Original Article

Vascular surgeries in West Africa: Challenges and prospects

Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 552–557 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314561646 aan.sagepub.com

Sunday A Edaigbini1, Ibrahim Z Delia1, Muhammad B Aminu1, Istifanus B Bosan2, Abdulrasheed Ibrahim3 and Ndubuisi Anumenechi1

Abstract Background: The field of vascular surgery is evolving in sub-Saharan Africa but the practice is bedeviled by lack of expertise and infrastructure challenges. The consequences are a low volume of operations and a dearth of data. Available data are not representative of the wider picture, therefore, this study was undertaken to evaluate the practice of vascular surgery in a tertiary institution, in the light of the prevailing challenges. Methods: Data from all patients with vascular-related pathologies managed in our surgical outpatient clinic and accident and emergency wards were obtained from the clinic and in-patient records from January 2008 to December 2012. Age, sex, diagnosis, treatment, and complications were noted. There were 73 patients comprising 45 (61.6%) males and 28 (38.4%) females. The age range was 1–90 years (mean 43.5 years). Results: The pathologies managed included end-stage renal disease (n ¼ 36, 49.3%), nontraumatic and posttraumatic aneurysms (n ¼ 13, 17.8%), vascular trauma (n ¼ 12, 16.4%), peripheral vascular disease (n ¼ 5, 6.9%), congenital vascular malformations (n ¼ 4, 5.5%), and thrombotic diseases (n ¼ 3, 4.1%). Fifty-four (74.0%) surgeries were performed, with a complication rate of 5.5% and 2.7% mortality. Conclusions: The practice of vascular surgery in Zaria, Nigeria, is fraught with challenges. The gap created by the dearth of skilled vascular surgeons is filled by competent cardiothoracic surgeons. Infrastructure decay and lack of prostheses limit the number and variety of operable cases. These challenges result in preventable morbidity and mortality.

Keywords Developing countries, nigeria, peripheral vascular diseases, vascular surgical procedures, vascular fistula, wounds and injuries

Introduction The practice of vascular surgery, although an evolving field in the sub-region, is not only in a rudimentary phase but the dearth of skilled manpower limits the practice to the performance of very basic or elementary operations that are handled by general, cardiothoracic, orthopedic, and plastic surgeons.1 This challenge is further compounded by a lack of equipment and prostheses as well as infrastructure decay, and the spectacle leaves one in a quandary.2 The end result is countless avoidable morbidities and mortalities and a lack of data due to the low volume of surgeries, while the available data are not representative of the wider picture.3 In addition to other options in the surgical

management of vascular pathologies, is the more recent use of microsurgical techniques for free graft and solid organ transplant surgery.4–6 These advances, 1 Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria, Nigeria 2 Division of Nephrology, Department of Medicine, Ahmadu Bello University, Zaria, Nigeria 3 Division of Plastic and Reconstructive Surgery, Ahmadu Bello University, Zaria, Nigeria

Corresponding author: Sunday A Edaigbini, FWACS, Division of Cardiothoracic Surgery, Ahmadu Bello University, Zaria, Nigeria. Email: [email protected]

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as seen in developed countries, have reduced both morbidity and mortality even for the highest emergency event to the barest minimum, except for the most fatal accidents that are best prevented. In most developing countries, vascular operations are indicated mostly for trauma, and these operations are limited more often than not to simple ligation and simple arteriorrhaphy, and at best, substitution arteriorrhaphy with a reversed autogenous saphenous vein graft (RASVG).3 This study was undertaken to evaluate the practice of vascular surgery in a Nigerian tertiary institution in the light of the prevailing challenges, and to proffer solutions where possible.

Patients and methods Data were collected from the records of all patients with vascular-related pathology seen and managed in the surgical outpatient clinic and accident and emergency wards over a period of 5 years (January 2008 to December 2012). The age, sex, diagnosis, treatment, and complications were noted. The frequencies of the selected variables were calculated as percentages. The hospital has no dedicated ward for vascular surgery patients. Emergency cases were admitted to the accident and emergency wards, and elective cases were admitted to the general open ward where only 10 beds are reserved for cardiothoracic and vascular surgery patients (6 beds for males, 3 for females, and 1 for children in the pediatric ward) before proceeding to the operating room. A total of 73 patients were managed during this period, of whom 45 (61.6%) were male and 28 (38.4%) were female. The age range was 1–90 years with a mean of 43.5 years. All patients with vascular occlusion or interruption (excluding those undergoing creation of arteriovenous fistulas) underwent Doppler studies and computed tomographic angiography for adequate definition of the pathology before surgery. We do not have an angiography machine for either invasive study or therapeutic interventions. Postoperatively, the patients were managed in the general intensive care unit and transferred to the general open ward when stable.

Results The pathologies managed included end-stage renal disease (n ¼ 36, 49.3%), nontraumatic and posttraumatic aneurysms (n ¼ 13, 17.8%), vascular trauma (n ¼ 12, 16.4%), peripheral vascular disease (n ¼ 5, 6.9%), congenital vascular malformations (n ¼ 4, 5.5%), and thrombotic diseases (n ¼ 3, 4.1%). Fifty-four (74.0%) operations were performed, of which 38 were in 36 patients with end-stage renal disease (2 patients had redo procedures). Three patients required surgery for

posttraumatic arteriovenous fistulas (pseudoaneurysm), one of whom had a second operation following recurrence and torrential bleeding. One patient underwent thrombectomy for iliofemoral arteriovenous thrombosis and died on the 5th postoperative day from upper gastrointestinal bleeding as a consequence of postoperative anticoagulation. One patient had excision of a chest wall hemangioma. The overall complication rate was 5.5% and mortality was 2.7%.

Discussion The management of vascular pathologies is still suboptimal in our region considering the total number of patients (73) treated over a period of 5 years. This low volume was evident in earlier publications and may be due to inadequate reporting or late presentation with consequent limb loss requiring orthopedic intervention.1–3,6 Furthermore, only 54 (74.0%) of these patients were operated on; the others died or were managed nonoperatively due mainly to the combination of lack of technical skill and infrastructure challenges. These challenges include institutional (frequent power outages, autoclave breakdowns), personnel (poorly motivated and poorly trained staff), and patient factors (poverty and ignorance).2 For example, all 6 patients who presented with an abdominal aortic aneurysm died without surgery (on admission or in the course of follow-up) due to the lack of an aortic graft or the patient’s insolvency. Similarly, all patients who presented with peripheral arterial occlusive disease required either balloon angioplasty and/or stenting but were managed nonoperatively due to lack of facilities, and these patients could not afford treatment outside the country. Despite being the major indication for surgery, the creation of an arteriovenous fistula (Figure 1) is still a challenge because most patients present late, by which time, the upper limb veins are thrombosed. We do not routinely investigate venous patency (ascending venography) before arteriovenous fistula creation, due to logistic difficulties. We therefore depend on clinical judgement which often leads to exploration of more than a single site (wrist and antecubital fossa) before a successful operation. Consequently, 2 patients required reoperations due to failure of the first attempt. Trauma remains a major indication for vascular intervention in our center as in most parts of the country, as reported in earlier publications.1,3 Posttraumatic vascular emergencies present a particularly worrisome challenge because of the associated organ loss (Figure 2) and sometimes death, resulting from either delayed intervention or institutional and infrastructure challenges.7 For example, one patient had multiple gunshot wounds, one of which caused a comminuted right supracondylar femoral fracture and adjacent femoral

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Figure 1. Arteriovenous fistula creation. Note the distended vein after construction.

Figure 2. A patient with big toe gangrene and ischemic necrosis of the skin of the left foot due to late presentation, despite surgical intervention.

artery injury (complete transection). He had a computed tomography scan of the limb at 18 h and surgical exploration at 22 h after the injury, and died on the first postoperative day from reperfusion syndrome.

RASVG is the main substitute for segmental vascular loss because synthetic grafts are rarely available when required in acute emergencies (Figure 3).3 In this study, we used 5 RASVG for segmental arterial replacement (Table 1). Thomas and colleagues1 had a different experience because they used more prosthetic grafts than RASVG. Therefore, when both saphenous veins are unavailable or the technical skill is lacking, limb loss is the natural consequence.1,7 Ajibade and colleagues7 reported that of 132 patients who required amputation, trauma constituted the major indication (42.4%). Similar findings have been reported in other studies in which trauma remains the major indication for amputation.8,9 Therefore, a possible reason for the small number of patients managed by us during this period is that those with vascular injury often present late with gangrene and thus end up with the orthopedic surgeons for amputation as reported by Ajibade and colleagues,7 although these authors did not state the actual percentage contributed specifically by vascular injury. In our series, aneurysms were the second most common reason for use of RASVG (17.8%), followed by trauma (16.4%). Three of the 13 aneurysm cases were posttraumatic pseudoaneurysms presenting years after the insult, and one was an acute posttraumatic thoracic pseudoaneurysm (Figure 4). Therefore, if these 4 cases are added to the trauma cases, trauma becomes the second most common indication for vascular operations in our series. The morbidities (5.5%) included 3 minor complications following arteriovenous fistula creation and one major

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Figure 3. Reversed autogenous saphenous vein graft for repair of the injured femoral artery of the patient in Figure 2.

Table 1. Vascular surgery in 54 patients. Indication

Procedure

No. of patients

End-stage renal disease

Creation of upper limb arteriovenous fistula

38

Vascular trauma

Thrombotic disease

Arteriorrhaphy Graft interposition Ligation Excision of arteriovenous fistula Excision of pseudoaneurysm patch angioplasty Thrombectomy

3 5 2 3 1 1

Chest wall hemangioma

Excision

1

Posttraumatic arteriovenous fistula/pseudoaneurysm

complication leading to death from anticoagulationrelated upper gastrointestinal hemorrhage in a patient with known peptic ulcer and iliofemoral arteriovenous thrombosis (Figure 5). Currently, in our institution, there are no strategic plans for the development of vascular surgery. The prospects are not entirely bleak because a few residents in training have expressed an interest in the field of vascular surgery. However, they need to travel beyond our shores because there is no center in the country dedicated or sufficiently equipped to train specialists in this field. This show of interest by residents must be backed by a corresponding zeal by the institution’s

Complication Limb edema (1), hematoma (2), thrombosis (3)

Upper gastrointestinal hemorrhage. Died

management not only to support the training of these specialists and allied staff but to make a concerted effort to procure all the necessary equipment to facilitate their work. While waiting for the actualization of these plans, the gap will continue to be filled by cardiothoracic surgeons who also need further training in this field, particularly in interventional techniques for peripheral arterial occlusive disease and the surgical management of thoracic aneurysms. The lack of technical skills in these areas is partly responsible for the zero number of patients operated on during this period in our institution. Furthermore, massive investment in infrastructure either by government or through

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Figure 4. A patient with posttraumatic femoral arteriovenous fistula who had initial repair with a reversed autogenous saphenous vein graft, recurrence with a failed attempt at a second repair, and ended up with above-knee amputation.

Figure 5. Thrombectomy for femoral arteriovenous thrombosis.

public-private partnership ventures is urgently required to provide an enabling environment for the practice and/or establishment of vascular surgery institutes for training, research, and treatment of vascular pathologies. These would not only improve the overall volume

but also the scope, quality, and efficiency of the services provided. We concluded that the practice of vascular surgery is still in its infant stage in our institution. The practise is bedevilled by infrastructure deficits and lack of

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equipment and materials. Other problems include inadequate skilled manpower in addition to late presentation and patients’ insolvency. There is therefore the need for improved infrastructure and manpower development to forestall the high morbidity and mortality associated with vascular diseases when not managed adequately and on time. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement None declared.

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3. Adeoye PO, Adebola SO, Adesiyun OA and Braimoh KT. Peripheral vascular surgical procedures in Ilorin, Nigeria: indications and outcome. Afr Health Sci 2011; 11: 433–437. 4. Larsen DW. Traumatic vascular injuries and their management. Neuroimaging Clin N Am 2002; 12: 249–269. 5. Lee AB, Dupin CL, Colen L, Jones NF, May JW and Chiu ES. Microvascular free tissue transfer in organ transplantation patients: is it safe? Plast Reconstr Surg 2008; 121: 1986–1992. 6. Pierce WH and Yao JST. Advances in Vascular Surgery. Chicago: Precept Press, 2001, p. 577. 7. Ajibade A, Akinniyi OT and Okoye CS. Indications and complications of major limb amputations in Kano, Nigeria. Ghana Med J 2013; 47: 185–188. 8. Kidmas AT, Nwadiaro CH and Igun GO. Lower limb amputation in Jos. Nigeria East Afr Med J 2004; 81: 427–429. 9. Onuminya JE, Obekpa PO, Ihezue HC, Ukegbu ND and Onabowale BO. Major amputations in Nigeria: a plea to educate traditional bone setters. Trop Doct 2000; 30: 133–213.

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