS prevents late dementia. The 2023 ESVS guidelines have not changed its recommendation compared with the 2017 version.
• Different endovascular modalities of treatment for isolated atherosclerotic popliteal artery lesions (EMO-POP) registry

  Saratzis, Athanasios; Katsogridakis, Emmanuel (2022-08-04)

  Background: The mid-term results after treatment of isolated popliteal lesions have been limited. The aim of the present study was to report the mid-term outcomes after endovascular treatment of isolated atherosclerotic popliteal artery lesions. Methods: A multicenter (15 hospitals in five countries) retrospective cohort study was performed. Between June 2016 and June 2021, 651 consecutive patients who had been treated for isolated popliteal lesions using endovascular methods exclusively were included in the present study. Six techniques were identified, including plain balloon angioplasty (PTA; n = 286; 43.9%), drug-coated balloon angioplasty (n = 98; 15.1%), stenting with low-chronic outward force (COF) stents (n = 84; 12.9%), stenting with high-COF stents (n = 76; 11.7%), atherectomy alone (n = 17; 2.6%), and directional atherectomy with drug-coated balloons (n = 90; 13.8%). The primary outcomes measures were primary and secondary patency and freedom from clinically driven target lesion revascularization (F-CDTLR). Results: The mean patient age was 74.5 years. Most of the patients (n = 409; 62.9%) had had chronic limb-threatening ischemia. Popliteal occlusion was found in 400 cases (61.4%). High-grade calcification was present in 36.7% of cases. Immediate technical success was 94.8%. The median follow-up was 26 months (range, 6-42 months). The actuarial rate for all patients at 26 months (per outcome measure) was as follows: primary patency, 73.9%; secondary patency, 88%; and F-CDTLR, 76.5%. When comparing PTA vs all other treatments in an adjusted regression analysis, the F-CDTLR was 75.2% for PTA vs 76.5% for all other treatment (hazard ratio, 1.06; 95% confidence interval, 0.75-1.48; P = .46, adjusted regression). The difference in secondary patency also was not statistically significant (85.7% for PTA vs 88%; P = .20). Adjusted Kaplan-Meier analysis revealed that the estimated primary patency was inferior for PTA in pairwise comparisons vs other treatments (P < .001 vs atherectomy; P = .002 vs directional atherectomy with drug-coated balloons; and P = .002 vs low-COF stenting). Conclusions: The results from our study have shown that endovascular treatment of isolated popliteal lesions is safe and associated with acceptable patency and F-CDTLR in the mid-term.
• PHACTR1 modulates vascular compliance but not endothelial function: a translational study

  Wood, Alice; Marsh, Anna-Marie; Sian, Manjit; Meisuria, Mitul; McCann, Gerry; Adlam, David (2022-06-02)

  Introduction: The non-coding locus at 6p24 located in intron 3 of PHACTR1 has consistently been implicated as a risk allele in myocardial infarction and multiple other vascular diseases. Recent murine studies have identified a role for Phactr1 in the development of atherosclerosis. However, the role of PHACTR1 in vascular tone and in vivo vascular remodelling has yet to be established. The aim of this study was to investigate the role of PHACTR1 in vascular function. Methods and results: Prospectively recruited coronary artery disease (CAD) patients undergoing bypass surgery and retrospectively recruited spontaneous coronary artery dissection (SCAD) patients and matched healthy volunteers were genotyped at the PHACTR1 rs9349379 locus. We observed a significant association between the PHACTR1 loci and changes in distensibility in both the ascending aorta (AA = 0.0053 ± 0.0004, AG = 0.0041 ± 0.003, GG = 0.0034 ± 0.0009, P < 0.05, n = 58, 54 and 7 respectively) and carotid artery (AA = 12.83 ± 0.51, AG = 11.14 ± 0.38, GG = 11.69 ± 0.66, P < 0.05, n = 70, 65 and 18 respectively). This association was not observed in the descending aorta or in SCAD patients. In contrast, the PHACTR1 locus was not associated with changes in endothelial cell function with no association between the rs9349379 locus and in vivo or ex vivo vascular function observed in CAD patients. This finding was confirmed in our murine model where loss of Phactr1 on the pro-atherosclerosis ApoE-/- background did not alter ex vivo vascular function. Conclusion: In conclusion, we have shown a role for PHACTR1 in arterial compliance across multiple vascular beds. Our study suggests that PHACTR1 has a key structural role within the vasculature.
• Effect of COVID-19 on outpatient services in patients with aortovascular disease: a UK multicentre study

  Roman, Marius (2022-05-31)

  Introduction: The SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare services worldwide. Outpatient services have necessarily been restructured to accommodate COVID-19 patients and to maintain social distancing measures. The aim of our study was to investigate how the COVID-19 pandemic has affected outpatient healthcare provision for patients with aortovascular disease. Methods: In this prospective study, a standardised proforma was circulated to seven aortic centres in the UK. Data on outpatient encounters were collected from March to July 2020. Captured data included demographic details, disease pattern, type of encounter (face-to-face, video or telephone), clinic outcome and availability of imaging. Results: A total of 632 patients were included in the study, including 164 (25.9%) new referrals. In this cohort, clinic settings have shifted towards remote consultations, with 424 (67.1%) patients undergoing telephone appointments. Over a third of new patients (34.8%) had a delay in diagnostic tests, which might be attributable to the indirect effects of COVID-19. A total of 102 (16.1%) patients were added to a surgical waiting list following clinic. Conclusions: To the best of our knowledge, this is the largest study of outpatient activity during the COVID-19 pandemic in patients with aortovascular disease. We demonstrate how the speciality has adapted to accommodate government-endorsed changes in healthcare provision, and question how COVID-19 may have affected access to diagnostics. Finally, we discuss how COVID-19 will affect patients added to surgical waiting lists.

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