Peripheral vascular disease

This chapter assesses peripheral vascular disease. It begins with acute limbic ischaemia; chronic upper limb ischaemia; chronic lower limb ischaemia; intermittent claudication; and critical limb ischaemia. The chapter then turns to aneurysms; ruptured abdominal aortic aneurysm; vascular developmental abnormalities; carotid disease; vasospastic disorders; varicose veins; deep venous thrombosis; and thrombolysis. It also considers the diabetic foot and amputations, as well as complications in vascular surgery. Complications may occur in the perioperative, early, or late post-operative periods. In general, vascular patients are older and have increased cardiac, cerebral, pulmonary, and renal comorbidities. This is due to the associated risk factors of hypertension, diabetes mellitus, hypercholesterolaemia, and smoking.

Endovascular thrombectomy for critical lower limb ischaemia in a patient with COVID-19

Hypercoagulable and proinflammatory states induced by the novel coronavirus (SARS-CoV-2) lead to thrombotic and embolic events. In this case report, the authors describe how they successfully managed acute critical limb ischaemia in a patient of COVID-19 illness with severe pulmonary disease and high thrombus burden in the infrapopliteal arteries.

A Thermoresponsive Chitosan/β-Glycerophosphate Hydrogel for Minimally Invasive Treatment of Critical Limb Ischaemia

A reduction in blood supply to any limb causes ischaemia, pain and morbidity. Critical limb ischaemia is the most serious presentation of peripheral vascular disease. One in five patients with critical limb ischaemia will die within six months of diagnosis and one in three will require amputation in this time. Improving blood flow to the limb, via the administration of angiogenic agents, could relieve pain and avoid amputation. Herein, chitosan is combined with β-glycerophosphate to form a thermoresponsive formulation (chitosan/β-GP) that will flow through a syringe and needle at room temperature but will form a gel at body temperature. The chitosan/β-GP hydrogel, with or without the angiogenic molecule desferrioxamine (DFO), was injected into the mouse hind limb, following vessel ligation, to test the ability of the formulations to induce angiogenesis. The effects of the formulations were measured using laser Doppler imaging to determine limb perfusion and CD31 staining to quantify the number of blood vessels. Twenty-eight days following induction of ischaemia, the chitosan/β-GP and chitosan/β-GP + 100 µM DFO formulations had significantly (p < 0.001 and p < 0.05, respectively) improved blood flow in the ischaemic limb compared with an untreated control. Chitosan/β-GP increased vessel number by 1.7-fold in the thigh of the ischaemic limb compared with an untreated control, while chitosan/β-GP + 100 µM DFO increased vessel number 1.8-fold. Chitosan/β-GP represents a potential minimally invasive treatment for critical limb ischaemia.

EP.WE.690PPI Prescribing in Vascular Discharges

Aims Aspirin and clopidogrel are ubiquitously seen in prescriptions of most attendees to hospitals, especially those being admitted to a vascular unit. Most, if not all, are on at least one anti-platelet agent, and some are on dual antiplatelets (DAPA) or an anticoagulant. These increase the risk for upper gastrointestinal (UGI) bleeds, which lead to significant morbidity and mortality. In order to prevent this, proton pump inhibitors (PPIs) are recommended to be prescribed for patients with increased risk of UGI bleeds. Our aim for this audit was to evaluate the prescription of PPIs in vascular patients discharged from a major vascular hub. Methods Data was collected from a prospectively maintained database of consecutive primary vascular discharges between 01/09/2020 and 31/09/2020. Results 87 patients discharged in this period (71% Male, Median age 72 (22-92) yrs). 26% of admissions accounted for Diabetic foot infection management, 25% for Critical Limb Ischaemia management and 20% for Thoracic or Aortic Aneurysm management. 70% of patients were discharged with either a single or DAPA. 94% of patients met the NICE guideline for requirement for a PPI. 49% of those patients were not discharged with a PPI. Of the patients who should have been prescribed a PPI on discharge, 5% suffered UGI bleeds in the follow up period (2/42). Conclusions PPIs are often not prescribed when discharging vascular patients, most of whom are high risk for having UGI bleeds. We will re-audit this after education and protocols have been implemented.

EP.WE.859Pain management in critical limb ischaemia patients: a clinical audit

Aims Critical Limb Ischaemia (CLI) patients often present with ischaemic rest pain and uncontrolled pain can impact on quality of life. To improve pain control, a set a of trust-wide guidelines were developed to standardise pain management for CLI patients. Methods This was a prospective cross-sectional audit, which initially involved 30 patients admitted under vascular surgery at a tertiary centre with CLI between May and June 2020. The improvements implemented included an analgesia education session for junior doctors, inclusion of an analgesia dosing table in the vascular clerking proforma and a simplified analgesia table as a poster. The re-audit included 22 patients with CLI between September and October 2020. Data was collected from drug charts and Fisher’s exact test was used for the statistical analysis. Results Baseline data suggested poor compliance with guidelines with only 3% of patients prescribed the guideline recommended PRN opiate doses. This improved post-intervention to 52% (p &lt; 0.05). Following the interventions, naloxone prescribing significantly improved from 37% to 91% (p &lt; 0.05). Standard dosing of opiates was seen irrespective of age or renal function. 14% of patients with renal impairment were prescribed opiate analgesia above the initial ranges indicated by the guidelines; compared to 33% in the first cycle (p = 0.58). Conclusion This audit has demonstrated the successful implementation of targeted changes to improve compliance with trust pain management guidelines for patients with CLI. The challenge remains of overcoming the unknown eGFR at time of prescription and unknown background analgesia that can lead to over and under prescribing.

Infrared Thermography as a Diagnostic Tool for the Assessment of Patients with Symptomatic Peripheral Arterial Disease Undergoing Infrafemoral Endovascular Revascularisations

Aim: The aim of this study was to evaluate the utility and reliability of temperature foot changes measured by infrared thermography (IRT) for the evaluation of patients with atherosclerotic peripheral arterial disease (PAD) before and after endovascular revascularisation. Methods: This is an observational prospective study carried out on symptomatic PAD patients. Evaluations consisted of a clinical examination, duplex scan with ankle–brachial index calculation (ABI) and IRT measurements with infrared camera FLIR-ONE connected to a smartphone with android technology. Locations on the foot sampled with IRT were the anterior tibial, pedal, posterior and arcuate arteries. Results obtained with IRT on the symptomatic foot were compared to the contralateral foot and with the ABI values obtained bilaterally before and 24 h after revascularisation. Results: Within one year, 40 patients were enrolled, among whom 87,5% suffered from critical limb ischaemia. In three patients, it was impossible to obtain ABI measurements because of ulcerations on the limb. Skin temperature changes obtained by IRT between the symptomatic limb and the contralateral limb had a mean difference of 1.7 °C (range: 1.1–2.2 °C), p < 0.001. There was a positive correlation between ABI and temperature values of the limb needed for treatment before revascularisation (p = 0.025; r = 0.36) and after revascularisation (p = 0.024, r = 0.31). The technical success rate was 100% in all cases, achieving a significant increase in temperature at all points of the foot analysed, with a median change of 2 °C (p < 0.001). Conclusion: IRT is a safe, reliable and simple application. It could be a valuable tool for the assessment of the clinical presentation and severity of foot blood perfusion in symptomatic PAD patients and the evaluation of the technical success of endovascular revascularisation. IRT might have a role in follow-up of revascularisation procedures.

1529 Management of A Rare Case of Bilateral Persistent Sciatic Artery Aneurysms Causing Critical Limb Ischaemia With Staged Embolisation And Femoropopliteal Bypass: A Case Report

Introduction Bilateral persistent sciatic arteries (PSA) are rare with an incidence of 0.001%. They represent a persistence of the embryonic axial limb circulation via the internal iliac artery. Normally the PSA involutes and is replaced by the superficial femoral artery (SFA). Failure of regression leads to a PSA with varying configurations. Up to 50% of PSAs are aneurysmal and may present with rupture or acute/chronic ischaemia, typically at 40-50 years old. Case Report A 74-year-old female presented with limb threatening ischaemia manifesting with rest pain, sensory deficit and early tissue loss (Rutherford IIb). She had a left femoral pulse but absent pulses distally. Pedal pulses were noted on the contralateral limb. CT angiogram revealed bilateral complete PSAs with incomplete hypoplastic SFAs (Pillet-Gauffre 2a). Both PSAs were aneurysmal; the left PSA was acutely occluded distal to the aneurysm. She underwent staged intervention with percutaneous embolisation of the left PSA, followed by femoropopliteal bypass. She was discharged six days later with good symptomatic relief at one month follow up. We are planning to treat the contralateral limb in a similar manner electively in case complications occur. Conclusions PSAs are commonly associated with limb threatening complications but due to their rarity there are limited reports on the management of this condition. Here we can report a good outcome in a late presentation using staged embolisation with open reconstruction.

One-year outcomes of drug-coated balloon treatment for long femoropopliteal lesions: a multicentre cohort and real-world study

Background Drug-coated balloons (DCBs) have shown superiority in the endovascular treatment of short femoropopliteal artery disease. Few studies have focused on outcomes in long lesions. This study aimed to evaluate the safety and effectiveness of Orchid® DCBs in long lesions over 1 year of follow-up. Methods This study is a multicentre cohort and real-world study. The patients had lesions longer than or equal to 150 mm of the femoropopliteal artery and were revascularized with DCBs. The primary endpoints were primary patency, freedom from clinically driven target lesion revascularization (TLR) at 12 months and major adverse events (all-cause death and major target limb amputation). The secondary endpoints were the changes in Rutherford classification and the ankle brachial index (ABI). Results One hundred fifteen lesions in 109 patients (mean age 67 ± 11 years, male proportion 71.6%) were included in this study. The mean lesion length was 252.3 ± 55.4 mm, and 78.3% of the lesions were chronic total occlusion (CTO). Primary patency by Kaplan–Meier estimation was 98.1% at 6 months and 82.1% at 12 months. The rate of freedom from TLR by Kaplan–Meier estimation was 88.4% through 12 months. There were no procedure- or device-related deaths through 12 months. The rate of all-cause death was 2.8%. Cox regression analysis suggested that renal failure and critical limb ischaemia (CLI) were statistically significant predictors of the primary patency endpoint. Conclusion In our real-world study, DCBs were safe and effective when used in long femoropopliteal lesions, and the primary patency rate at 12 months by Kaplan–Meier estimation was 82.1%.

Peripheral blood mononuclear cell transplantation to treat no-option critical limb ischaemia: effectiveness and safety

Objective: Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. Method: This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5–10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×10 10 ) with CD34+ cells (2.1±1.2×10 8 ) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle–brachial index, toe–brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. Results: Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. Conclusion: Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.