Purpose Vascular surgical training in Australia and New Zealand is overseen by the ANZSVS. Trainees move yearly between units for the five-year training program to ensure varied operative exposure. Posts are allocated by the training board after consideration of trainee preferences, training requirements and deficiencies. Whilst anecdotally there is regional variation in vascular surgical practice, there is little published data to inform trainees about prospective training-post case mix. Methodology Data was collected from the Australasian Vascular Audit for operations between 2017-2021. Hospitals without SET vascular registrar were excluded, and analysis was limited to operations with a registrar as primary or shared primary operator. Statistical analysis was performed with operations stratified into major procedural groups. An interactive web tool was created to allow trainees to directly compare training sites. Results Across the five-year period there was significant case-mix variation between sites. Open aortic surgery comprised an average 2.9% of cases (0.1%-7.3%). Similarly divergent results were found for carotid endarterectomy (Mean 9.7%, 1.2-22.1%), EVAR (Mean 10.5%, 5.9-19.1%) and Infrainguinal bypass (Mean 12.2%, 0.2-29.6%). Peripheral endovascular intervention represented an average 49.5% of trainee’s cases with the largest range between 7.9-82.7%. Endovascular intervention was more common in NSW/ACT and WA (72%, 70%), with open surgery more common in NZ and VIC/TAS (56%,42%). Conclusion Comprehensive vascular training requires broad exposure to a diverse range of open and endovascular procedures. Shifting practice towards endovascular intervention may limit open surgical exposure. This paper demonstrates significant regional case-mix variation. ANZSVS encourages trainee mobility to increase experience in a variety of techniques and the findings of this research will assist trainees to preference posts with a case-mix aligned to their ongoing requirements.

Introduction: Asymptomatic carotid artery stenosis may be identified in patients with unrelated symptoms, prior focal neurological symptoms (contralateral symptoms or symptoms from more than six months ago) or with no symptoms. It is unclear whether these distinct presentations have different stroke risk. The aim of this study was to examine risks of stroke in patients with different presentations of asymptomatic carotid artery stenosis. Methods: A multi-centre prospective cohort study was conducted across three Australian vascular centres. Patients with a 50-99% asymptomatic carotid artery stenosis were included with documentation of presentation type. The primary outcome was non-perioperative ipsilateral ischaemic stroke. Secondary outcomes included ischaemic stroke and cardiovascular death. Data were analysed using Cox proportional hazard and Kaplan-Meier analyses. Results: Between 2002 and 2020, 598 patients were enrolled (mean age 71 years, 30% women) and followed for a median of 5.2 [quartiles 2.3-8.8] years. 83% were taking aspirin, 84% were on at least one antihypertensive agent and 77% were taking a statin at baseline. After 5-years the incidence of non-perioperative ipsilateral stroke was 6.0% (95% CI 4.1-8.7%). The rates of ipsilateral stroke were similar among people with unrelated symptoms (stroke rate ratio [RR] 1.12, 95% CI 0.41-3.05) and prior focal neurological symptoms (RR 0.54, 0.24-1.20) compared to those with no symptoms (p=0.328). There were no significant differences in rates of any ischaemic stroke or cardiovascular death across groups. Conclusion: The risk of ischaemic stroke is similar for patients with different presentations of asymptomatic carotid stenosis.

Purpose: This retrospective observational study investigated shunting and stroke prevalence in patients undergoing carotid endarterectomy (CEA) with contralateral carotid artery occlusion (CCO), under general (GA) and local/regional anaesthesia (LA/RA). Methods: The Australasian Vascular Audit (AVA) was interrogated to identify all CEAs performed in Australia and New Zealand, between 2010 and 2020. Among the 22,671 CEAs identified, shunt usage and in-hospital stroke and death rates were compared between 1,490 (6.6%) patients with a CCO and 21,180 (93.4%) patients with a patent contralateral carotid artery. Within the CCO group, shunt and anaesthetic choice were analysed using stroke rates. Results: Surgeons were more likely to shunt in patients with a CCO (n=1,044 [70.1%]) compared to without (n=9,438 [44.6%]), and when using GA compared to LA/RA (n=10,037 [56.5%] vs. n=445 [9.1%]). Shunt use was also higher in patients presenting with symptomatic carotid stenosis compared to asymptomatic (47.7% vs. 42.4%). Across 22,671 CEAs, 312 (1.4%) strokes and 94 (0.4%) deaths were recorded whilst an inpatient following CEA. The odds of experiencing a stroke were higher in the CCO versus non-CCO group (2.1% vs. 1.3%) and higher in the shunted group (OR 1.45; 95% CI 1.16 – 1.82; P<.001). Within the CCO group, more strokes occurred when shunted (OR 3.05; 95% CI 1.06 – 8.73; P=.038), but no statistical difference was observed using GA compared to LA/RA (OR 2.94; 95% CI 0.69 – 12.48; P=.143). Conclusion: The use of shunting during CEA is associated with higher odds of a stroke in patients with CCO, regardless of anaesthetic choice. However, further data is required to validate the results of this study.

Introduction Transcarotid Artery Revascularisation (TCAR) is an emerging hybrid carotid revascularisation technique requiring a combination of open and endovascular carotid revascularisation skills. In recent years, transfemoral carotid stenting (tfCAS) is not performed as frequently as open surgery in Australia and New Zealand. The aim of this study is to evaluate Australia and New Zealand's current experience in traditional (tfCAS). Method A retrospective review was performed of all tfCAS procedures performed by vascular surgeons recorded on the Australasian Vascular Audit (AVA) from 2010 to 2020. Results A total of 1839 procedures were identified across a ten-year period. Combined peri-operative stroke and death rates (SD rate) were higher in symptomatic vs asymptomatic indications (1.4% vs 0.4%, p=0.03). Use of an embolic protection device was associated with a significantly lower SD rate (0.9% vs 3.1%, p=0.04). Post-stenting angioplasty was not associated with an increased risk of perioperative stroke (0.5% vs 0.8%, p=0.47). Regression analysis revealed a logarithmic inverse relationship between tfCAS volume and SD rates, both at a surgeon and institutional level. 101 out of 120 surgeons (84.1%) had less than 20 tfCAS procedures recorded. Surgeons with >20 procedures had a significantly lower SD rate (0.7% vs 1.9%, p=0.03). Institutions with >20 procedures had a lower SD rate that was not statistically significant (0.09% vs 1.8%, p=0.17). Conclusion A higher operative volume of tfCAS at both a surgeon and institutional level should ideally be sought prior to the introduction of TCAR.

Introduction The management of patients undergoing coronary artery bypass grafting (CABG) who have concurrent carotid disease remains controversial. The 2023 European Society for Vascular Surgery (ESVS) reviewed the latest data regarding this subject (Naylor 2022). Report For patients undergoing CABG, routine screening for carotid disease is not recommended (III, C). For patients undergoing CABG, duplex ultrasound screening (DUS) for carotid disease should be considered in patients aged >70 years and/or those with a history of TIA/stroke, carotid bruit or left mainstem disease, so that the patient can be better informed of the increased risks associated with CABG if they have concurrent carotid disease (IIa, C). CABG patients with a history of TIA/stroke <6 months and who have an ipsilateral 50-99% ipsilateral internal carotid artery (ICA) stenosis should be considered for staged/synchronous carotid endarterectomy (CEA) and CABG (IIa, B), rather than staged/synchronous carotid artery stenting (CAS)+CABG (IIa, B). The currently available evidence does not support an aetiological role for a unilateral asymptomatic carotid stenosis in post-CABG stroke and staged/synchronous CEA+CABG is not recommended (III, B). However, in CABG patients with asymptomatic bilateral 70-99% ICA stenoses or a 70-99% stenosis + contralateral occlusion, staged/synchronous CEA or CAS may be considered (IIb, B). Conclusion The ESVS 2023 recommendations (Naylor 2022) for the management of CABG patients with concurrent carotid artery disease have not changed, compared with the 2017 ESVS guidelines (Naylor 2018). Key references Naylor AR, Rantner B, Ancetti S, de Borst GJ, de Carlo M, Halliday AH et al. European Society for Vascular Surgery (ESVS): 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery disease. Eur J Vasc Endovasc Surg (in press; doi: 10.1016/j.ejvs.2022.04.011). Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, et al. Management of atherosclerotic carotid and vertebral artery disease: 2017 Clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018;55:3-86.

Purpose: The incidence and natural history of morbidity and mortality attributable to BVAI is unclear. However, given that the majority of BVAI are asymptomatic, the consensus is that they should be managed non-operatively. The purpose of this project is to evaluate the management and outcomes of patients with Blunt vascular injuries, in particular the current treatment strategies, the natural history and long-term surveillance imaging. Methods: A single centre retrospective review of patients who presented with BVAI was undertaken between January 2017 and January 2021. Primary outcomes include overall severity of BVAI on presentation, in hospital morbidity and mortality. Results: 27 patients were identified as having BVAI over the last 5 years (male n=19, 70.4%, median age 45). The mechanism of injury ranged between motor vehicle accidents or fall from a height, with a median Injury Severity Score of 16. 62.9% of patients presented with associated C spine fractures. 81.4% of patients were treated with antiplatelets, 7.4% were treated with anticoagulation, 7.4% patients underwent endovascular intervention and 7.4% patients did not receive treatment. Median length of hospital admission and ICU admission was 10 and 6 days respectively. 33.3% of patients had evidence of a stroke on imaging. 14.8% of patients died within 30 days of their presentation. Follow up ranged between 6 weeks to 12 months. 55.55% of patients did not have follow up. Imaging modality during follow up included MRA (22.22%), CTA (11.11%), DSA (3.7%) and DUS (3.7%). At some point during surveillance, 33.3% of patients had changes in their medication. Conclusion: BVAI should be suspected in the setting of traumatic C spine fractures. BVAI have an increased risk of stroke. Based on our experience, antiplatelets are the standard of management, with anticoagulation and surgical intervention being used less commonly. Follow up with imaging is encouraged to assess for resolution of the injury.

Purpose: Acute arterial thrombosis with the background of COVID presents a unique set of challenges. Understanding the pathophysiology and the management of COVID evolved and with it, the extent of treatment of patients. We present our data spread over two years involving all the major vascular centres in India. Methodology: 9 centres with highest volume of vascular patients were included. After obtaining ethics and research approvals, data from March 2020 to April 2021 was retrospectively collected and analysed. Patients that presented with acute limb ischemia and concomitant COVID were included. The parameters evaluated included demographics, vaccination status, risk factors for severe COVID and peripheral arterial disease, angiographic segments, interventions and outcomes with relation to immediate, 14 day and limb salvage. Results: There were a total of 268 patient who were entered into the study over the period mentioned above. After a preliminary 2 x 2 table analysis of all the factors mentioned above, some of the significant factors along with important risk factors were entered into a logistic regression analysis for 3 outcomes; immediate, 14 day and overall limb salvage. After correcting for variables, the factors that showed a significance for all three outcomes were Rutherford Grade of acute limb ischemia Grade 2b and 3 along with aorto iliac and femoro popliteal thrombosis. Interventions were not entered into the logistic regression as they made the analysis unstable. However, no intervention had the worst outcomes across all grades of ischemia Conclusion: As the understanding of COVID evolved, so did treatment of patients with acute limb ischemia and COVID. Aggressive treatment was not possible in some patients due to severity of COVID infection, however the best outcomes were seen in patients mild to moderate COVID and lesser grades of acute limb ischemia

Purpose: Popliteal artery injuries continue to be associated with a high incidence of amputation despite the emergence of CTA and endovascular surgery techniques. Western Australian (WA) patients must contend with challenging geography when accessing timely vascular interventions. We sought to review the epidemiology, investigations, treatment approaches and outcomes of WA patients sustaining popliteal artery injuries. This also served to update a prior study conducted locally(1). Methodology: A retrospective cohort study was conducted, identifying patients within the Western Australian Major Trauma Registry from 1995-2019. Inclusion criteria were all adult patients sustaining traumatic popliteal artery injuries within WA. Primary outcome was defined as amputation at the index operative intervention, with secondary outcomes being delayed amputation and in-hospital mortality. Interim Results: Eighty-seven patients met the inclusion criteria; mean age was 37 years; 77% were male. Three patients died. Twenty-two patients required amputation however only 6 were performed as an index operation. Delayed amputation rates decreased from 29% to 8% for the periods 1995-2002 and 2011-2019 respectively. CTA rates increased from 4% to 80% across the same time periods. Interposition vein grafting was the most common repair technique (42% of all cases where limb salvage was attempted). Time from presentation to a tertiary vascular centre to theatre was unchanged over time. Conclusions: Limb salvage rates have improved in WA patients sustaining popliteal artery injuries. Though CTA has become the most common preoperative investigation, this has not facilitated an improvement in timing of operative interventions. References: 1. Yahya, M. M., Mwipatayi, B. P., Abbas, M., Rao, S., & Sieunarine, K. (2005). Popliteal artery injury: Royal Perth experience and literature review. ANZ Journal of Surgery, 75(10), 882– 886.

Purpose: Trauma presentations are not uncommon in Australia, with road traffic accidents being one of the leading causes. The Alfred has some of the highest volumes of trauma presentations in Australia. The aim of this study was to retrospectively assess the incidence, mechanisms, operative management and outcomes of vascular trauma surgery at a level 1 Victorian trauma centre. Methodology: A 5-year audit was conducted of all vascular trauma operations at The Alfred. Operations were identified from the Australian and New Zealand Society for Vascular Surgery Australasian Vascular Audit. Individual records were examined to clarify the mechanism of trauma, vascular injuries, vascular procedures and outcomes. Long-term disability, 30-day mortality and limb loss were also assessed. Results: Between May 2017 and May 2022, 101 vascular trauma procedures were performed on 88 patients. The incidence of vascular trauma was stable over this period of time. The median age was 37 years (range 17-93 years) and 18 patients were female (21%). 41 (47%) presentations were from road traffic accidents, 21 (24%) from stabbings and 26 (29%) from other injuries. The most common vascular structures involved were the thoracic aorta (17%) and popliteal artery (14%). 95 primary vascular procedures were performed, including 57 open repairs, 20 hybrid procedures and 18 endovascular procedures. Of these, there were 18 local repairs, 15 Thoracic Endovascular Aneurysm Repair Grafts and 13 bypass grafts. 30-day mortality occurred in 9 patients (10%) and 11 patients (13%) suffered limb loss within 30 days. 23 patients (26%) reported long-term symptoms after a median follow-up of 6 months. Conclusion: Vascular trauma was common at this level 1 trauma centre. Patients were predominately young, and many of the injuries encountered were successfully managed with standard open vascular, endovascular or hybrid procedures, with open repairs being the most common management.

Purpose: Vascular surgical emergencies which pose a threat to life or limb often present in rural locations where only an emergency rural general surgery service is available. This study aimed to assess whether rural General Surgeons felt prepared to manage vascular surgical emergencies in the bush according to their demographics and training. Methods: A 10 question online survey via Qualtrics was distributed to rural Australian general surgeons via the RACS rural newsletter and email. Statistical analysis was undertaken using STATA to determine associations between general surgeon demographics and training compared to their confidence and perceived competence managing vascular emergencies using a logistic regression and odds ratio. Results: Sixty-seven (16%) rural general surgeons from across Australia responded. Significantly for limb revascularisation (p=0.01), revision of arterio-venous fistula (p=0.004), open repair of a ruptured abdominal aortic aneurysm (p=0.01) and limb embolectomy/thrombectomy(p=0.001) a rural General Surgeon needed to be older to feel confident surgically managing the above conditions. Other significant indicators (p < 0.05) for rural general surgeons feeling confident surgically managing vascular emergencies included obtaining FRACS prior to 2012, undertaking more than six months of vascular training, and believing that general surgical training adequately prepared one-self for managing vascular emergencies rurally. Conclusion: Younger and recently graduated (post 2012) rural general surgeons do not feel confident and competent managing vascular surgical emergencies in their rural communities. Given these findings it should be considered whether vascular surgery is incorporated into general surgical training and rural general surgery fellowship positions.