[Hybrid operating room is indispensable for minimally invasive surgery]. / Hybride OK onmisbaar bij minimaal invasieve chirurgie.

The hybrid operating room is on the rise in the Netherlands. In this sterile room, more and more complex patients can be treated with minimally invasive techniques, supported by advanced image-guided technology, with special care for the safety of the patient and the operating team. This sterile room offers many possibilities for various specialties such as vascular surgery, interventional radiology, cardiology, oncology and traumatology. As a result, more and more patients will be treated with endovascular techniques in the hybrid operating room, which will improve the quality and outcome of this multidisciplinary care.

First- and second-generation drug-eluting balloons for femoro-popliteal arterial obstructions: update of technique and results.

The use of drug-eluting balloons for treatment of long-segment femoropopliteal artery obstructions has become widespread in recent years. The possibility to deliver a drug into the arterial wall with sustained antiproliferative effects, without leaving behind metal scaffolding, seems very promising. The current generation of drug-eluting balloons differs in the formulation of the drug (usually paclitaxel), technique of coating, and the elution excipients. Results of published randomized trials are reviewed in this report. A new innovative coating technique has been introduced recently. The PRIMUS® coronary drug-eluting balloon and the Legflow® peripheral drug-eluting balloon consist of paclitaxel nanoparticles that are embedded underneath the surface of the balloon as well as inside a new shellolic acid drug-release matrix. Risk for dislodgement of the paclitaxel particles is minimized in the newest generation of drug-eluting balloons. Short-term in vitro and in vivo results of this stable, coated balloon are promising, and large randomized trials have been started recently to gather more long-term and robust clinical data.

The basilic vein and the cephalic vein perform equally in upper arm arteriovenous fistulae.

OBJECTIVE: To compare the brachiocephalic (BC) and basilic vein transposition (BVT) arteriovenous fistula (AVF) with regard to maturation, patency, blood flow and complication rates. DESIGN: A retrospective chart review. MATERIALS AND METHOD: Between January 2000 and December 2010, consecutive patients undergoing BC or BVT AVF were included. Patient characteristics were collected retrospectively from digital patient files and a prospective database of haemodialysis patients. RESULTS: A total of 173 autologous upper arm AVFs (87 BC and 86 BVT) were created in 151 patients. Mean (±SEM) follow-up was 19 ± 1.4 months (range 0-100). There were no differences between the groups in respect to brachial artery and cubital fossa vein diameters, time to first use, flow and the number of secondary interventions. Operative time was significantly longer (P < 0.001) and the mid upper arm vein diameter before bifurcation greater (P = 0.038) in BVT patients. The 1- and 2-year primary patency rates for the whole cohort was 40.8% and 30.2% with secondary patency rates of 78.0% and 72.4%. There was no difference between the groups for these outcomes (P = 0.951, P = 0.516, respectively). CONCLUSION: With the exception of the efferent vein diameter in the mid upper arm and operative time, there was no difference between a BC and BVT AVF.

Ultrasound-accelerated thrombolysis for lower extremity ischemia: multicenter experience and literature review.

AIM: This study evaluates the short-term outcome of ultrasound-accelerated thrombolysis in patients with lower extremity ischemia caused by thromboembolic occlusions. METHODS: A retrospective cohort study was conducted from December 2008 to May 2011 of 57 patients (42 men; median age, 66 ± 11 years) undergoing 62 episodes of ultrasound-accelerated thrombolysis for thromboembolic arterial occlusions of the lower extremities. The EKOS EndoWave System (EKOS Corporation, Bothell, WA, USA) was combined with urokinase (100000 IU/hour). Thirty-day and 6-month follow-up consisted of clinical evaluation, and Duplex scan or magnetic resonance angiography of the treated extremity. RESULTS: Initial technical success was 97%, radiologic success was 82%, and overall clinical success was 77%. Median thrombolysis time was 21 hours (IQR, 15-24). In 38 of 51 procedures with successful lysis (75%) complete lysis was achieved within 24 hours. Major hemorrhage occurred in 2 procedures (3%), and distal embolization in 2 procedures (3%). During the initial hospitalization, the major amputation rate was 8% (N.=5) and the mortality rate was 2% (N.=1). The 30-day patency rate was 81%, without additional mortality. During a median 6-month (range, 2-14) follow-up, 9 reinterventions were performed. Two patients underwent major amputation and 3 patients died; because of malignancy (N.=2) and stroke (N.=1). CONCLUSION: Initial success rates of ultrasound-accelerated thrombolysis are high and complication rate is low. However, reintervention rate during short-term follow-up for recurrent ischemia is substantial. Results from a randomized controlled trial comparing ultrasound-accelerated thrombolysis with standard thrombolysis for lower extremity ischemia (DUET, Current Controlled Trials, ISRCTN72676102) are eagerly awaited.

[Radiofrequency ablation of colorectal metastases to the liver: results since the first application in the Netherlands]. / Radiofrequente ablatie van colorectale levermetastasen: resultaten vanaf de eerste toepassing in Nederland.

OBJECTIVE: To provide an overview of the morbidity, mortality and survival following the introduction of radiofrequency ablation (RFA) of colorectal liver metastases in the Netherlands. DESIGN: Prospective, descriptive study. METHOD: Between June 1999 and December 2003 in eight hospitals in the Netherlands, 87 patients treated by RFA for colorectal liver metastases were included in the study. The outcome measures were morbidity, 30-day mortality and the percentage local recurrence. RESULTS: In 104 RFA procedures, 199 metastases were ablated; 31 procedures were performed percutaneously and 73 by laparotomy. In 29 procedures, RFA was combined with partial liver resection. The overall postoperative morbidity rate was 19% and the RFA-related morbidity was 14%. 1 patient died following right hemihepatectomy and RFA in the remaining parenchyma (mortality: 1%). Median survival following RFA was 25 months, with a median progression-free survival of 13 months. The overall local recurrence rate was 46%. Since January 2004, this percentage has decreased to approximately 6. Diameter and central location of the metastases were independent risk factors for the development of a local recurrence. CONCLUSION: RFA is an alternative treatment for patients who are not eligible for partial liver resection. The high local recurrence rate in this series reflects the limited experience with this technique during its introduction in the Netherlands. In specialised centres the percentage local recurrence is now 5. Treatment by RFA should always be weighed against the option of partial liver resection and possible (neoadjuvant) chemotherapy. RFA should therefore preferably be carried out in a centre with expertise in the field of liver surgery.

Precoagulation minimizes blood loss during standardized hepatic resection in an experimental model.

BACKGROUND: Precoagulation of liver tissue before transection is a novel concept in hepatic surgery. Comparative data with conventional techniques are lacking. This study tested the hypothesis that precoagulation results in reduced blood loss during hepatic transection. METHODS: Precoagulation was performed with two different devices, the TissueLink floating ball (group 1) and a dissecting sealer (group 2), and compared with ultrasonic dissection (group 3). For each technique 12 partial liver resections were performed in six pigs. Blood loss per dissection surface area was the main outcome parameter. RESULTS: The transected surface area was similar in all groups. Animals in groups 1 and 2 had significantly less blood loss than those in group 3 (3.6 and 1.3 versus 11.9 ml/cm2 respectively; P = 0.009 and P = 0.002). One pig in group 1 died as a result of wound dehiscence. In one animal in group 2 a gastric perforation was observed after death. In group 3 bile leakage occurred in two animals, and a large haematoma was observed on the transection surface in one animal after death. CONCLUSION: Precoagulation of liver tissue before transection is associated with less blood loss compared with ultrasonic dissection.

Transcatheter embolization of extremity vascular malformations: the long-term success of multiple interventions.

Vascular malformations of the extremities present a difficult therapeutic challenge. Ligation of feeding vessels may lead to tissue necrosis and limb loss and can make subsequent attempts at transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic vascular malformations in the upper and lower extremities in 50 patients. A retrospective review was conducted of a computerized database of all patients undergoing transcatheter therapy of peripheral vascular malformations at our institution. The mean age of the patients was 22 years (range 1-51 years), and 34% were male. The most common presenting symptoms included pain (80%), swelling (68%), ulceration or distal ischemia (18%), and hemorrhage (6%). Previous unsuccessful surgical treatment or embolization had been performed in 24% and 18% of patients, respectively. Predominantly venous lesions were treated by sclerotherapy with injection of ethanol. Arteriovenous and arterial lesions were treated by embolization via the arterial branch feeding vessels with cyanoacrylate. The most common vessels involved and treated were branches of the profunda femoris and tibial arteries (83% of lower extremity lesions), and branches of the brachial and radial arteries (82% of upper extremity lesions). Patients required a mean of 1.6 embolization procedures (range 1-5) over a mean period of 57 months. Sixteen patients (32%) underwent more than one embolization procedure. Of these, one was a planned staged procedure and 15 were performed secondary to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization in three cases (6%). Ninety-two percent of patients remained asymptomatic or improved at a mean follow-up of 56 months. There was one case of limb loss (2%). Diffuse extremity vascular malformations are difficult to eradicate completely and recurrences are common. Although patients may require multiple embolization procedures and occasional adjunctive surgical resection, directed transcatheter embolization should be the treatment of choice for symptomatic extremity vascular malformations.

[Partial liver resections: mortality, morbidity and risk factors for postoperative complications in 133 patients/137 operations; Utrecht University Medical Center 1991/2000]. / Partiële leverresecties: sterfte, morbiditeit en risicofactoren voor postoperatieve complicaties bij 133 patiënten/137 operaties; Universitair Medisch Centrum Utrecht, 1991/'00.

OBJECTIVE: Evaluation of the results of partial liver resections for both benign and malignant abnormalities and the identification of risk factors for the development of complications. DESIGN: Descriptive, retrospective. METHOD: All consecutive partial liver resections performed between January 1991 and October 2000 at the University Medical Centre Utrecht, the Netherlands, were reviewed for preoperative, peroperative and postoperative parameters. Risk factors were determined by means of a univariate analysis and a multiple logistic regression analysis. The 5-year survival rates were calculated using the Kaplan-Meier method. RESULTS: A total of 133 patients (71 men and 62 women; median age: 58 years (range: 17-79)) underwent 137 hepatic resections for benign (n = 29) and malignant (n = 108) liver abnormalities. In total, 74 procedures (54%) were considered to be major hepatic resections and blood transfusion was required in 97 patients (71%). A total of 43 complications was observed in 32 patients (32/137; 23%). Eight patients died as a result of postoperative complications (8/137; 5.8%). Independent risk factors associated with the development of major complications were a major resection (OR: 3.6) and more than 2 peroperative units of packed cells (OR: 5.0). The principal indication for liver resection were colorectal metastases (n = 69). The 5-year survival rate after liver resection for colorectal metastases was 38% (95% CI: range 21-54) with a 5-year disease-free survival rate of 25% (range 10-41). The postoperative mortality in this group was 2.9%. CONCLUSION: After partial liver resection for benign and malignant lesions the mortality was 5.8% and the morbidity 23%. The risk of postoperative morbidity was related to the number of peroperative units of packed cells and the extent of the resection.

Congenital vascular malformations in the hand and forearm.

PURPOSE: To review a single-center experience in the management of symptomatic congenital vascular malformations of the hand and forearm with special attention to embolotherapy. METHODS: A retrospective chart review was performed to identify patients with vascular malformations referred for arteriography and possible intervention between 1983 and 1998. Arteriography and venography were performed in all patients to differentiate between true high-flow arteriovenous malformations (AVM) and low-flow primary venous malformations (PVM). The clinical and radiological data, procedural results, and follow-up data were retrieved and reviewed. RESULTS: In a 15-year period, 39 patients (22 men; mean age 22.5 years, range 1-51) had symptomatic vascular lesions diagnosed in the forearm and hand: 21 AVMs, 17 PVMs, and one complex lesion with both AVM and PVM. Thirty-four (87%) lesions were treated with immediate technical success achieved in 31 (91%) cases; 5 (13%) lesions were not amenable to percutaneous treatment. There were no major complications, but 3 embolized AVMs had significant residual flow (81.6% technical success on intention to treat basis). Long-term follow-up ranging to 5 years was available in 26 of the 34 treated patients; the mean symptom-free period was 30 months for the AVM patients and 30.5 months for the PVM group, with an average of 1.5 and 1.2 embolization procedures, respectively. CONCLUSIONS: Vascular malformations of the hand and forearm are extremely rare lesions that demand a multidisciplinary approach for optimal diagnosis and management. Microembolotherapy with or without surgery has offered the highest level of safety and success to date.

Transcatheter embolization of complex pelvic vascular malformations: results and long-term follow-up.

OBJECTIVES: Vascular malformations of the pelvis are rare and present a difficult therapeutic challenge. Surgical treatment is notoriously difficult and carries a high likelihood of recurrence. Surgical proximal ligation of a feeding vessel may in fact be contraindicated, because it can make subsequent transcatheter therapy impossible. The purpose of this study was to review our results with transcatheter embolization therapy in symptomatic complex pelvic vascular malformations in 35 patients. METHODS: A retrospective review was conducted of a prospectively compiled database of all patients undergoing transcatheter therapy of a pelvic vascular malformation at our institution. RESULTS: The mean age of the patients was 34 years (range, 16 months-66 years), and 51% were male. The most common presenting symptoms included pain (59%), a visible or palpable lesion (62%), associated palpable pulsation or thrill (44%), hemorrhage (27%), congestive heart failure (18%), and symptoms due to mass effect (35%). A significant number of patients had undergone previous, unsuccessful attempted surgical treatment of the lesion (32%). The most common type of lesion noted on arteriography was arteriovenous shunting (89%). Patients required a mean of 2.4 embolization procedures (range, 1-11 procedures) over a mean period of 23.3 months (range, 1-144 months). The most common agents used were rapidly polymerizing acrylic adhesives. The most common vessels involved and treated were branches of the hypogastric artery (82%). More than one procedure were performed in 20 patients (53%). Seven were planned as staged embolizations, whereas 13 were due to residual or recurrent symptoms. Adjunctive surgical procedures were performed subsequent to embolization therapy in five patients (15%). Eighty-three percent of patients were asymptomatic or significantly improved at a mean follow-up of 84 months (range, 1-204 months). CONCLUSIONS: Pelvic vascular malformations are difficult to eradicate completely, and recurrences are common. Many patients require multiple therapeutic interventions. However, most of these difficult cases have good results in the long term. Transcatheter embolization plays a significant role in, and may be the treatment of choice for, symptomatic pelvic vascular malformations.