Vascular Surgery Edition

Ivan Möller

What is Vascular Surgery?

Vascular surgery, a specialised branch of general surgery, focuses on treating intricate issues within the vascular system. To become vascular surgeons in South Africa, doctors undergo extensive training. After completing medical school, internship, and community service, aspiring vascular surgeons must undergo a rigorous 5-year registrarship in general surgery, followed by an additional 2-year subspecialist program in vascular surgery. However, with only 14 available traineeship positions at seven institutions nationwide each year, competition is fierce.^[1]

The Colleges of Medicine South Africa (CMSA) Regulations for the Sub-Specialty Certificate In Vascular Surgery broadly divides vascular surgery into surgery of the arteries and surgery of the veins. Surgery of the arteries includes peripheral vascular disease, visceral ischaemia, and aneurysms of the abdominal aorta, femoral arteries, extracranial vessels, etc.^[2]

 

 

 

 

 

 

 

 

 

Surgery of the veins include deep vein thrombosis, venous incompetence, and venous hypertension. Vascular surgeons also work at the forefront of endovascular surgery as well as offer intra-operative consults for vascular trauma. ^[2]

 

 

 

 

 

 

 

 

The following are reputable journals in vascular surgery obtained from the DHET’s 2024 Scopus accredited list^[3]:

 

 

 

 

 

 

 

Journal in the Spotlight: Eur J Vasc Endovasc Surg

The European Journal of Vascular and Endovascular Surgery (Eur J Vasc Endovasc Surg) is a peer-reviewed, hybrid journal (both exclusive for subscribers and open access to the public) from the European Society for Vascular Surgery (ESVS) published by Elsevier BV.^[4]  Previously known as the European Journal of Vascular Surgery (1987 to 1994), in its current rendition it has published more than 8,400 articles since 1995 that garnered over 211,732 citations.^[5-6]

In their own words: “The EJVES is aimed primarily at vascular surgeons dealing with patients with arterial, venous, and lymphatic diseases. It includes contributions on epidemiology, prevention, diagnosis, investigation, and management of these vascular disorders. In addition, papers that consider the technical aspects of vascular surgery are encouraged, and the journal includes invited state-of-the-art articles.”^[4]

Article Reviews

Going in a Second Time: Open Conversion or Endovascular for Failed EVAR?^[7]

Aortic aneurysm is a common vascular pathology that requires surgery. A popular modern surgical approach to repairing an aortic aneurysm is called EVAR, which stands for Endovascular Aneurysm Repair. However, what happens when this repair fails? How do you repair a failed repair? Well, luckily there are multiple way in which such a situation can be approached – the more common options being: a) fenestrated and branched endovascular repairs (F/B-EVAR) or b) open surgical endoprosthesis explant with aortic reconstruction.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In a recent article titled Systematic Review and Meta-Analysis of Elective Open Conversion versus Fenestrated and Branched Endovascular Repair for Previous Non-Infected Failed Endovascular Aneurysm Repair by Davide Esposito et al. (a collaboration between Careggi University Hospital, Florence, Italy and Imperial College London, London, UK) researchers set out to see which one of these repair option work best.

The aim of their study was to evaluate the outcomes of patients electively (not emergency) undergoing F/B-EVAR or open conversion for failed previous non-infective EVAR. The study hopes to add value by  providing surgeons with guidance on which method to choose. To determine which is better, the death/ survival and complication rates at 30 days and 18 months post-opt respectively were compared and evaluated for statistical significance.

A Systematic Review and Meta-Analysis following the PRISMA guidelines was used by the authors to conduct their study. They started with 4 141 articles and applied their inclusion and exclusion criteria until they were left with only 38 articles left . They then graded the quality of these 38 articles using the MINORS criteria and used a funnel plot and Egger’s test to assess for publication bias. Finally, the results were presented using Forest plots.

The results of their study showed that at 30 days post-opt, the mortality rate of both open conversion and F/B-EVAR were similar (2.3% vs 2.4%, p=0.36), however the complication rate for open conversion was slightly higher (21.4% vs 15.7%, p=0.52). At 18 months post-opt,  both the survival rate (26% vs 4.5%, p <0.001) and rate of complications (81.6% vs 92.5%, p =0.005) was overwhelmingly in favour of open conversion.

In the discussion, various limitations to the study were listed. Some include the presence of selection bias, publication bias, anatomical variation between patients, incomplete information surrounding confounding factors such as age and comorbidities, and poor to fail quality levels of their selected articles as per the MINORS criteria.

Regardless of the limitations, the authors finally concluded that in acceptably healthy patients, open conversion may be considered as a preferred option over F/B-EVAR following a failed non-infective EVAR.

 

 

 

 

 

 

 

 

 

 

 

Exercise Therapy for Symptomatic Chronic PAD: The New Consensus^[8]

Regular physical activity, including exercise, plays a crucial role in cardiovascular health and the management of cardiovascular diseases (CVDs). The European Society of Cardiology (ESC) issued guidelines in 2020 addressing exercise therapy and sports practice for cardiac conditions. Peripheral artery disease (PAD), affecting approximately 237 million people globally, often presents with walking impairment as a primary symptom. Despite existing guidelines emphasizing supervised exercise therapy for PAD management, a comprehensive framework for exercise therapy in this context was lacking. To fill this void, collaborative efforts by the ESC Working Group on Aortic and Peripheral Vascular Diseases, the European Society of Vascular Medicine, and the European Society for Vascular Surgery aimed to provide guidance for establishing and implementing exercise therapy programs for PAD patients.

 

 

 

 

 

 

 

 

The following is a summary of the 13 consensus points reached by the researchers:

1. Supervised exercise is recommended as primary treatment for PAD and exercise-induced limb symptoms.
2. Supervised exercise is also advised for PAD patients’ post-revascularization.
3. Vascular physicians should oversee these programs, with sessions supervised by exercise professionals.
4. Prior to exercise, patients require medical history, examination, and contraindication screening.
5. Assessments should include walking ability, functional status, and quality of life before and after the program.
6. Walking training is preferred, but alternatives should be available.
7. Exercise sessions should occur at least thrice weekly.
8. Each session should last minimum 30 minutes.
9. The program should continue for at least three months.
10. Exercise intensity should match moderate to high claudication pain, with gradual progression.
11. If supervision isn’t feasible, consider community or home-based programs with behavior change techniques.
12. Education on risk reduction, including smoking cessation, should be part of the program.
13. Encourage patients to maintain high regular physical activity levels post-training.

Acknowledgements

This article was brought to you by the TSSS Research Sub-Committee of 2024. The principal author of the piece was Ivan Möller, with chief editor Catherine Joseph overseeing quality.

Bibliography

1. Cassimere I, le Roux D, Pillai J, Veller M. Vascular surgery in South Africa in 2021. Eur J Vasc Endovasc Surg 2021;61:719–720. https://doi.org/10.1016/j.ejvs.2021.03.001
2. The Colleges of Medicine of South Africa: Sub-specialty Certificate in Vascular Surgery of the College of Surgeons of South Africa. https://www.cmsa.co.za/view_exam.aspx?QualificationID=104 (accessed March 28, 2024).
3. University of Pretoria Department of Library Services. DHET acknowledged lists (2024) – Scopus. https://www.library.up.ac.za/ld.php?content_id=75601286 (accessed March 28, 2024).
4. European Journal of Vascular and Endovascular Surgery. Aims and Scope. https://www.ejves.com (accessed 28 March 2024).
5. European journal of vascular surgery. https://www.ncbi.nlm.nih.gov/nlmcatalog/8709440 (accessed 28 March 2024).
6. European Journal of Vascular and Endovascular Surgery. https://typeset.io/journals/european-journal-of-vascular-and-endovascular-surgery-1ped43dn (accessed 28 March 2024).
7. Esposito D, Rawashdeh M, Onida S, Turner B, Machin M, Pulli R, et al. Systematic review and meta-analysis of elective open conversion versus fenestrated and branched endovascular repair for previous non-infected failed endovascular aneurysm repair. Eur J Vasc Endovasc Surg 2023;67:393–405. https://doi.org/10.1016/j.ejvs.2023.09.036.
8. Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, et al. Editor’s choice — exercise therapy for chronic symptomatic peripheral artery disease: A clinical consensus document of the European society of cardiology working group on aorta and peripheral vascular diseases in collaboration with the European society of vascular medicine and the European society for vascular surgery. Eur J Vasc Endovasc Surg 2024;67:373–92. https://doi.org/10.1016/j.ejvs.2024.01.009.
9. EVAR(600×531).jpg. https://eu-csite-storage-prod.s3.amazonaws.com/www-cirse-org/files/images/Patients/EVAR(600×531).jpg (accessed April 7, 2024).
10. Endovascular-fig1-revised.jpg (796×507). https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2014/09/22/13/49/endovascular-fig1-revised.jpg (accessed April 7, 2024).
11. jpg (300×407). https://i.pinimg.com/originals/4e/89/25/4e8925d74caff388db9f28a9c3048e5a.jpg (accessed April 7, 2024).
12. Peripheral-Artery-Disease-Graphic-scaled.png (2500×1054). https://images.squarespace-cdn.com/content/v1/633ba514bb0a7342b4a41bc8/d247f7cb-eb07-4ef0-8cbd-82fbb433089e/Peripheral-Artery-Disease-Graphic-scaled.png (accessed April 7, 2024).