Acute limb ischaemia due to vasospasm: a rare presentation

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

Fatal disseminated paradoxical embolism in inferior sinus venosus atrial septal defect

Inferior sinus venosus arterial septal defect (ASD) is a rare congenital cardiac anomaly. As with other types of ASDs and patent foramen ovale (PFO), this defect results in arteri-venous shunting with the risk of developing paradoxical embolism (PDE) to the systemic circulation from venous emboli. We report a case of a 67-year-old lady presented to emergency department (ED) with massive pulmonary embolism (PE) and recurrent acute limb ischaemia. On CT pulmonary angiography (CTPA), an incidental finding of inferior sinus venosus ASD was discovered that has caused the PDE. Thrombolysis was administered followed by open mechanical thrombectomy. The patient developed massive lower gastrointestinal bleed post thrombolysis then passed away despite embolization. This case report describes the catastrophic effect of PDE to cause disseminated multisystem thromboembolism. It also emphasizes the importance of early detection of a possible right-to-left shunt in patients presented with recurrent acute limb ischaemia. Transthoracic echocardiography has reduced sensitivity for inferior sinus venosus ASD requiring further assessment with transoesophageal echocardiography in selected cases.

An 18 year data-linkage study on the association between air pollution and acute limb ischaemia

Summary: Background: There is limited information regarding the effects of air pollutants, such as nitrogen oxides (NOx), nitric oxide (NO2), nitrous oxide (NO) and particulate matter with a diameter smaller than 10 μm (PM10), on acute limb ischaemia (ALI), a peripheral arterial disease (PAD) often with a poor clinical outcome. Patients and methods: We conducted an 18-year retrospective cohort study using routinely collected healthcare records from Ninewells Hospital, Dundee, and Perth Royal Infirmary, in Tayside, Scotland, UK from 2000 to 2017. ALI hospitalisation events and deaths were linked to daily NOx, NO2, NO and PM10 levels extracted from publicly available data over this same time period. Distributed lag models were used to estimate risk ratios for ALI hospitalisation and for ALI mortality, adjusting for temperature, humidity, day of the week, month and public holiday. Results: 5,608 hospital admissions in 2,697 patients were identified over the study period (mean age 71.2 years, ±11.1). NOx and NO were associated with an increase of ALI hospital admissions on days of exposure to pollutant (p=.018), while PM10 was associated with a cumulative (lag 0–9 days) increase (p=.027) of ALI hospital admissions in our study. There was no increase of ALI mortality associated with pollution levels. Conclusions: ALI hospital admissions were positively associated with ambient NOx and NO on day of high measured pollution levels and a cumulative effect was seen with PM10.

Effect of evolocumab on acute arterial events across all vascular territories : results from the FOURIER trial

Aims We assessed the impact of the proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor evolocumab on acute arterial events across all vascular territories, including coronary, cerebrovascular, and peripheral vascular beds, in patients with established atherosclerotic cardiovascular disease (ASCVD). Methods and results In the FOURIER trial, 27 564 patients with stable ASCVD on statin therapy were randomly assigned to evolocumab or placebo. Acute arterial events were a composite of acute coronary (coronary heart disease death, myocardial infarction, or urgent coronary revascularization), cerebrovascular (ischaemic stroke, transient ischaemic attack, or urgent cerebral revascularization), or peripheral vascular (acute limb ischaemia, major amputation, or urgent peripheral revascularization) events. Of the 2210 first acute arterial events, 74% were coronary, 22% were cerebrovascular, and 4% were peripheral vascular. Evolocumab reduced first acute arterial events by 19% (hazard ratio [HR] 0.81 [95% confidence interval 0.74–0.88]; P < 0.001), with significant individual reductions in acute coronary (HR 0.83 [0.75–0.91]), cerebrovascular (HR 0.77 [0.65–0.92]), and peripheral vascular (HR 0.58 [0.38–0.88]) events. There were 3437 total events (first plus recurrent), with evolocumab reducing total events by 24% (incidence rate ratio 0.76 [0.69–0.85]). The magnitude of reduction in acute arterial events with evolocumab numerically increased over time, with a 16% reduction (HR 0.84 [0.75–0.95]) in the first year followed by a 24% reduction (HR 0.76 [0.67–0.85]) thereafter. Conclusion The addition of the PCSK9 inhibitor evolocumab to statin therapy reduced acute arterial events across all vascular territories with a robust effect over time, indicating a pan-vascular impact of aggressive lipid-lowering therapy on these acute and clinically meaningful events. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT01764633.

1476 North Wales Vascular Surgery Zoom Webinar Teaching Programme for Medical Students and Junior Doctors

Aim Surgical Education is now more widely delivered on virtual platforms due to the COVID-19 pandemic. Due to centralisation of Vascular Surgery services in North Wales to Glan Clwyd Hospital (Central), Medical Students, Junior Doctors and General Surgical Registrars have reduced exposure to the speciality and the management of common cases in neighbouring hospitals (East and West). Subsequently, we developed a regional virtual teaching programme to help bridge gaps in knowledge and to instil confidence when providing a service. Method We developed a 4-part didactic webinar educational programme which covered parts of the medical undergraduate and MRCS curricula pertaining to Vascular Surgery. Under/Postgraduate educational leads from Central, East and West were contacted to promote our programme. Webinars were delivered on ZOOM video conferencing once weekly throughout December 2020. Feedback forms were collected on Google Forms™ and used 5-point Linkert scales to grade responses and analysis of data was carried out on Microsoft Excel®. Results 186 feedback forms were collected and respondents reported significant improvements in knowledge in each of the subjects covered: [1] Abdominal Aortic Aneurysms - (2.59±1.07/5 to 4.23±0.65/5, p = <0.0001, n = 60), [2] Acute Limb Ischaemia – (2.55±1.11/5 to 4.21±0.72/5, p = <0.0001, n = 42); [3] Chronic Limb Ischaemia (2.57±1.03/5 to 4.23±0.77/5, p = <0.0001, n = 35); [4] Vascular Emergencies (2.94±1.28/5 to 4.37±0.63/5, p = <0.0001, n = 49). Overall topic interest, presentational skills and clinical usefulness was also rated highly. Conclusions Through this virtually delivered regional teaching programme, we successfully enhanced Vascular Surgery knowledge and addressed the educational needs of Medical Students and Junior Doctors across North Wales.