Can we objectively measure ‘frailty’ in elderly population in preparation for a major vascular surgery? 

REF. BJS Jan 16 special issue. Wiki on sarcopenia. 

We appearantly can, and this is how: 

Similarly to the 1996 World Health Organization (WHO) methodology for definitive diagnosis of osteoporosis, which uses DEXA, which uses a cut point of 2 standard deviations below the mean of DEXA results for gender specific healthy young adults to define osteoporosis. In here, we use a measure of lean mass rather than bone mineral density (BMD).  

The European society on clinical nutrition and metabolism special interest group on geriatric nutrition had a concerns us definition for sarcopenia: 

1) A low muscle mass, >2 standard deviations below that mean measured in young adults (aged 18–39 years in the 3rd NHANES population) of the same sex and ethnic background, and

2) Low gait speed (e.g. a walking speed below 0.8 m/s in the 4-m walking test).

Linda Fried / Johns Hopkins Frailty Criteria Edit

A popular approach to the assessment of geriatric frailty encompasses the assessment of five dimensions that are hypothesized to reflect systems whose impaired regulation underlies the syndrome. These five dimensions are:
unintentional weight loss,


muscle weakness,

slowness while walking, and

low levels of activity.[1]

Corresponding to these dimensions are five specific criteria indicating adverse functioning, which are implemented using a combination of self-reported and performance-based measures. Those who meet at least three of the criteria are defined as “frail”, while those not matching any of the five criteria are defined as “robust”. 

The Bmj (based on research commissioned by  National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London) provided another way of measuring fragility, as in the following figure: 

Authors in the BJS JAN 2016 measured the psoas as volume as a proxy for sarcopenia, and showed a significant predictive power to estimate the risk of frailty on patients undergoing major HBP surgery.

Nhs England has produced a document on how to measure frailty and how to provide a better care to elderly population. 

Is it necessary to admit patients to level 2 care to administer intraarterial catheter-directed thrombolysis?

Ref. EJVES MAY 2016- Type: cohort study

This cohort study says NO. The outcome of 252 patients treated with thrombolysis was not different on the site of admission: 

There were no differences in the frequency of non-bleeding related complications between Centre 1 and Centre 2. Patients on the vascular ward had a higher frequency of minor bleeding (p = .002) but there was no difference in major bleeding (p = .12). Eleven patients on the ward required an increased level of care for medical reasons and six were moved for a lack of resources. The presence of cardiac disease was an independent risk factor for patient transfer (OR 3.2; 95% CI 1.04–9.8, p = .04).

Adjuvant AV fistula in high risk lower limb bypass surgery: is it useful?

Ref. EJVES MAY 2016

It is well described and well know; yet again, there is no evidence that it helps in improving latency rate. Things are slightly different on using a synthetic graft. It appears that the patency rate improves primarily (as compared to secondary intervention)

Two randomised controlled trials and seven retrospective cohort studies comprising 966 participants were included. Pooled standardized data showed no difference in primary graft patency (pooled RR = 1.25, 95% CI 0.73–2.16), secondary patency (pooled RR = 1.16, 95% CI 0.82–1.66), or limb salvage at 12-months (pooled RR = 1.13, 95% CI 0.80–1.60) for the peripheral bypass with AVF group compared with peripheral bypass alone. Subgroup analysis indicated a reduction in reintervention rates associated with AVF when performed in conjunction with a synthetic graft (pooled RR = 0.55, 95% CI 0.30–0.98).

Ruptured AAA are NOT necessarily associated with coagulopathy

Ref. EJVES MAY 2016

This is the first systematic review of this kind. Very interesting findings. 

Seven studies, comprising 461 patients were included in this systematic review. Overall weighted prevalence of coagulopathy was 12.3% (95% CI 10.7–13.9), 11.7% for INR (95% CI 1–31.6), 10.1% for platelet count (95% CI 1–26.8), and 11.1% for aPTT (95% CI 0.78–31). Fibrinogen serum concentration level was normal in 97%, and 46.2% (n = 55) of patients had elevated D-dimer. Only 6% of the entire population demonstrated significant coagulopathy. DIC was noted in 2.4% of the population.

So the question is: do you consider heparin for those patients? 

Chimneys and periscopes are good enough … 

Ref. EJVES MAY 2916

This is a series of a 100 cases, with total 224 chimney/periscope devices used. The outcome are fairly good as follows:

CPG immediate technical success was 99% (222/224 branches). Mean follow up was 29 months (range 0–65; SD 17); 59% patients were followed > 2 years, 30% > 3 years, and 16% > 4 years. Post-operatively, CPG occlusion was observed early (≤30 days) in three (1.3%) branches and during follow up in 10 (4.5%). At 36 and 48 months, the estimated primary patency was 93% and 93%. After corrective percutaneous (10) or surgical (3) re-interventions, the estimated secondary patency was 96% and 96%. Thirty day mortality was 2%; at 36 and 48 months the estimated patient survival was 79%. Significant shrinkage (72 [SD 23] vs. 62 [SD 24] mm; p < .001) was observed, with a substantial reduction (>5 mm) in 55 patients, and sac enlargement in four. Incomplete aneurysm sac sealing was treated successfully by a secondary intervention in 15 patients.

Amplatz embolisation of internal iliac artery in preparation for EVAR. the biggest series ever! 

Source: EJVES MAY 2016

This is a multi centre series of 169 patients who neededamplatz to proceed with their surgery. Out of all, technical success rate was 97.6%. The embolisation was uni or bilateral. Buttock claudications occurred in ~ 25%, almost 60% of them resolved at first follow up. Bowel is genera occurred in 2 patients (1%) and east treated with limited bowel resection. 

Is it possible to predict and protect against endo leak type II

Ref EJVES MAY 2016

The answer is yes, if we look at this case control study. Identifying  6 afferent vessels, or the presence of AAA thrombus volume ratio (VR%) <40% have been shown clearly and significantly to be asociatied with increas type II risk rate, and that emboli station of which has reduced significantly the type II endoleak when compared to a arching group 30% vs 75% at 6 months and similar at 12 months. 

So it is so correct to presume this is a first step towards reducing the annoying type II endoleak risk. 

Carotid plaque echolucency is simply dangerous

Ref. EJVES MAY 2016

A retrospective analysis of well collected data in ACST1 trial, looking specifically on the presence of clear echolucency (homogenous > 25%) vs clear nonecholuecency shows a significant different in stroke rateb8% vs 3%. The risk of ten presence of echolucency cry increases therefore by 2.5 times. 

This is now significant level of evidence, and has to be taken always into consideration.