Factors influencing the fascial closure rate after open abdomen treatment: Results from the European Hernia Society (EuraHS) Registry : Surgical technique matters.

PURPOSE: Definitive fascial closure is an essential treatment objective after open abdomen treatment and mitigates morbidity and mortality. There is a paucity of evidence on factors that promote or prevent definitive fascial closure. METHODS: A multi-center multivariable analysis of data from the Open Abdomen Route of the European Hernia Society included all cases between 1 May 2015 and 31 December 2019. Different treatment elements, i.e. the use of a visceral protective layer, negative-pressure wound therapy and dynamic closure techniques, as well as patient characteristics were included in the multivariable analysis. The study was registered in the International Clinical Trials Registry Platform via the German Registry for Clinical Trials (DRK00021719). RESULTS: Data were included from 630 patients from eleven surgical departments in six European countries. Indications for OAT were peritonitis (46%), abdominal compartment syndrome (20.5%), burst abdomen (11.3%), abdominal trauma (9%), and other conditions (13.2%). The overall definitive fascial closure rate was 57.5% in the intention-to-treat analysis and 71% in the per-protocol analysis. The multivariable analysis showed a positive correlation of negative-pressure wound therapy (odds ratio: 2.496, p < 0.001) and dynamic closure techniques (odds ratio: 2.687, p < 0.001) with fascial closure and a negative correlation of intra-abdominal contamination (odds ratio: 0.630, p = 0.029) and the number of surgical procedures before OAT (odds ratio: 0.740, p = 0.005) with DFC. CONCLUSION: The clinical course and prognosis of open abdomen treatment can significantly be improved by the use of treatment elements such as negative-pressure wound therapy and dynamic closure techniques, which are associated with definitive fascial closure.

Ruptured popliteal artery aneurysm.

BACKGROUND: Popliteal artery aneurysms (PAAs) are generally complicated by thrombosis and distal embolization, whereas rupture is rare. The aim of this study was to describe the clinical characteristics and outcome in a cohort of patients who had surgery for ruptured PAA (rPAA). METHODS: Operations for rPAA were identified from the Swedish Vascular Registry, Swedvasc, 1987-2012. Medical records and imaging were reviewed. Comparison was made with patients treated for PAA without rupture. RESULTS: Forty-five patients with rPAA were identified. The proportion with rupture among those operated on for PAA was 2·5 per cent. Patients with rPAA were 8 years older (77·7 versus 69·7 years; P < 0·001), had more lung and heart disease (P = 0·003 and P = 0·019 respectively), and a larger mean popliteal aneurysm diameter (63·7 versus 30·9 mm; P < 0·001) than patients with PAA treated for other indications. At time of surgery, 22 of 45 patients were already receiving anticoagulants, seven for concomitant deep venous thrombosis (DVT) in the affected leg. There was extensive swelling of the whole leg in 20 patients. In 27 patients, the initial diagnosis was DVT or a Baker's cyst. All patients underwent surgery, all but three by the open method. There were four amputations, all performed within 1 week of surgery. One year after surgery, 26 of the 45 patients were alive. Among these, the reconstructions were patent in 20 of 22 patients. CONCLUSION: The diagnosis of rPAA is difficult, and often delayed. The condition affects old patients, who often are on anticoagulation treatment and have large aneurysms. The immediate surgical results are acceptable, but the condition is associated with a high risk of death within the first year after surgery.

Open or endovascular revascularization in the treatment of acute lower limb ischaemia.

BACKGROUND: Consensus is lacking regarding intervention for patients with acute lower limb ischaemia (ALI). The aim was to study amputation-free survival in patients treated for ALI by either primary open or endovascular revascularization. METHODS: The Swedish Vascular Registry (Swedvasc) was combined with the Population Registry and National Patient Registry to determine follow-up on mortality and amputation rates. Revascularization techniques were compared by propensity score matching 1 : 1. RESULTS: Of 9736 patients who underwent open surgery and 6493 who had endovascular treatment between 1994 and 2014, 3365 remained in each group after propensity score matching. Results are from the matched cohort only. Mean age of the patients was 74·7 years; 47·5 per cent were women and mean follow-up was 4·3 years. At 30-day follow-up, the endovascular group had better patency (83·0 versus 78·6 per cent; P < 0·001). Amputation rates were similar at 30 days (7·0 per cent in the endovascular group versus 8·2 per cent in the open group; P = 0·113) and at 1 year (13·8 versus 14·8 per cent; P = 0·320). The mortality rate was lower after endovascular treatment, at 30 days (6·7 versus 11·1 per cent; P < 0·001) and after 1 year (20·2 versus 28·6 per cent; P < 0·001). Accordingly, endovascular treatment had better amputation-free survival at 30 days (87·5 versus 82·1 per cent; P < 0·001) and 1 year (69·9 versus 61·1 per cent; P < 0·001). The number needed to treat to prevent one death within the first year was 12 with an endovascular compared with an open approach. Five years after surgery, endovascular treatment still had improved survival (HR 0·78, 99 per cent c.i. 0·70 to 0·86) but the difference between the treatment groups occurred mainly in the first year. CONCLUSION: Primary endovascular treatment for ALI appeared to reduce mortality compared with open surgery, without any difference in the risk of amputation.

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging.

BACKGROUND: Lifelong postoperative surveillance is recommended following endovascular aneurysm repair (EVAR). Although the purpose is to prevent and/or identify complications early, it also results in increased cost and workload. This study was designed to examine whether it may be possible to identify patients at low risk of complications based on their first postoperative CT angiogram (CTA). METHODS: All patients undergoing EVAR in two Swedish centres between 2001 and 2012 were identified retrospectively and categorized based on the first postoperative CTA as at low risk (proximal and distal sealing zone at least 10 mm and no endoleak) or high risk (sealing zone less than 10 mm and/or presence of any endoleak) of complications. RESULTS: Some 326 patients (273 men) with a CTA performed less than 1 year after EVAR were included (low risk 212, 65·0 per cent; high risk 114, 35·0 per cent). There was no difference between the groups in terms of sex, age, co-morbidities, abdominal aortic aneurysm (AAA) diameter, preoperative AAA neck anatomy, stent-graft type or duration of follow-up (mean(s.d.) 4·8(3·2) years). Five-year freedom from AAA-related adverse events was 97·1 and 47·7 per cent in the low- and high-risk groups respectively (P < 0·001). The corresponding freedom from AAA-related reintervention was 96·2 and 54·1 per cent (P < 0·001). The method had a sensitivity of 88·3 per cent, specificity of 77·0 per cent and negative predictive value of 96·6 per cent to detect AAA-related adverse events. The number of surveillance imaging per AAA-related adverse event was 168 versus 11 for the low-risk versus high-risk group. CONCLUSION: Two-thirds of patients undergoing EVAR have an adequate seal and no endoleak on the first postoperative CTA, and a very low risk of AAA-related events up to 5 years. Less vigilant follow-up after EVAR may be considered for these patients.

Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden.

BACKGROUND: There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non-operative factors influence risk-adjusted outcomes. This study compared 90-day and 5-year mortality for patients undergoing elective AAA repair in England and Sweden. METHODS: Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety-day mortality and 5-year survival were compared after adjustment for age and sex. Separate within-country analyses were performed to examine the impact of co-morbidity, hospital teaching status and hospital annual caseload. RESULTS: The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69-79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68-78) years, of whom 82·9 per cent were men. Ninety-day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five-year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. CONCLUSION: Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England.

Editor's Choice - Assessment of International Outcomes of Intact Abdominal Aortic Aneurysm Repair over 9 Years.

BACKGROUND: Case mix and outcomes of complex surgical procedures vary over time and between regions. This study analyses peri-operative mortality after intact abdominal aortic aneurysm (AAA) repair in 11 countries over 9 years. METHODS: Data on primary AAA repair from vascular surgery registries in 11 countries for the years 2005-2009 and 2010-2013 were analysed. Multivariate adjusted logistic regression analyses were carried out to adjust for variations in case mix. RESULTS: A total of 83,253 patients were included. Over the two periods, the proportion of patients ≥80 years old increased (18.5% vs. 23.1%; p < .0001) as did the proportion of endovascular repair (EVAR) (44.3% vs. 60.6; p < .0001). In the latter period, 25.8% of AAAs were less than 5.5 cm. The mean annual volume of open repairs per centre decreased from 12.9 to 10.6 between the two periods (p < .0001), and it increased for EVAR from 10.0 to 17.1 (p < .0001). Overall, peri-operative mortality fell from 3.0% to 2.4% (p < .0001). Mortality for EVAR decreased from 1.5% to 1.1% (p < .0001), but the outcome worsened for open repair from 3.9% to 4.4% (p = .008). The peri-operative risk was greater for octogenarians (overall, 3.6% vs. 2.1%, p < .0001; open, 9.5% vs. 3.6%, p < .0001; EVAR, 1.8% vs. 0.7%, p < .0001), and women (overall, 3.8% vs. 2.2%, p < .0001; open, 6.0% vs. 4.0%, p < .0001; EVAR, 1.9% vs. 0.9%, p < .0001). Peri-operative mortality after repair of AAAs <5.5 cm was 4.4% with open repair and 1.0% with EVAR, p < .0001. CONCLUSIONS: In this large international cohort, total peri-operative mortality continues to fall for the treatment of intact AAAs. The number of EVAR procedures now exceeds open procedures. Mortality after EVAR has decreased, but mortality for open operations has increased. The peri-operative mortality for small AAA treatment, particularly open surgical repair, is still considerable and should be weighed against the risk of rupture.

Long-term Outcome after Thrombolysis for Acute Lower Limb Ischaemia.

OBJECTIVES: The purpose was to study long-term outcome after thrombolysis for acute arterial lower limb ischaemia, and to evaluate the results depending on the underlying aetiology of arterial occlusion. METHODS: This was a retrospective study of patients entered into a prospective database. Patients were identified in prospective databases from two vascular centres, including a large number of variables. Case records were analysed retrospectively. Through cross linkage with the Population Registry 100% accurate survival data were obtained. Between January 2001 and December 2013, 689 procedures were included. The aetiology of ischaemia was graft/stent/stent graft occlusion in 39.8%, arterial thrombosis in 27.7%, embolus in 25.1% and popliteal aneurysm in 7.4%. RESULTS: The mean follow-up was 59.4 months (95% CI, 56.1-62.7), during which 32.9% needed further re-interventions, 16.4% underwent amputation without re-intervention, and 50.7% had no re-intervention. The need for re-intervention during follow-up was 48.0% in the graft/stent occlusions group, 34.0% of the popliteal aneurysm group, 25.4% in the thrombosis group, and 16.3% in the embolus group (p < .001). The overall primary patency rates were 69.1% and 55.9% at 1 and 5 years, respectively. Primary patency at 5 years was higher for the embolus group (83.3%, p = .002) and lower for the occluded graft/stent group (43.3%, p < .001). Secondary patency rates were 80.1% and 75.2% at 1 and 5 years, respectively, without difference between the subgroups. The amputation rate was lower in the embolic group at 1 and 5 years (8.1% and 11.1%, respectively, p = .001). Survival was higher in the group with occluded popliteal aneurysms at 5 years (83.3%, p = 0.004). Amputation free survival was 72.1% and 45.2% at 1 and 5 years; lower in the occluded graft/stent group at five years (37.9%, p = .007). CONCLUSION: Intra-arterial thrombolytic therapy achieves good medium and long-term clinical outcome, reducing the need of open surgical treatment in most patients.

Editor's Choice - Carotid Stenosis Treatment: Variation in International Practice Patterns.

OBJECTIVES: The aim was to determine current practice for the treatment of carotid stenosis among 12 countries participating in the International Consortium of Vascular Registries (ICVR). METHODS: Data from the United States Vascular Quality Initiative (VQI) and the Vascunet registry collaboration (including 10 registries in Europe and Australasia) were used. Variation in treatment modality of asymptomatic versus symptomatic patients was analysed between countries and among centres within each country. RESULTS: Among 58,607 procedures, octogenarians represented 18% of all patients, ranging from 8% (Hungary) to 22% (New Zealand and Australia). Women represented 36%, ranging from 29% (Switzerland) to 40% (USA). The proportion of carotid artery stenting (CAS) among asymptomatic patients ranged from 0% (Finland) to 26% (Sweden) and among symptomatic patients from 0% (Denmark) to 19% (USA). Variation among centres within countries for CAS was highest in the United States and Australia (from 0% to 80%). The overall proportion of asymptomatic patients was 48%, but varied from 0% (Denmark) to 73% (Italy). There was also substantial centre level variation within each country in the proportion of asymptomatic patients, most pronounced in Australia (0-72%), Hungary (5-55%), and the United States (0-100%). Countries with fee for service reimbursement had higher rates of treatment in asymptomatic patients than countries with population based reimbursement (OR 5.8, 95% CI 4.4-7.7). CONCLUSIONS: Despite evidence about treatment options for carotid artery disease, the proportion of asymptomatic patients, treatment modality, and the proportion of women and octogenarians vary considerably among and within countries. There was a significant association of treating more asymptomatic patients in countries with fee for service reimbursement. The findings reflect the inconsistency of the existing guidelines and a need for cooperation among guideline committees all over the world.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival.

BACKGROUND: Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS: Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS: The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION: Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Negative-pressure wound therapy for prevention and treatment of surgical-site infections after vascular surgery.

BACKGROUND: Indications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds. METHODS: A PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms 'wound infection', 'abdominal aortic aneurysm (AAA)', 'fasciotomy', 'vascular surgery' and 'NPWT' or 'VAC'. RESULTS: NPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0-10 and 83-100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96-100 per cent) and low risk of graft infection (0-7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT. CONCLUSION: NPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury.

OBJECTIVE: Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. METHOD: The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. RESULTS: Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." CONCLUSIONS: Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Is It Worthwhile Treating Occluded Cold Stored Venous Allografts by Thrombolysis?

OBJECTIVES: Thrombolysis has been reported to be suboptimal in occluded vein grafts and cryopreserved allografts, and there are no data on the efficacy of thrombolysis in occluded cold stored venous allografts. The aim was to evaluate early outcomes, secondary patency and limb salvage rates of thrombolysed cold stored venous allograft bypasses and to compare the outcomes with thrombolysis of autologous bypasses. METHODS: This was a single center study of consecutive patients with acute and non-acute limb ischemia between September 1, 2000, and January 1, 2014, with occlusion of cold stored venous allografts, and between January 1, 2012, and January 1, 2014, with occlusion of autologous bypass who received intra-arterial thrombolytic therapy. RESULTS: Sixty-one patients with occlusion of an infrainguinal bypass using a cold stored venous allograft (n = 35) or an autologous bypass (n = 26) underwent percutaneous intra-arterial thrombolytic therapy. The median duration of thrombolysis was 20 h (IQR 18-24) with no difference between the groups (p = .14). The median follow up was 18.5 months (IQR 11.0-52.0). Secondary patency rates of thrombolysed bypass at 6 and 12 months were 44 ± 9% and 32 ± 9% in patients with a venous allograft bypass and 46 ± 10% and 22 ± 8% with an autologous bypass, with no difference between groups (p = .40). Limb salvage rates at 1, 6, and 12 months after thrombolysis in the venous allograft group were 83 ± 7%, 72 ± 8% and 63 ± 9%, and in the autologous group 91 ± 6%, 76 ± 9%, and 65 ± 13%, with no difference between groups (p = .69). CONCLUSIONS: Long-term results of thrombolysis of venous allograft bypasses are similar to those of autologous bypasses. Occluded cold stored venous allograft can be successfully re-opened in most cases with a favorable effect on limb salvage.

Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction.

PURPOSE: To report incisional hernia (IH) incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). METHODS: Five-year follow-up of patients included in a prospective study 2006-2009. The protocol included physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire. RESULTS: Fifty-five (12 women, 43 men; median age 70 years) of 111 included patients were alive. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 %. One-third of the IHs was repaired. At 5-year follow-up 59 % of IHs were clinically detectable. AW symptoms were equivalent in patients with (15/23) and without (11/21) IH (p = 0.541). SF-36 scores were lower than population mean for component scores and all subscales except bodily pain. Patients with major co-morbidity had lower physical component score [31.6 (95 %, CI 25.6-37.4)] compared to those without [48.9 (95 %, CI 46.2-51.4)]. Major co-morbidity was not associated with IH (p = 0.56), AW symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW symptoms had similar SF-36 results compared to those without, whereas patients with a stoma had >5 point lower mean scores for general health, social function and physical component score compared to those without. CONCLUSIONS: VAWCM treatment results in high incidence of IH. However, at five years, there was no detectable difference in abdominal wall complaints and QoL in patients with IH compared to those without. Lower QoL appeared mainly to be associated with the presence of major co-morbidity.

Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm: A Nationwide Population Based Study.

OBJECTIVE/BACKGROUND: The understanding of abdominal compartment syndrome (ACS), and its importance for outcome, has increased over time. The aim was to investigate the incidence and clinical consequences of ACS after open (OR) and endovascular repair (EVAR) for ruptured and intact infrarenal abdominal aortic aneurysm (rAAA and iAAA, respectively). METHODS: In 2008, ACS and decompression laparotomy (DL) were introduced as variables in the Swedish vascular registry (Swedvasc), offering an opportunity to study this complication in a prospective, population based design. Operations carried out in the period 2008-13 were analysed. Of 6,612 operations, 1,341 (20.3%) were for rAAA (72.0% OR) and 5,271 (79.7%) for iAAA (41.9% OR). In all, 3,171 (48.0%) were operated on by OR and 3,441 by EVAR. Prophylactic open abdomen (OA) treatment was validated through case records. Cross-matching with the national population registry secured valid mortality data. RESULTS: After rAAA repair, ACS developed in 6.8% after OR versus 6.9% after EVAR (p = 1.0). All major complications were more common after ACS (p < .001). Prophylactic OA was performed in 10.7% of patients after OR. For ACS, DL was performed in 77.3% after OR and 84.6% after EVAR (p = .433). The 30 day mortality rate was 42.4% with ACS and 23.5% without ACS (p < .001); at 1 year it was 50.7% versus 31.8% (p < .001). After iAAA repair, ACS developed in 1.6% of patients after OR versus 0.5% after EVAR (p < .001). Among those with ACS, DL was performed in 68.6% after OR and in 25.0% after EVAR (p = .006). Thirty day mortality was 11.5% with ACS versus 1.8% without it (p < .001); at 1 year it was 27.5% versus 6.3% (p < .001). When ACS developed, renal failure, multiple organ failure, intestinal ischaemia, and prolonged intensive care were much more frequent (p < .001). Morbidity and mortality were similar, regardless of primary surgical technique (OR/EVAR/iAAA/rAAA). CONCLUSION: ACS and OA were common after treatment for rAAA. ACS is a devastating complication after surgery for rAAA and iAAA, irrespective of operative technique, emphasizing the importance of prevention.

Amended Classification of the Open Abdomen.

BACKGROUND: In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research. METHODS: As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen. RESULTS: The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue. CONCLUSIONS: The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.

Editor's Choice - Long-term Outcome After EndoVAC Hybrid Repair of Infected Vascular Reconstructions.

OBJECTIVE/BACKGROUND: Vascular graft infection is a serious and challenging complication. In situations when neither traditional radical surgery nor conservative negative pressure wound therapy (VAC) alone, are considered feasible or safe, for example due to bleeding, adverse anatomy, or severe comorbidity, a novel hybrid procedure was developed. The EndoVAC technique consists of (i) relining of the infected reconstruction with a stent graft; (ii) surgical revision (without clamping the reconstruction); and (iii) VAC therapy, to permit granulation and secondary delayed healing, and long-term antibiotic treatment. The aim of the study is to report long-term follow up data of this new treatment modality. METHODS: From November 2007 to June 2015, 17 EndoVAC procedures were performed in 16 patients (eight men, aged 16-91 years): six infected carotid patches after carotid endarterectomy, three infected neck deviations, two infected femoro-popliteal bypasses, three infected patches after femoral thrombo-endarterectomy, and two infected vascular accesses. Surveillance was performed routinely every 3-6 months and included clinical examination, hematologic tests, duplex ultrasonography, and imaging techniques, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography. RESULTS: Primary technical success rate was 100%. Antibiotics were prescribed for a median of 3 months (range 1-20 months). The median duration of VAC treatment was 14 days (range 9-57 days). Complications included early, transient stroke (n = 1), temporary hypoglossal palsy (n = 1), and late, asymptomatic occluded bypasses (n = 2), stent graft thrombosis (n = 1), and moderate carotid stenosis (n = 1). After a median of 5 years (range 1-90 months) of follow up, all patients had healed graft infections with no recurrence was observed. Eight patients died as a result of severe comorbidities, unrelated to the infection or hybrid procedure, 1 month-7 years after treatment. CONCLUSION: The EndoVAC technique is an alternative, less invasive, option for treatment of infected vascular reconstructions in selected cases, when neither traditional radical surgery, nor conservative simple negative pressure wound therapy are considered feasible or safe. The exact indications for this alternative hybrid treatment need to be established.