Rachel Bell - Academia.edu (original) (raw)

Papers by Rachel Bell

Research paper thumbnail of Neurological presentation of acute aortic syndrome: Type A intramural haematoma presenting as ischaemic hemisection of the spinal cord

Spinal Cord Series and Cases, 2020

Introduction Intramural haematoma (IMH) describes the presence of blood within the aortic wall, a... more Introduction Intramural haematoma (IMH) describes the presence of blood within the aortic wall, and is associated with a significant morbidity and mortality. Early diagnosis is essential for institution of medical, and sometimes surgical, management. Neurological complications have rarely been described during the initial presentation of IMH, or other forms of acute aortic syndrome. Case presentation We describe a 56-year-old man who presented with sudden onset chest pain and left leg weakness and numbness, and the loss of right leg pain and temperature sensation. CT Angiography showed a Type A intramural haematoma extending from the ascending to the infra-renal aorta. He was managed successfully with cerebrospinal fluid drainage and thoracic endografting to cover the intimal entry lesion. His neurological symptoms improved and he remained well at 3 years with minor residual neurological deficits. Discussion Spinal cord infarction is a rare but documented complication of acute aortic syndrome; Brown-Séquard syndrome typically results from a traumatic injury. To the best of our knowledge, this is the first report of IMH presenting with Brown-Séquard syndrome. This case highlights the need to consider acute aortic syndromes in a patient presenting with chest pain and acute neurological symptoms.

Research paper thumbnail of Visual Scoring Improves the Utility of 18F-FDG PET/CT in the Diagnosis of Aortic Graft Infection

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Selecting Patients for Aortic Aneurysm Repair and oUtcomes Associated with Operative and Non-operative Management: Low Aneurysm Related Mortality in Elective patients Managed Non-operatively

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Endovascular Aneurysm Sealing (EVAS). Outcomes and Anatomical Suitability, a Single Centre Experience

European Journal of Vascular and Endovascular Surgery, 2019

Introduction: In abdominal aortic aneurysm (AAA), open surgical repair (OSR) is reportedly more i... more Introduction: In abdominal aortic aneurysm (AAA), open surgical repair (OSR) is reportedly more invasive but also, over the long-term, more durable and may have a lower reintervention rate than is observed in endovascular aneurysm repair (EVAR). Therefore, strict patient selection based on assessments of both short-and long-term outcomes and patient frailty (sarcopenia and nutrition) is needed because most affected patients are elderly. However, little information is available about patient frailty and long-term outcomes in OSR. The aim of this study was to identify prognostic factors of long-term mortality, including frailty. Methods: We reviewed 360 consecutive AAA patients who underwent OSR from 2007 to 2014. We collected data on patient characteristics, nutrition (controlling nutritional status [CONUT] score), and muscle size (skeletal muscle mass index [SMI]). 1 A Cox proportional analysis and logistic regression analysis identified independent predictors of longterm mortality and Clavien-Dindo class IV complications, respectively. A P value <.05 was considered significant. Results: During the study period, 360 patients underwent elective OSR. The following patient characteristics were associated with long-term mortality: 3 71 years old (HR, 4.92; 95%CI, 1.41-17.13, P¼0.01), low SMI (HR, 4.32; 95%CI, 1.16-16.13, P¼0.03), CONUT score indicating moderate risk of malnutrition (vs normal/mild risk, HR, 4.16; 95%CI, 1.03-16.76, P¼0.045), and eGFR<30 mL/min/1.73 m 2 (HR, 3.54; 95%CI, 1.09-11.47, P¼0.035). Two patients died within 30 days after OSR (0.6%). A CONUT score indicating moderate risk (HR, 4.42; 95%CI, 1.01-19.28, P¼0.048), eGFR <30 mL/ min/1.73 m 2 (HR, 7.34; 95%CI, 2.20-24.51, P< 0.001) and diabetes mellitus (HR, 3.71; 95%CI, 1.25-11.00, P¼0.02) were independent predictors of Clavien-Dindo class IV complications. Conclusion: These results may be useful for identifying and optimizing high-risk patients who would not benefit from OSR so that they can be directed towards EVAR. Considering nutritional status and sarcopenia may therefore support a more personalized treatment strategy.

Research paper thumbnail of Radiation-Associated DNA Damage in Operators During Endovascular Aortic Repair

European Journal of Vascular and Endovascular Surgery, 2016

spinal cord ischemia, respiratory and renal and insufficiency. Secondary end points included bloo... more spinal cord ischemia, respiratory and renal and insufficiency. Secondary end points included blood loss, operative time, ICU stay, the length of hospital stay. Results: Primary endpoints: 30 days mortality rate 24.1% (7.18% standard group, p ¼ 0.001), spinal cord ischemia rate 13.8% (14.1% standard group, p ¼ 0.964), respiratory failure rate 13.8% (4.95% standard group, p ¼ 0.0442) and renal failure rate 27.6% (26.2% standard group, p ¼ 0.869). Secondary endpoints: mean blood loss 7062 mL (5246 mL standard group, p ¼ 0.018), mean operative time 5,39 h (4,79 h standard group, p ¼ 0.021), mean ICU stay 3.4 days (2.7 days standard group, p ¼ 0.068), length of hospital stay 10.7 days (10.4 days standard group, p ¼ 0.852). Conclusion: Previous thoracic endovascular repair is a significant preoperative risk factor for patients requiring subsequent open TAA repair. Not only does it increase the complexity of the repair with longer operative time and blood loss but also there is a worsening in terms of both mortality and respiratory morbidity.

Research paper thumbnail of Abstract No. 149: Endovascular Repair of Abdominal Aortic Aneurysms with Large Proximal Necks: Does Size Matter?

Journal of Vascular and Interventional Radiology, 2009

RESULTS: All 59 patients underwent successful coil embolization procedures. No major immediate po... more RESULTS: All 59 patients underwent successful coil embolization procedures. No major immediate post-procedure complications developed. Mean sac diameter pre-treatment was 3.5 cm (range 2-8.6 cm) and post treatment was 3.1 cm (range 2-8.6 cm). Mean follow-up was 25 months (range 1-97 months). 51/59 (86%) of patients developed buttock claudication following embolization with the majority of patients 45/51 (88%) reporting resolution of symptoms at 6 month follow up. There were no cases of overt pelvic ischemia observed. Stability or interval decrease in aneurysm size was demonstrated in 69/70 (98.6%) aneurysms. One case with an enlarging aneurysm sac was diagnosed with an endoleak requiring reintervention. There were no ruptures observed during follow up. CONCLUSION: Endovascular repair of hypogastric artery aneurysms is a safe and effective form of therapy. There is excellent durability observed in this cohort with a low incidence of aneurysm enlargement and re-intervention.

Research paper thumbnail of Management of Aortic Graft Infections and Mycotic Aneurysms: Improved Outcomes and Promising Early Results Through a Multidisciplinary Team Approach and In-situ Reconstruction Using Biological Conduits

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Successful Endovascular Repair of Acute Type B Aortic Dissection in Undiagnosed Ehlers–Danlos Syndrome Type IV

European Journal of Vascular and Endovascular Surgery, 2009

A 61-year-old man presented with an acute type B aortic dissection for which a stent-graft was in... more A 61-year-old man presented with an acute type B aortic dissection for which a stent-graft was introduced. He remains complication-free 4 years onwards and has since been diagnosed with EhlerseDanlos syndrome type IV (EDS IV). His particular mutation is predicted to result in lesser levels of normal collagen and may explain his favourable outcome from endovascular intervention. Understanding the genotypeephenotype correlation may influence the choice of therapy offered to patients with EDS IV.

Research paper thumbnail of Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC)

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2016

The management of aortic graft infection (AGI) is highly complex and in the absence of a universa... more The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI. A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition. Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graf...

Research paper thumbnail of Abstract 19994: Outcomes Following Thoracic Endovascular Aortic Repair in Patients With Bovine Aortic Arch Anatomical Variants: A 14-year Single Centre Experience

Circulation, 2014

Introduction: Bovine aortic arch (BA) anatomical variants have been associated with an increased ... more Introduction: Bovine aortic arch (BA) anatomical variants have been associated with an increased incidence of thoracic aortic disease but whether this anatomical variant affects outcomes after intervention remains unknown. We compare thoracic endovascular aortic repair (TEVAR) in patients with BA and those with a normal aortic arch configuration (NA). Methods: A prospectively maintained database of 250 patients who underwent elective and emergency TEVAR between 2000 and 2014 was analysed retrospectively. Computerised tomography angiograms were reconstructed using a TeraRecon Aquarius workstation to assess aortic morphology. Data analysed included in-patient mortality, stroke, papraplegia, incidence of endoleak, coverage/revascularization of the left subclavian artery (LSA) and the length of aorta covered. Results: Bovine aortic arch variants were identified in 48 patiens (19%), half of whom underwent TEVAR for thoracic aneursymal disease (TAA) and the remaining 24 for thoracic aorti...

Research paper thumbnail of Predicting recovery from paraplegia after thoracoabdominal aneurysm repair

European Journal of Vascular and Endovascular Surgery

Research paper thumbnail of Spinal cord ischemia in pancreas transplantation

Transplantation

Supplemental Digital Content is available in the text. Background. Spinal cord ischemia (SCI) is ... more Supplemental Digital Content is available in the text. Background. Spinal cord ischemia (SCI) is a rare but devastating condition that can occur in the perioperative period resulting in paraplegia. Although diabetes mellitus is a risk factor for SCI in other types of major surgery, SCI is not widely recognized in transplantation. The aim of this study was to quantify the risk of SCI in pancreatic transplantation. Methods. All UK pancreas transplant units were surveyed between 2017 and 2018. The risk of SCI in pancreas transplantation was estimated using the number of radiologically confirmed cases relative to the number of pancreatic transplants from UK registry data during the same time period. Results. There have been 6 cases of SCI during pancreas transplantation since 2002. No aortic clamping occurred in any recipient. During or after surgery, all patients experienced episodes of hypotension (systolic blood pressure ≤ 90 mm Hg) before the onset of neurological symptoms. Epoprostenol, epidural anesthesia, and postoperative hemodialysis may have contributed to systemic hypotension. The mainstay of early treatment for SCI for all cases was blood pressure control. Conclusions. Based on these findings, there is approximately a 1:440 risk of SCI in pancreas transplantation. Hypotension appears to be a prominent risk factor. Strategies for mitigating the risk of SCI are discussed, drawing on evidence from thoraco-abdominal aortic aneurysm surgery. The risk of long-term neurological deficit should be discussed with prospective pancreas recipients given the potential impact on posttransplant quality of life.

Research paper thumbnail of The implications of changes in vascular practice on higher surgical training: ASGBI: Vascular 01-12

Research paper thumbnail of Mycotic aneurysm following a dog bite: the value of the clinical history and molecular diagnostics

Annals of vascular surgery, Jan 20, 2016

A 63-year-old caucasian taxi-driver presented with a 3-week history of malaise, night sweats, 7kg... more A 63-year-old caucasian taxi-driver presented with a 3-week history of malaise, night sweats, 7kg weight loss, generalized arthralgia and persistent mid-lower abdominal pain. Blood inflammatory markers were raised, and a CT scan demonstrated an irregular degeneration of the infra-renal aorta, with a differential diagnosis including aortic infection. An urgent type IV thoracoabdominal aneurysm repair was performed with a rifampicin-soaked aortic tube graft during an open procedure. No organisms were grown from multiple peripheral blood cultures or culture of the affected aorta. However, subsequent polymerase chain reaction of the resected aorta identified Capnocytophaga canimorsus as the causative organism - a commensal that lives in the mouth of dogs and cats. The patient subsequently gave a history of multiple bites from his pet dog over recent months - the likely source of infection. He was treated with 8 weeks of intravenous antibiotics before switching to oral antibiotics for an...

Research paper thumbnail of Pragmatic minimum reporting standards for thoracic endovascular aortic repair

Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 2015

Research paper thumbnail of Pathology specific early outcome after thoracic endovascular aortic repair

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2014

Endovascular intervention is established for treatment of thoracic aortic dissection and aneurysm... more Endovascular intervention is established for treatment of thoracic aortic dissection and aneurysm. The aim of this study was to compare the incidence of all-cause and aortic-related in-hospital mortality, stroke, spinal cord ischaemia, and major adverse event rate for patients undergoing thoracic aortic endovascular intervention to see if there is a pathology-specific effect. Data were collected prospectively and analysed retrospectively for a cohort of 309 consecutive patients with either thoracic aortic dissection or aneurysm over a 14-year period. There were 209 men and 100 women with a median age of 72 years (interquartile range [IQR] 63-78 years). Aneurysm affected 62% (193/309) of patients and 37% (116/309) had complicated type B aortic dissection, of whom 43% (50/116) had acute and 57% (66/116) chronic presentations. In patients with aortic dissection compared to aneurysm, there was no significant difference in all-cause in-hospital mortality (6.9% vs. 8.3% respectively, p = ...

Research paper thumbnail of The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients

Journal of Vascular Surgery, 2014

Objective: The objectives of this observational cohort study were to investigate the prevalence o... more Objective: The objectives of this observational cohort study were to investigate the prevalence of undiagnosed cognitive impairment in older patients presenting for vascular surgery, to examine its association with adverse postoperative outcomes, and to test the feasibility of a preoperative cognitive assessment tool. Methods: Patients aged 60 years or older were recruited by consent on admission to the vascular surgical ward of an innercity teaching hospital with a large tertiary referral practice for proposed elective or emergency aortic or lower limb arterial intervention. Cognition was assessed preoperatively by the Montreal Cognitive Assessment (MoCA), and a score below 24/30 indicated cognitive impairment or dementia. The mean length of time taken to complete the assessment was recorded. Baseline characteristics (medical multimorbidity, frailty, and laboratory tests), hospital length of stay (LOS), and postoperative complications were documented. Results: Preoperative MoCA was completed in 114 patients with a mean age of 76.3 years (standard deviation, 7.36 years); 67.5% were men, and 55.3% of procedures were elective. The MoCA was completed in 100% of patients and was quick and acceptable to patients in this setting. Cognitive impairment or dementia was found in 68% of patients (77 of 114) and was previously unrecognized in 88.3% of patients (68 of 77). Therefore, 60.5% of patients (68 of 114) aged 60 years or older presenting for vascular surgery had previously undiagnosed cognitive impairment. MoCA <24 was univariately associated with pre-existing frailty (Edmonton Frail Scale [EFS] score 6.5)andlongerLOS(6.5) and longer LOS (6.5)andlongerLOS(12 days). In logistic regression modeling, MoCA <24 was strongly independently associated with frailty EFS score 6.5(oddsratio,12.55;P<.001).Byuseoftheareaunderthereceiveroperatingcharacteristiccurve(AUC),MoCA<24waspredictiveoflongerLOSof6.5 (odds ratio, 12.55; P < .001). By use of the area under the receiver operating characteristic curve (AUC), MoCA <24 was predictive of longer LOS of 6.5(oddsratio,12.55;P<.001).Byuseoftheareaunderthereceiveroperatingcharacteristiccurve(AUC),MoCA<24waspredictiveoflongerLOSof12 days (AUC, 0.621; P [ .049). The strength of predictive power increased with the addition of frailty (EFS score $6.5) to the models (AUC, 0.695; P [ .002). Conclusions: The prevalence of cognitive impairment among older patients presenting for vascular surgery is high and frequently undiagnosed before admission. It is feasible to use the MoCA to identify cognitive impairment in this high-risk surgical group preoperatively. The combined assessment of frailty and cognition is predictive of adverse postoperative outcomes and longer LOS.

Research paper thumbnail of Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection

Vascular, 2014

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management chal... more Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3–51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due...

Research paper thumbnail of Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm: The Way Forward?

Vascular, 2010

We present the early results of a policy of treating all anatomically suitable ruptured abdominal... more We present the early results of a policy of treating all anatomically suitable ruptured abdominal aortic aneurysms (rAAAs) by emergency endovascular aneurysm repair (eEVAR), regardless of hemodynamic instability. Data were retrospectively collected from prospectively maintained databases identifying patients with rAAA from 2006 to 2007. Forty-seven patients with true rAAA were identified (87% men; median age 76 years [range 63-97 years]), of whom 18 (38%) were treated with eEVAR, 19 (40%) received open aneurysm repair (OAR), and 10 (21%) were managed nonoperatively. Fifteen of 18 (83%) eEVAR patients received an aortouni-iliac device + femorofemoral crossover, 2 patients (11%) had bifurcated devices, and 1 patient (6%) had a new iliac limb. Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.

Research paper thumbnail of Endovascular treatment of acute aortic syndrome

Journal of Vascular Surgery, 2011

Research paper thumbnail of Neurological presentation of acute aortic syndrome: Type A intramural haematoma presenting as ischaemic hemisection of the spinal cord

Spinal Cord Series and Cases, 2020

Introduction Intramural haematoma (IMH) describes the presence of blood within the aortic wall, a... more Introduction Intramural haematoma (IMH) describes the presence of blood within the aortic wall, and is associated with a significant morbidity and mortality. Early diagnosis is essential for institution of medical, and sometimes surgical, management. Neurological complications have rarely been described during the initial presentation of IMH, or other forms of acute aortic syndrome. Case presentation We describe a 56-year-old man who presented with sudden onset chest pain and left leg weakness and numbness, and the loss of right leg pain and temperature sensation. CT Angiography showed a Type A intramural haematoma extending from the ascending to the infra-renal aorta. He was managed successfully with cerebrospinal fluid drainage and thoracic endografting to cover the intimal entry lesion. His neurological symptoms improved and he remained well at 3 years with minor residual neurological deficits. Discussion Spinal cord infarction is a rare but documented complication of acute aortic syndrome; Brown-Séquard syndrome typically results from a traumatic injury. To the best of our knowledge, this is the first report of IMH presenting with Brown-Séquard syndrome. This case highlights the need to consider acute aortic syndromes in a patient presenting with chest pain and acute neurological symptoms.

Research paper thumbnail of Visual Scoring Improves the Utility of 18F-FDG PET/CT in the Diagnosis of Aortic Graft Infection

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Selecting Patients for Aortic Aneurysm Repair and oUtcomes Associated with Operative and Non-operative Management: Low Aneurysm Related Mortality in Elective patients Managed Non-operatively

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Endovascular Aneurysm Sealing (EVAS). Outcomes and Anatomical Suitability, a Single Centre Experience

European Journal of Vascular and Endovascular Surgery, 2019

Introduction: In abdominal aortic aneurysm (AAA), open surgical repair (OSR) is reportedly more i... more Introduction: In abdominal aortic aneurysm (AAA), open surgical repair (OSR) is reportedly more invasive but also, over the long-term, more durable and may have a lower reintervention rate than is observed in endovascular aneurysm repair (EVAR). Therefore, strict patient selection based on assessments of both short-and long-term outcomes and patient frailty (sarcopenia and nutrition) is needed because most affected patients are elderly. However, little information is available about patient frailty and long-term outcomes in OSR. The aim of this study was to identify prognostic factors of long-term mortality, including frailty. Methods: We reviewed 360 consecutive AAA patients who underwent OSR from 2007 to 2014. We collected data on patient characteristics, nutrition (controlling nutritional status [CONUT] score), and muscle size (skeletal muscle mass index [SMI]). 1 A Cox proportional analysis and logistic regression analysis identified independent predictors of longterm mortality and Clavien-Dindo class IV complications, respectively. A P value <.05 was considered significant. Results: During the study period, 360 patients underwent elective OSR. The following patient characteristics were associated with long-term mortality: 3 71 years old (HR, 4.92; 95%CI, 1.41-17.13, P¼0.01), low SMI (HR, 4.32; 95%CI, 1.16-16.13, P¼0.03), CONUT score indicating moderate risk of malnutrition (vs normal/mild risk, HR, 4.16; 95%CI, 1.03-16.76, P¼0.045), and eGFR<30 mL/min/1.73 m 2 (HR, 3.54; 95%CI, 1.09-11.47, P¼0.035). Two patients died within 30 days after OSR (0.6%). A CONUT score indicating moderate risk (HR, 4.42; 95%CI, 1.01-19.28, P¼0.048), eGFR <30 mL/ min/1.73 m 2 (HR, 7.34; 95%CI, 2.20-24.51, P< 0.001) and diabetes mellitus (HR, 3.71; 95%CI, 1.25-11.00, P¼0.02) were independent predictors of Clavien-Dindo class IV complications. Conclusion: These results may be useful for identifying and optimizing high-risk patients who would not benefit from OSR so that they can be directed towards EVAR. Considering nutritional status and sarcopenia may therefore support a more personalized treatment strategy.

Research paper thumbnail of Radiation-Associated DNA Damage in Operators During Endovascular Aortic Repair

European Journal of Vascular and Endovascular Surgery, 2016

spinal cord ischemia, respiratory and renal and insufficiency. Secondary end points included bloo... more spinal cord ischemia, respiratory and renal and insufficiency. Secondary end points included blood loss, operative time, ICU stay, the length of hospital stay. Results: Primary endpoints: 30 days mortality rate 24.1% (7.18% standard group, p ¼ 0.001), spinal cord ischemia rate 13.8% (14.1% standard group, p ¼ 0.964), respiratory failure rate 13.8% (4.95% standard group, p ¼ 0.0442) and renal failure rate 27.6% (26.2% standard group, p ¼ 0.869). Secondary endpoints: mean blood loss 7062 mL (5246 mL standard group, p ¼ 0.018), mean operative time 5,39 h (4,79 h standard group, p ¼ 0.021), mean ICU stay 3.4 days (2.7 days standard group, p ¼ 0.068), length of hospital stay 10.7 days (10.4 days standard group, p ¼ 0.852). Conclusion: Previous thoracic endovascular repair is a significant preoperative risk factor for patients requiring subsequent open TAA repair. Not only does it increase the complexity of the repair with longer operative time and blood loss but also there is a worsening in terms of both mortality and respiratory morbidity.

Research paper thumbnail of Abstract No. 149: Endovascular Repair of Abdominal Aortic Aneurysms with Large Proximal Necks: Does Size Matter?

Journal of Vascular and Interventional Radiology, 2009

RESULTS: All 59 patients underwent successful coil embolization procedures. No major immediate po... more RESULTS: All 59 patients underwent successful coil embolization procedures. No major immediate post-procedure complications developed. Mean sac diameter pre-treatment was 3.5 cm (range 2-8.6 cm) and post treatment was 3.1 cm (range 2-8.6 cm). Mean follow-up was 25 months (range 1-97 months). 51/59 (86%) of patients developed buttock claudication following embolization with the majority of patients 45/51 (88%) reporting resolution of symptoms at 6 month follow up. There were no cases of overt pelvic ischemia observed. Stability or interval decrease in aneurysm size was demonstrated in 69/70 (98.6%) aneurysms. One case with an enlarging aneurysm sac was diagnosed with an endoleak requiring reintervention. There were no ruptures observed during follow up. CONCLUSION: Endovascular repair of hypogastric artery aneurysms is a safe and effective form of therapy. There is excellent durability observed in this cohort with a low incidence of aneurysm enlargement and re-intervention.

Research paper thumbnail of Management of Aortic Graft Infections and Mycotic Aneurysms: Improved Outcomes and Promising Early Results Through a Multidisciplinary Team Approach and In-situ Reconstruction Using Biological Conduits

European Journal of Vascular and Endovascular Surgery, 2019

Research paper thumbnail of Successful Endovascular Repair of Acute Type B Aortic Dissection in Undiagnosed Ehlers–Danlos Syndrome Type IV

European Journal of Vascular and Endovascular Surgery, 2009

A 61-year-old man presented with an acute type B aortic dissection for which a stent-graft was in... more A 61-year-old man presented with an acute type B aortic dissection for which a stent-graft was introduced. He remains complication-free 4 years onwards and has since been diagnosed with EhlerseDanlos syndrome type IV (EDS IV). His particular mutation is predicted to result in lesser levels of normal collagen and may explain his favourable outcome from endovascular intervention. Understanding the genotypeephenotype correlation may influence the choice of therapy offered to patients with EDS IV.

Research paper thumbnail of Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC)

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2016

The management of aortic graft infection (AGI) is highly complex and in the absence of a universa... more The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI. A process of expert review and consensus, involving formal collaboration between vascular surgeons, infection specialists, and radiologists from several English National Health Service hospital Trusts with large vascular services (Management of Aortic Graft Infection Collaboration [MAGIC]), produced the definition. Diagnostic criteria from three categories were classified as major or minor. It is proposed that AGI should be suspected if a single major criterion or two or more minor criteria from different categories are present. AGI is diagnosed if there is one major plus any criterion (major or minor) from another category. (i) Clinical/surgical major criteria comprise intraoperative identification of pus around a graf...

Research paper thumbnail of Abstract 19994: Outcomes Following Thoracic Endovascular Aortic Repair in Patients With Bovine Aortic Arch Anatomical Variants: A 14-year Single Centre Experience

Circulation, 2014

Introduction: Bovine aortic arch (BA) anatomical variants have been associated with an increased ... more Introduction: Bovine aortic arch (BA) anatomical variants have been associated with an increased incidence of thoracic aortic disease but whether this anatomical variant affects outcomes after intervention remains unknown. We compare thoracic endovascular aortic repair (TEVAR) in patients with BA and those with a normal aortic arch configuration (NA). Methods: A prospectively maintained database of 250 patients who underwent elective and emergency TEVAR between 2000 and 2014 was analysed retrospectively. Computerised tomography angiograms were reconstructed using a TeraRecon Aquarius workstation to assess aortic morphology. Data analysed included in-patient mortality, stroke, papraplegia, incidence of endoleak, coverage/revascularization of the left subclavian artery (LSA) and the length of aorta covered. Results: Bovine aortic arch variants were identified in 48 patiens (19%), half of whom underwent TEVAR for thoracic aneursymal disease (TAA) and the remaining 24 for thoracic aorti...

Research paper thumbnail of Predicting recovery from paraplegia after thoracoabdominal aneurysm repair

European Journal of Vascular and Endovascular Surgery

Research paper thumbnail of Spinal cord ischemia in pancreas transplantation

Transplantation

Supplemental Digital Content is available in the text. Background. Spinal cord ischemia (SCI) is ... more Supplemental Digital Content is available in the text. Background. Spinal cord ischemia (SCI) is a rare but devastating condition that can occur in the perioperative period resulting in paraplegia. Although diabetes mellitus is a risk factor for SCI in other types of major surgery, SCI is not widely recognized in transplantation. The aim of this study was to quantify the risk of SCI in pancreatic transplantation. Methods. All UK pancreas transplant units were surveyed between 2017 and 2018. The risk of SCI in pancreas transplantation was estimated using the number of radiologically confirmed cases relative to the number of pancreatic transplants from UK registry data during the same time period. Results. There have been 6 cases of SCI during pancreas transplantation since 2002. No aortic clamping occurred in any recipient. During or after surgery, all patients experienced episodes of hypotension (systolic blood pressure ≤ 90 mm Hg) before the onset of neurological symptoms. Epoprostenol, epidural anesthesia, and postoperative hemodialysis may have contributed to systemic hypotension. The mainstay of early treatment for SCI for all cases was blood pressure control. Conclusions. Based on these findings, there is approximately a 1:440 risk of SCI in pancreas transplantation. Hypotension appears to be a prominent risk factor. Strategies for mitigating the risk of SCI are discussed, drawing on evidence from thoraco-abdominal aortic aneurysm surgery. The risk of long-term neurological deficit should be discussed with prospective pancreas recipients given the potential impact on posttransplant quality of life.

Research paper thumbnail of The implications of changes in vascular practice on higher surgical training: ASGBI: Vascular 01-12

Research paper thumbnail of Mycotic aneurysm following a dog bite: the value of the clinical history and molecular diagnostics

Annals of vascular surgery, Jan 20, 2016

A 63-year-old caucasian taxi-driver presented with a 3-week history of malaise, night sweats, 7kg... more A 63-year-old caucasian taxi-driver presented with a 3-week history of malaise, night sweats, 7kg weight loss, generalized arthralgia and persistent mid-lower abdominal pain. Blood inflammatory markers were raised, and a CT scan demonstrated an irregular degeneration of the infra-renal aorta, with a differential diagnosis including aortic infection. An urgent type IV thoracoabdominal aneurysm repair was performed with a rifampicin-soaked aortic tube graft during an open procedure. No organisms were grown from multiple peripheral blood cultures or culture of the affected aorta. However, subsequent polymerase chain reaction of the resected aorta identified Capnocytophaga canimorsus as the causative organism - a commensal that lives in the mouth of dogs and cats. The patient subsequently gave a history of multiple bites from his pet dog over recent months - the likely source of infection. He was treated with 8 weeks of intravenous antibiotics before switching to oral antibiotics for an...

Research paper thumbnail of Pragmatic minimum reporting standards for thoracic endovascular aortic repair

Journal of endovascular therapy : an official journal of the International Society of Endovascular Specialists, 2015

Research paper thumbnail of Pathology specific early outcome after thoracic endovascular aortic repair

European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2014

Endovascular intervention is established for treatment of thoracic aortic dissection and aneurysm... more Endovascular intervention is established for treatment of thoracic aortic dissection and aneurysm. The aim of this study was to compare the incidence of all-cause and aortic-related in-hospital mortality, stroke, spinal cord ischaemia, and major adverse event rate for patients undergoing thoracic aortic endovascular intervention to see if there is a pathology-specific effect. Data were collected prospectively and analysed retrospectively for a cohort of 309 consecutive patients with either thoracic aortic dissection or aneurysm over a 14-year period. There were 209 men and 100 women with a median age of 72 years (interquartile range [IQR] 63-78 years). Aneurysm affected 62% (193/309) of patients and 37% (116/309) had complicated type B aortic dissection, of whom 43% (50/116) had acute and 57% (66/116) chronic presentations. In patients with aortic dissection compared to aneurysm, there was no significant difference in all-cause in-hospital mortality (6.9% vs. 8.3% respectively, p = ...

Research paper thumbnail of The prevalence and impact of undiagnosed cognitive impairment in older vascular surgical patients

Journal of Vascular Surgery, 2014

Objective: The objectives of this observational cohort study were to investigate the prevalence o... more Objective: The objectives of this observational cohort study were to investigate the prevalence of undiagnosed cognitive impairment in older patients presenting for vascular surgery, to examine its association with adverse postoperative outcomes, and to test the feasibility of a preoperative cognitive assessment tool. Methods: Patients aged 60 years or older were recruited by consent on admission to the vascular surgical ward of an innercity teaching hospital with a large tertiary referral practice for proposed elective or emergency aortic or lower limb arterial intervention. Cognition was assessed preoperatively by the Montreal Cognitive Assessment (MoCA), and a score below 24/30 indicated cognitive impairment or dementia. The mean length of time taken to complete the assessment was recorded. Baseline characteristics (medical multimorbidity, frailty, and laboratory tests), hospital length of stay (LOS), and postoperative complications were documented. Results: Preoperative MoCA was completed in 114 patients with a mean age of 76.3 years (standard deviation, 7.36 years); 67.5% were men, and 55.3% of procedures were elective. The MoCA was completed in 100% of patients and was quick and acceptable to patients in this setting. Cognitive impairment or dementia was found in 68% of patients (77 of 114) and was previously unrecognized in 88.3% of patients (68 of 77). Therefore, 60.5% of patients (68 of 114) aged 60 years or older presenting for vascular surgery had previously undiagnosed cognitive impairment. MoCA <24 was univariately associated with pre-existing frailty (Edmonton Frail Scale [EFS] score 6.5)andlongerLOS(6.5) and longer LOS (6.5)andlongerLOS(12 days). In logistic regression modeling, MoCA <24 was strongly independently associated with frailty EFS score 6.5(oddsratio,12.55;P<.001).Byuseoftheareaunderthereceiveroperatingcharacteristiccurve(AUC),MoCA<24waspredictiveoflongerLOSof6.5 (odds ratio, 12.55; P < .001). By use of the area under the receiver operating characteristic curve (AUC), MoCA <24 was predictive of longer LOS of 6.5(oddsratio,12.55;P<.001).Byuseoftheareaunderthereceiveroperatingcharacteristiccurve(AUC),MoCA<24waspredictiveoflongerLOSof12 days (AUC, 0.621; P [ .049). The strength of predictive power increased with the addition of frailty (EFS score $6.5) to the models (AUC, 0.695; P [ .002). Conclusions: The prevalence of cognitive impairment among older patients presenting for vascular surgery is high and frequently undiagnosed before admission. It is feasible to use the MoCA to identify cognitive impairment in this high-risk surgical group preoperatively. The combined assessment of frailty and cognition is predictive of adverse postoperative outcomes and longer LOS.

Research paper thumbnail of Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection

Vascular, 2014

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management chal... more Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3–51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due...

Research paper thumbnail of Emergency Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysm: The Way Forward?

Vascular, 2010

We present the early results of a policy of treating all anatomically suitable ruptured abdominal... more We present the early results of a policy of treating all anatomically suitable ruptured abdominal aortic aneurysms (rAAAs) by emergency endovascular aneurysm repair (eEVAR), regardless of hemodynamic instability. Data were retrospectively collected from prospectively maintained databases identifying patients with rAAA from 2006 to 2007. Forty-seven patients with true rAAA were identified (87% men; median age 76 years [range 63-97 years]), of whom 18 (38%) were treated with eEVAR, 19 (40%) received open aneurysm repair (OAR), and 10 (21%) were managed nonoperatively. Fifteen of 18 (83%) eEVAR patients received an aortouni-iliac device + femorofemoral crossover, 2 patients (11%) had bifurcated devices, and 1 patient (6%) had a new iliac limb. Thirty-day mortality was 11% (2 of 18) for eEVAR and 32% (6 of 19) for OAR (p = not significant). At the 6-month follow-up, mortality was 22% (4 of 18) for eEVAR and 37% (7 of 19) for OAR (p = not significant). A clinically significant early survival advantage is suggested for eEVAR in patients presenting with rAAA.

Research paper thumbnail of Endovascular treatment of acute aortic syndrome

Journal of Vascular Surgery, 2011