The use of thoracic stent grafts for endovascular repair of abdominal aortic aneurysms.

Objectives Stent grafts for endovascular repair of infrarenal aneurysms are commercially available for aortic necks up to 32 mm in diameter. The aim of this study was to evaluate the feasibility of endovascular repair with large thoracic stent grafts in the infrarenal position to obtain adequate proximal seal in wider necks. Methods All patients who underwent endovascular aneurysm repair using thoracic stent grafts with diameters greater than 36 mm between 2012 and 2016 were included. Follow-up consisted of CT angiography after six weeks and annual duplex thereafter. Results Eleven patients with wide infrarenal aortic necks received endovascular repair with thoracic stent grafts. The median diameter of the aneurysms was 60 mm (range 52-78 mm) and the median aortic neck diameter was 37 mm (range 28-43 mm). Thoracic stent grafts were oversized by a median of 14% (range 2-43%). On completion angiography, one type I and two type II endoleaks were observed but did not require reintervention. One patient experienced graft migration with aneurysm sac expansion and needed conversion to open repair. Median follow-up time was 14 months (range 2-53 months), during which three patients died, including one aneurysm-related death. Conclusions Endovascular repair using thoracic stent grafts for patients with wide aortic necks is feasible. In these patients, the technique may be a reasonable alternative to complex endovascular repair with fenestrated, branched, or chimney grafts. However, more experience and longer follow-up are required to determine its position within the endovascular armamentarium.

Systematic review of mortality risk prediction models in the era of endovascular abdominal aortic aneurysm surgery.

BACKGROUND: The introduction of endovascular aneurysm repair (EVAR) has reduced perioperative mortality after abdominal aortic aneurysm (AAA) surgery. The objective of this systematic review was to assess existing mortality risk prediction models, and identify which are most useful for patients undergoing AAA repair by either EVAR or open surgical repair. METHODS: A systematic search of the literature was conducted for perioperative mortality risk prediction models for patients with AAA published since 2006. PRISMA guidelines were used; quality was appraised, and data were extracted and interpreted following the CHARMS guidelines. RESULTS: Some 3903 studies were identified, of which 27 were selected. A total of 13 risk prediction models have been developed and directly validated. Most models were based on a UK or US population. The best performing models regarding both applicability and discrimination were the perioperative British Aneurysm Repair score (C-statistic 0·83) and the preoperative Vascular Biochemistry and Haematology Outcome Model (C-statistic 0·85), but both lacked substantial external validation. CONCLUSION: Mortality risk prediction in AAA surgery has been modelled extensively, but many of these models are weak methodologically and have highly variable performance across different populations. New models are unlikely to be helpful; instead case-mix correction should be modelled and adapted to the population of interest using the relevant mortality predictors.

Adjusted Hospital Outcomes of Abdominal Aortic Aneurysm Surgery Reported in the Dutch Surgical Aneurysm Audit.

OBJECTIVE/BACKGROUND: The Dutch Surgical Aneurysm Audit (DSAA) is mandatory for all patients with primary abdominal aortic aneurysms (AAAs) in the Netherlands. The aims are to present the observed outcomes of AAA surgery against the predicted outcomes by means of V-POSSUM (Vascular-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity). Adjusted mortality was calculated by the original and re-estimated V(physiology)-POSSUM for hospital comparisons. METHODS: All patients operated on from January 2013 to December 2014 were included for analysis. Calibration and discrimination of V-POSSUM and V(p)-POSSUM was analysed. Mortality was benchmarked by means of the original V(p)-POSSUM formula and risk-adjusted by the re-estimated V(p)-POSSUM on the DSAA. RESULTS: In total, 5898 patients were included for analysis: 4579 with elective AAA (EAAA) and 1319 with acute abdominal aortic aneurysm (AAAA), acute symptomatic (SAAA; n = 371) or ruptured (RAAA; n = 948). The percentage of endovascular aneurysm repair (EVAR) varied between hospitals but showed no relation to hospital volume (EAAA: p = .12; AAAA: p = .07). EAAA, SAAA, and RAAA mortality was, respectively, 1.9%, 7.5%, and 28.7%. Elective mortality was 0.9% after EVAR and 5.0% after open surgical repair versus 15.6% and 27.4%, respectively, after AAAA. V-POSSUM overestimated mortality in most EAAA risk groups (p < .01). The discriminative ability of V-POSSUM in EAAA was moderate (C-statistic: .719) and poor for V(p)-POSSUM (C-statistic: .665). V-POSSUM in AAAA repair overestimated in high risk groups, and underestimated in low risk groups (p < .01). The discriminative ability in AAAA of V-POSSUM was moderate (.713) and of V(p)-POSSUM poor (.688). Risk adjustment by the re-estimated V(p)-POSSUM did not have any effect on hospital variation in EAAA but did in AAAA. CONCLUSION: Mortality in the DSAA was in line with the literature but is not discriminative for hospital comparisons in EAAA. Adjusting for V(p)-POSSUM, revealed no association between hospital volume and treatment or outcome. Risk adjustment for case mix by V(p)-POSSUM in patients with AAAA has been shown to be important.

The influence of choice of therapy on quality of life in patients with neurogenic thoracic outlet syndrome.

OBJECTIVES: We aimed to compare quality of life (QoL) after surgical decompression of the thoracic outlet versus non-operative therapy in patients with neurogenic thoracic outlet syndrome (N-TOS). DESIGN AND METHODS: We retrospectively identified 46 patients, diagnosed with N-TOS between 1999 and 2008. Twenty-four operated and 22 conservatively treated patients were sent questionnaires on their current symptoms and QoL. A matched control group (n = 24) of healthy individuals was selected for QoL comparison. Statistics were performed with linear and logistic regression analysis. RESULTS: ANOVA revealed a significant QoL difference between the three groups (p = 0.001). Separate analysis between groups demonstrated that all patients with N-TOS-like symptoms have a lower QoL than healthy controls (p = 0.001 resp. p < or = 0.000). No difference was found between conservatively and surgically treated patients (p = 0.26). EQ-5D response rate was 83%. Of the 24 surgically treated patients, 15 would choose surgery again in a similar situation, although 4 did not benefit in terms of symptom reduction. Symptom relief and VAS pain scores in the conservatively and surgically treated patients did not show significant differences (p = 0.95 resp. p = 0.40). CONCLUSIONS: All patients with N-TOS have a significantly decreased QoL compared with healthy individuals, regardless of the type of therapy they received. In this small study, surgical decompression fails to improve QoL in patients with N-TOS to the level measured in the healthy control group, despite symptom reduction consistent with previous reports. Variables significantly associated with outcome were duration of symptoms and localisation (variables included in the prediction model: age, sex, duration of symptoms, presence of paraesthesias, localisation, Adson's, Wright's and Roos' test, history of trauma, cervical arthrosis). In the perspective of QoL, the benefit of decompressive surgery is questionable. Improving patient selection seems imperative in order to achieve better results in our surgically treated patients.

Can transcutaneous oxygen tension measurement determine re-amputation levels?

OBJECTIVE: To review the preoperative transcutaneous oxygen tension (TcPO2) measurements in patients having major lower leg amputation, and also consider the re-amputation rate, wound infection and the definitive level of amputation. METHOD: A case-control study was performed in a consecutive cohort of 170 patients (1999-2003). Fifty-two patients underwent preoperative TcPO2 measurements (cases) and 118 patients did not (control). Multiple logistic regression analysis was performed to analyse independent risk factors associated with re-amputations. RESULTS: Primary and definitive (in case of a re-amputation) amputation levels were lower in the TcPO2 group, although this did not reach statistical significance. The number of re-amputations in the TcPO2 group was significantly higher: 15 versus 18 patients (p=0.039). Selection of an amputation level with aTcPO2 of 30mmHg resulted in a positive predictive value of re-amputation of 41% and a negative predictive value of 90%. A cut off value of 20mmHg resulted in 41% and 77% respectively. CONCLUSION: The use of TcPO2 measurements for major amputation level selection resulted in an increased rate of re-amputation. However, there was a trend in gaining a more distal definitive amputation level. Selection of an amputation level solely based on a TcPO2 value is unreliable.

The use of a percutaneous closure device for closure of an accidental puncture of the aortic arch; a simple solution for a difficult problem.

Percutaneous closure devices are now often used for closure of the femoral puncture site after percutaneous vascular interventions. We describe a case were an accidental puncture in the aortic arch during placement of a central venous catheter is successfully closed with a closure device.

The visceral perfusion system and distal bypass during thoracoabdominal aneurysm surgery: an alternative for physiological blood flow?

There are potential benefits to addition of visceral organ perfusion, by means of a 9-Fr. catheter system (octopus), to distal aortic perfusion during thoracoabdominal aneurysm surgery. However, in the literature there are reports of adverse effects. The authors therefore compared two groups of patients who underwent thoracoabdominal aneurysm surgery with and without visceral organ perfusion. In the group in which the visceral perfusion was applied, the use of platelets (26 versus 11 units; P < 0.05), fresh frozen plasma (3.4 versus 1.5 units; P < 0.05) and packed cells (20 versus 8 units, P < 0.05) was significantly increased. An equal number of patients in both groups developed renal failure postoperatively. An explanation for this adverse effect can be found in the high shear rates in the catheters used, mainly as a result of the small diameter. High shear rates cause haemolysis. Also, the flow through the catheters is insufficient to maintain adequate perfusion of the visceral organs. A higher flow in these catheters would result in an even higher shear rate. It is therefore concluded that coagulopathy and insufficient bloodflow is caused by the small internal diameter of the catheters, which renders the device insufficient.

Risk factors for premature atherosclerosis.

OBJECTIVES: to investigate the prevalence of risk factors in patients with premature atherosclerosis. DESIGN: retrospective controlled study. MATERIALS: 135 consecutive patients with premature atherosclerosis /= 65 years (group II) with atherosclerosis. Statistical analysis was performed with Chi-squared test and logistic regression analysis. RESULTS: group I versus group II: diabetes 11% vs. 27% (p=0.001), smoking 84% vs. 67% (p=0.002), hypertension 36% vs. 58% (p=0.001), hypercholesterolaemia 47% vs. 34% (p=0.04), family history of cardiovascular disease 53% vs. 42% (p=0.08). In group I hyperhomocysteinaemia was present in 24 of the 108 patients tested, anticardiolipin antibodies were present in four of the 34 tested and coagulation abnormalities were found in four of the 22 patients tested. CONCLUSION: the difference in the prevalence of the different risk factors between the two groups suggests that either certain risk factors are more likely to cause premature atherosclerosis, or that other risk factors must be present in addition to the known risk factors in order to induce premature atherosclerosis.