Research:
1) Title: Risk Reduction in Patients with Peripheral Arterial Disease: Where Do We Stand?
Journal: Submitted to the Annals of Vascular Surgery
In Collaboration with the Systemic Assessment of Vascular Risk (SAVR) group in University of Toronto, Canada
Abstract for the In-term analysis:
Background: Current evidence suggests that atherosclerosis risk factors modification plays an important role in improving the adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). This study was undertaken to identify the utilization of risk factor modification therapy in this high risk group.
Methods and Results: We prospectively collected data from 391 consecutive PAD patients who were referred to the Vascular Surgery outpatient clinic at a Tertiary Care Hospital between July 2004 and July 2006. The mean age for these patients was 67 years and 35% were women. The mean number of atherosclerotic risk factors (hypercholesterolemia, hypertension, diabetes mellitus (DM), overweight/obesity (BMI>24.9), current smoker) was 3 (SD +/- 1). Hypertension was identified in 56.8% of patients (222/391). Of theses patients, only 37.4% had an optimal control of blood pressure (BP < 140/90 mmHg). The prevalence of DM was 35 % (137/391). Of theses patients, only 49% (67/137) had an optimal control of blood sugar (HbA1c < 7%). Statins were currently prescribed in 61% of patients (238/391). Of those on statins, 38.7% continued to have LDL >2.5mmol/L compared to 76.5% of non-statin users (p<0.001 The prevalence of obesity/overweight was 72.4% (283/391). Current nonsmokers made up 67.3% of patients (263/391), of whom 73.4 % (193/263) were former smokers. Antiplatelets were prescribed for 78.3% of patients (306/391), of whom 70.6% (216/306) were on aspirin. Angiotensin converting enzyme (ACE) inhibitors were prescribed for 44.8% of patients (175/391), however only 36.8% of rampril users (53/144) were on an optimal dose.
Conclusion: Although the atherosclerotic risk factors were prevalent in patients with PAD, sub-optimal use of risk reduction therapy was observed. Effective strategies to encourage health professionals to use these adjunctive therapies need to be developed.
2) Title: Perception of Physicians in Saudi Arabia towards Risk Reduction Therapy in Patients with Peripheral Arterial Disease Compared to Coronary Artery Disease.
In Collaboration with the Saudi Society for Vascular Surgery and the Atherosclerosis Risk Reduction Program in Saudi Arabia (STAR-KSA)
Abstract for the In-term analysis:
Introduction: Peripheral Arterial Disease (PAD) is a marker of advanced atherosclerosis with an elevated risk of cardiovascular mortality and morbidity. Although intensive risk reduction therapy is critical in reducing the adverse cardiovascular outcomes in patients with PAD, the awareness of this information among all physicians is felt to be low. Given the role of family physicians (FP), general internists (GI), Cardiologists (C), and vascular surgeons (VS) in treating patients with PAD, we sought to determine their perceptions and knowledge of risk reduction therapy in these patients.
Methods: We conducted a cross-sectional self-administered survey of 458 physicians who work in different provinces of Saudi Arabia.
Results: FP, GI, C, and VS represent 62%, 23%, 10%, and 5% of the surveyed physicians, respectively. The recommended targets of LDL-cholesterol, blood glucose and blood pressure in PAD patients were known to 37.3%, 94.1% and 35.3% of physicians, respectively. The majority of physicians reported to screen for risk factors in PAD. Although 86.3 % of physicians would recommend antiplatelets therapy in PAD, only 17.6% would recommend angiotensin converting enzyme (ACE) inhibitors; 25.5% would recommend nicotine replacement therapy for smokers and 62.7% would recommend statins. Compared to other specialties, cardiologists had the lowest threshold, whereas GI had the highest threshold for initiating antiplatelets and statins for patients with PAD.
Conclusion: The perceptions towards risk reduction in PAD identify glaring knowledge and action gaps. Effective strategies to encourage health professionals to use risk reduction therapy are needed.
3) Title: Risk Reduction Status in patients with Peripheral Arterial Disease presenting to a Major Teaching Hospital.
Abstract for the In-term analysis:
Introduction: Current evidence suggests that atherosclerosis risk factors modification plays an important role in improving the adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). This study was undertaken to identify the prevalence of risk factors and the utilization of risk factor modification therapy in this high risk group.
Methods: We prospectively collected data from 140 consecutive patients with PAD who were referred to the Vascular Surgery outpatient clinic at a Tertiary Care Hospital between January 2006 and December 2006.
Results: The mean age for these patients was 57 years and 25% were women. The mean number of atherosclerotic risk factors (hypercholesterolemia, hypertension, diabetes mellitus (DM), overweight/obesity (BMI>24.9), current smoker) was 3 (SD +/- 1). Hypertension was identified in 58.5% of patients. Of theses patients, only 37% had an optimal control of blood pressure (BP < 140/90 mmHg). The prevalence of DM was 85.4 %. Of theses patients, only 15.2% had an optimal control of blood sugar (HbA1c < 7%). Statins were currently prescribed in 40% of patients. Of those on statins, 36.4% continued to have LDL >2.5mmol/L compared to 76.5% of non-statin users (p<0.001). The prevalence of obesity/overweight was 68.8.4%. Current nonsmokers made up 78.3% of patients, of whom 58.4 % were former smokers. Antiplatelets were prescribed for 80% of patients, of whom 70.6% were on aspirin. Angiotensin converting enzyme (ACE) inhibitors were prescribed for 36.7% of patients.
Conclusion: Although the atherosclerotic risk factors were prevalent in patients with PAD, sub-optimal use of risk reduction therapy was observed. Effective strategies to encourage health professionals to use these adjunctive therapies need to be developed.
4) Title: Does Visfatin Correlates with the Severity of Peripheral Arterial Disease in Diabetic Patients?
In Collaboration with the College of Medicine Research center, King Saud University
Abstract for the In-term analysis:
Introduction: Visfatin is a peptide that is highly expressed in visceral fat and was isolated as a secreted factor that promotes the growth of B cell precursors and more recently was reported to act as an insulin mimetic factor. This study was undertaken to investigate the role of visfatin in the development of PAD in diabetic patients.
Methods: We prospectively collected data from 100 consecutive diabetic patients who were referred to the Vascular Surgery outpatient clinic at a Tertiary Care Hospital for assessment for their PAD between January 2006 and December 2006. According to the patients’ ankle brachial index (ABI), they were divided into two groups; group I where their ABI <0.5, and group II where their ABI between 0.5 and 0.9. Fasting blood samples were collected for blood sugar (FBS), triglycerides (TG), total cholesterol, HbAc1, and plasma visfatin. Measurements of systolic & diastolic blood pressure and body mass index (BMI) were done.
Results: The mean age for these patients was 57 years and 24% were women. No differences were detected between the two groups regarding, TG, FBS, total cholesterol, HbAc1, BMI and blood pressure. The plasma visfatin level in group I was 87.1 ng/ml compared to 63.1 ng/ml in group II (p=0.034). The glucose/visfatin ratio was markedly lower in group I compared to group II (13.1 vs. 17.9; p=0.04). Furthermore, plasma visfatin level was negatively correlated with ABI (P<0.005), suggesting its association with the severity of PAD.
Conclusions: Visfatin probably plays a role in the pathophysiology of PAD regardless of the diabetic status. Whether the elevated plasma levels of visfatin in patients with PAD is a compensatory mechanism or initiative of the disease process needs further investigation
5) Title: Endovenous Laser Therapy for Varicose Veins: A Single Institute Experience.
Abstract for the In-term analysis:
Background: Endovenous laser therapy (EVLT) is a new, minimally invasive percutanous endovenous technique for ablation of the incompetent great saphenous vein (GSV). The aim of this study was to evaluate the early and intermediate results of occlusion and recanalization rates and complications after EVLT of the GSV.
Methods: Between March 1, 2006, and June 30, 2008, we conducted a prospective clinical trial to treat patients with incompetent GSV using a 980-nm multidiode laser (inter-medic) with intermittent fiber pullback and tumescent local anesthesia. Patients were followed up prospectively with duplex ultrasonography at day 1 and at 1, 3, 6 and 12 months.
Results: Endovenous GSV ablation was performed on 250 limbs in 180 patients. General anesthesia was used in 2% of the patients. The mean age was 35 years and 66% were females. According to the CEAP classification, majority were C2 (80%). The average voltage use was 14 W (range from 10 to 15 W). The pulse time was 5 seconds with 1 second pause. GSV occlusion rates were 99 % at day 1, 98.7 % at 1 week, 97.6 % at 1 month, 96.3 % at 3 months, 95.4 % at 6 months, and 94.2 % at 12 months after EVLT. Subanalysis of the patients who received a voltage of 15W showed a GSV occlusion rate of 100% at 1 week, 99.2 % at 3 months, 97.5% at 6 months, and 96.6% at 12 months. Concomitant avulsion phlebectomy was performed in 140 limbs. Significant bruising was seen in 17 limbs (6.8%) and superficial thrombophlebitis was seen in 2 limbs (0.8%) however, edema, excessive pain, hematoma, or cellulitis were not seen. Thrombus protruded into the lumen of the common femoral vein (CFV) was seen in two limbs (0.8%) after EVLT. Both patients were treated with anticoagulation. Duplex follow-up scans of these two patients performed at 12 weeks, showed that the thrombus previously identified at duplex scan was no longer protruding into the CFV.
Conclusion: Short term and intermediate results of EVLT are excellent. Greater doses of energy delivered are associated with better results. Long-term follow-up and comparison with standard GSV stripping are required to confirm the durability of EVLT.
6) Title: Outcome of Surgical Treatment for Carotid Body Tumors: King Khalid University Hospital Experience.
Abstract for the In-term analysis:
Background: Carotid body tumors (CBT) are a rare condition but are the most common form of head and neck paraganglioma. The aim of this study was to evaluate the outcome for surgical excision of CBT.
Method: We conducted a retrospective cohort study between 1994 and 2007, using the medical records database from King Khalid University Hospital, Riyadh, Saudi Arabia.
Results During the study period, 19 patients with CBT were identified. Of these, 3 patients had bilateral CBT. About 66% were female and mean age was 40.5 years. CBT was more common in the left side (58%). Neck lump and pain were the main presenting symptoms. Preoperative information derived from duplex scanning, magnetic resonance angiography, computed tomography, and in some patients the standard four-vessel Arteriography. All patients underwent surgical excision with no mortality. Two patients had hoarseness of voice postoperatively, 1 was due to permanent vagus nerve palsy in a patient who had excision for recurrent CBT and the other to transient vagus nerve palsy. One patient had a minor stroke postoperatively.
Conclusion: Careful surgical planning and prediction of perioperative complications using advanced radiological imaging coupled with the performance of CBT excision in high volume centers result in good outcomes.
7) Title: Evolution of Vascular Laboratory: The Saudi Arabian Experience
Abstract for the In-term analysis:
Methods: A prospective cohort study was conducted utilizing the records from a prospectively collected database that maintained all the information for the various non-invasive vascular tests (NIVTs) that were performed at the Vascular Laboratory, King Khalid University Hospital in Riyadh, Saudi Arabia from 1995 to 2007. NIVTs were grouped as indirect tests (CW Doppler & Others) and direct tests (Color Duplex Imaging [CDI]). Direct tests (CDI) were further grouped into Carotid, Lower & Upper Limb arterial, by pass Graft Surveillance, Aorto-Renal-Visceral, Venous & Vascular Access Color Duplex Imaging.
Results: A total number of 40,820 NIVTs were identified over the study period. Of these, 29,478 (72%) were direct tests. The number of NIVTs has increased significantly, from 498 cases/year to 4881 cases/year representing a 10-fold increase over the study period with an increase of 75% per year (R2 =0.91; p < 0.01, linear regression analysis). The trend for utilizing the direct tests was more pronounced than that for indirect tests; the number of direct tests has increased significantly, from 179 cases/year to 3812 cases/year representing a 21-fold increase over the study period with an increase of 1.6 fold per year (R2 =0.92; p < 0.01), whereas the number of indirect tests has increased significantly, from 319 cases/year to 1069 cases/year representing a 3.4-fold increase over the study period with an increase of 26% per year (R2 =0.85; p < 0.05).
Conclusion: The use of various non-invasive vascular tests in the management of vascular disorders has increased substantially over the past decade. In response to these trends, more trained personnel & vascular laboratory facilities are needed in different vascular surgery centers in Saudi Arabia.
8) Title: Supraclavicular Approach for the Treatment of Arterial Thoracic Outlet Syndrome: King Khalid University Hospital Experience
Abstract for the In-term analysis:
Introduction: Thoracic outlet syndrome (TOS) refers to a group of complex symptoms in the upper extremity caused by compression of the brachial plexus, subclavian artery and vein. The goal of surgical therapy involves relieving compression of the neurovascular structures at the superior thoracic aperture. Different surgical approaches were described for the management of TOS. However, there is no "gold standard" procedure. Supraclavicular incision is becoming a popular approach used in the treatment of TOS. The aim of this study was to evaluate the outcome for supraclavicular approach for the treatment of arterial TOS.
Method: We conducted a retrospective cohort study between 1995 and 2007, using the medical records database from King Khalid University Hospital, Riyadh, Saudi Arabia.
Results: During the study period, 22 patients with arterial TOS were identified. Of these, 5 patients had bilateral arterial TOS. About 50% were female and mean age was 26 years. Hand ischemia in form of claudication or rest pain was the main presenting symptom. Preoperative information derived from duplex scanning and upper limbs Arteriography, and in some patients’ magnetic resonance angiography and computed tomography. All patients underwent supraclavicular approach with a single incision with no mortality. In all cases, a complete scalenoectomy was performed. Whenever present the cervical rib was resected and in some cases the first rib was also taken out. Associated vascular procedures included resection and replacement of 1 subclavian artery aneurysm, one axillary-brachial bypass, as well as tow brachial embolectomies. The surgical procedures did not cause relevant complications. During follow-up; all patients were in complete resolution of symptoms and all reconstructed arteries were patent.
Conclusions: The supraclavicular approach is a safe and effective technique in managing arterial thoracic outlet compression.
9) Title: Endovascular Treatment of Acute Aortic Emergencies
Abstract for the In-term analysis:
Background: Acute aortic diseases are challenging to treat. If not treated, they carry high mortality rate. Endovascular stent grafting has emerged as an option to treat these emergencies with reported significant lower mortality and morbidity. The aim of this study was to evaluate the early results of endovascular stenting in treating a variety of acute aortic emergencies.
Methods: We prospectively collected data from consecutive patients who presented to King Khalid University Hospital with aortic pathology between April 1, 2007 and June 30, 2008 and were treated with endovascular stent grafts. From this cohort we analyzed the data of patients presented with acute aortic emergencies. Diagnosis was confirmed by multi-planer enhanced computed tomography with 2.5 mm cuts for accurate stent grafts sizing. Stent grafts were introduced through a common femoral artery cut down.
Results: From the 25 patients who underwent endovascular repair, 13 patients had acute aortic pathology. A total of 16 stent grafts (Gore Excluder, California USA) implanted in these 13 patients (11 males and 2 females) with a mean age of 43 years (16 – 73 years). Presentations of these patients were; blunt traumatic thoracic aorta ruptures (n= 7), ruptured true thoracic aortic aneurysms (n = 5), and ruptured proximal anastomotic aortic psudoaneurysm (n = 1). Technical success rate defined by complete exclusion of the pathology was 100%. Thirty -days mortality rate was 115.4%. Both patients who died were from the ruptured true thoracic aortic aneurysm group and no patients died from the traumatic thoracic aorta ruptures. One patient died from acute renal failure that also required an axillary bi-femoral bypass at the original procedure for lower limb revascularization due to distal aortic occlusion and another died from hemoptysis from bronchoscopic confirmed bronchogenic carcinoma. In addition, one patient suffered from myocardial infarction from the ruptured true thoracic aortic aneurysm group treated medically. None of the patient in the traumatic rupture group suffered from major complications.
Conclusion: Endovascular stent graft is an effective treatment option for an acute aortic emergencies particularly those who present with traumatic ruptures. Long-term follow-up is required to confirm its durability.
10) Title: Non-Surgical management of Iatrogenic Psudoaneurysms
Abstract for the In-term analysis:
Background: Iatrogenic arterial Psudoaneurysms are relatively common in busy tertiary centre. They occur following 0.5-1.0% of diagnostic angiographic procedures and up to 8% following percutaneous coronary interventions. Treatments of these Psudoaneurysms depend usually on the size, location in the arterial tree, the need of anticoagulation and the availability of resources.
Methods: We prospectively collected data from consecutive patients whom diagnosed to have iatrogenic Psudoaneurysms by duplex ultrasound at the vascular laboratory, King Khalid University Hospital between January 2001 to January 2008. Data collected include psudoanurysms size, location, procedure performed causing the psudoaneurysm, anticoagulant or antiplatlets used introducer sheath size, and presence of multicavity psudoaneursm. Patients whom are candidate to either ultrasound-directed compression or thrombin injection were used in the analysis. Results of immediate psudoaneurysm thrombosis, the need of recompression or re-injection of thrombin and follow up duplex ultrasound after successful psudoaneurysm thrombosis were reported.
Results:A total of 99 psudoaneurysms were treated by either ultrasound-directed compression (n=84) or ultrasound-guided thrombin injection (n=15). 95% of all Psudoaneurysms were from the femoral artery origin. Unusual locations psudoaneurysms treated with thrombin injection include one from the brachial artery, 3 from radial artery and one from the left subclavian artery. Successful Non-surgical psudoaneurysm thrombosis was achieved in more than 98% of patients. No distal embolization of thrombin or arterial thrombosis was encountered with either treatment.
Conclusion: Non-Surgical treatment of iatrogenic psudoaneurysms is an effective treatment option with very low complication rate.
Education:
1) Project: The 2nd Endovenous Laser Therapy Workshop
Setting: Will be held at King Khalid University Hospital on February, 11, 2009
In Collaboration with the Saudi Society for Vascular Surgery .
Overview:
The Endovenous Laser Therapy Workshop seeks to advance knowledge and skills of vascular surgeons in the use of endovenous laser therapy for varicose vein management.
2) Project: Annual Vascular Anastomosis Workshop
Setting: Will be held at King Khalid University Hospital on March 5, 2009
In Collaboration with the Saudi Society for Vascular Surgery .
Overview:
The Annual Vascular Anastomosis Workshop seeks to advance the knowledge and skills of vascular trainee in performing vascular anastomosis in simulation models and on animals.
3) Project: Annual Vascular Duplex and Doppler Course
Setting: Will be held at the vascular laboratory at King Khalid University Hospital on April 1-2, 2009
In Collaboration with the Saudi Society for Vascular Surgery .
Overview:
The Annual Vascular Duplex and Doppler Course seeks to advance the knowledge and skills of vascular specialists in the use of non-invasive vascular diagnostics studies. Topics of the course include:
· Principles of Doppler and Duplex ultrasound
· Duplex protocols and homodynamics
· Use of Doppler and Duplex in Arterial diseases (PAD, Carotid stenosis, aneurysms, renovascular diseases)
· Use of Doppler and Duplex in Venous diseases
4) Project: Postgraduate Research Program
In Collaboration with the Department of Physiology, the Department of Anatomy, College of Medicine , King Saud University and Li Ka Shing Knowledge Institute of St’ Michael’s Hospital, University of Toronto, Canada.
Overview:
The Postgraduate Research Program seeks to train postgraduate students in a structured Master and PhD program in the fields of Vascular Biology and Clinical Epidemiology. Few students have been accepted into this program and will start their training soon.
5) Project: Effect of Underwater Training on Intermittent Claudication in Patients with Peripheral Artery Insufficiency
Setting: Will be held at Physical Therapy department, King Khalid University Hospital
In Collaboration with Rehabilitation department, College of Applied Medical Sciences and Saudi Society for Vascular Surgery .
Overview:
The study will focus on the effect of underwater exercise training in PAD patients which would reduce leg pain, improve quality of life due to reduce the leg pain and improve walking distance.
