The Effect of a Suspended Radiation Protection System on Occupational Radiation Doses During Infrarenal EVAR Procedures: A Randomised Controlled Study.

OBJECTIVE: To compare the protective effect of Zero Gravity (ZG) with conventional radiation protection during endovascular aneurysm repair (EVAR). Secondly, user experience was surveyed with a questionnaire on ergonomics. METHODS: This was a single centre, prospective, randomised, two arm trial where 71 consecutive elective infrarenal EVAR procedures were randomised into two groups: (1) operator using ZG and assistant using conventional protection (n = 36), and (2) operator and assistant using conventional radiation protection (n = 35). A movable floor unit ZG system consists of a lead shield (1.0 mm Pb equivalent) for the front of the body and 0.5 mm Pb equivalent acrylic shielding for the head and neck. The ZG also includes arm flaps of 0.5 mm Pb equivalent covering the arm up to the elbow. Deep dose equivalent values, Hp(10) were measured with direct ion storage dosimeters (DIS) placed on various anatomical regions of the operator (axilla, chest, abdomen, and lower leg). Personal dose equivalent values, Hp(3) to eye lenses were measured in the operating and assisting surgeon using thermoluminescence dosimeters. The study was registered at the US National Institute of Health #NCT04078165. RESULTS: Protection with the standard protection was superior in chest (0.0 vs. 0.1 µSv), abdomen (0.0 vs. 0.6 µSv), and lower leg (0.4 vs. 2.2 µSv) (p < .001). On the other hand, the ZG system yielded better shielding for the axilla (1.5 vs. 0.0 µSv) and eyes (6.3 vs. 1.1 µSv) of the operator. The use of ZG hampered the deployment of ancillary shields, which is particularly relevant for protection of the assisting surgeon. Users found ZG more cumbersome than conventional garments, it also impaired communication and reduced field of view. CONCLUSION: Both ZG and conventional radiation protection reduced radiation exposure. Conventional protection allows better manoeuvrability at the price of wider exposure of the upper arm and axilla. ZG indirectly impaired protection of the assistant.

Ultrasound Surveillance is Feasible After Endovascular Aneurysm Repair.

BACKGROUND: Surveillance after endovascular aneurysm repair (EVAR) is traditionally done with computed tomography angiography (CTA) scans that exposes patient to radiation, nephrotoxic contrast media, and potentially increased risk for cancer. Ultrasound (US) is less labor intensive and expensive and might thus provide a good alternative for CTA surveillance. The aim of this study was to evaluate in real-life patient cohorts whether US is able to detect post-EVAR aneurysm-related complications similarly to CTA. METHODS: This retrospective study compared the outcome of consecutive patients who underwent EVAR for intact abdominal aortic aneurysm and were surveilled solely by CTA (CTA-only cohort, n = 168) in 2000-2010 or by combined CTA and US (CTA/US cohort, n = 300) in 2011-2016, as a standard surveillance protocol in the department of vascular surgery, Helsinki University Hospital. The CTA-only patients were imaged at 1, 3, and 12 months and annually thereafter. The CTA/US patients were imaged with CTA at 3 and 12 months, US at 6 months and annually thereafter. If there were suspicion of >5 mm aneurysm growth, CTA scan was performed. The patients were reviewed for imaging data, reinterventions, aneurysm ruptures, and death until December 2018. The 2 groups were compared for secondary rupture, aneurysm-related and cancer-related death, reintervention related to abdominal aortic aneurysm, and maximum aneurysm diameter increase ≥5 mm. The mean follow-up in the CTA-only cohort was 67 months and in CTA/US cohort 43 months. RESULTS: The 2 cohorts were alike for basic characteristics and for the mean aneurysm diameter. The total number of CT scans for detecting aneurysm was 84.1/100 patient years in the CTA-only cohort compared to 74.5/100 patient years for US/CTA cohort. Forty percent of patients under combined CTA/US surveillance received 1 or more additional CTA scans. The 2 cohorts did not differ for 1-year, 5-year and 8-year freedom from aneurysm related death, secondary sac rupture, nor the incidence of rupture preventing interventions. CONCLUSIONS: Based on the follow-up data of this real-life cohort of 468 patients, combined surveillance with US and additional CTA either per protocol or due to suspicion of aneurysm-related complications had comparable outcome with sole CTA-surveillance. Thus, US can be considered a reasonable alternative for the CTA. However, our study showed also that the need of additional CTAs due to suspicion of endoleak or aneurysm nonrelated reasons is substantial.

Treatment of Abdominal Aortic Aneurysm Ruptures in a Well-defined Geographical Area during 2012-2020-A Paradigm Shift.

BACKGROUND: The treatment of abdominal aortic aneurysm ruptures (rAAA) has changed from open to endovascular repair (rEVAR) during the last decade. The immediate survival benefit after endovascular treatment method is well-known, yet without conclusive support from randomized controlled studies. The aim of this study is to report the survival benefit of rEVAR during the transition between 2 treatment methods and to highlight the in-hospital protocol for rAAA patients, with continuous simulation training and a designated team. METHODS: This study is a retrospective review of rAAA patients diagnosed at Helsinki University Hospital during 2012-2020, including a total of 263 patients. Patients were divided by treatment method, and the primary end point was 30-day mortality. The secondary end points were 90-days mortality, one year mortality, and the length of stay in intensive care. RESULTS: Patients were divided into the rEVAR group (n = 119) and open repair group (rOR n = 119). The turndown rate was 9.5% (n = 25). The 30-day short-term survival favored endovascular treatment (rEVAR 83.2% vs. rOR 68.9%, P = 0.015). The 90-day postdischarge survival was higher in the rEVAR group (rEVAR 80.7% vs. rOR 67.2%, P = 0.026). One-year survival was also higher in the rEVAR group, however with less statistical significance (rEVAR 74.8% vs. rOR 64.7%, P = 0.120). The effect of the revised rAAA protocol was seen in improved survival, when comparing the first 3 years of the cohort (2012-2014) to the last 3 years of the cohort (2018-2020). Survival rates were higher at 30 days, 90 days, and one year in the late cohort (74% vs. 84%, 72% vs. 81%, and 70% vs. 77%). CONCLUSIONS: The rEVAR has its place as a first-line treatment option for most patients and reduces short-term and midterm mortality at least to 1-year follow-up compared to rOR. Dedicated vascular surgeons for rEVAR and continuous simulation training for the operating room staff are key elements of a low turndown and successful rAAA treatment. The use of an occlusive aortic balloon reduces overall mortality in both operative methods.

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease.

BACKGROUND: Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symptoms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. METHODS: A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were performed in Helsinki University Hospital between January 2013 and December 2018. First, information about patients' baseline characteristics, indications and details of surgery and technical/hemodynamic success, and complications and mortality were obtained from the vascular registry and patients records. Secondarily, a prospective assessment of mid-term patency was performed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed. RESULTS: One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n = 144 occlusions recanalized). Primary technical success was somewhat lower in lesions ≥ 90 mm (87.1%) compared to lesions shorter than 90 mm (95.7%; χ2P = 0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant residual stenosis remained in 1.2% of cases. Median operative time was 4 hr 34 min (interquartile range 2 hr 43 min) and median estimated blood loss was 743 mL (interquartile range 500 mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any major cardiovascular event or stroke perioperatively. Primary patency at 30 day, 6 months, 1 year, and 2 years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoccluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. CONCLUSIONS: Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this population often suffers from universal atherosclerosis. The involvement of the aorta represents a significant determinant of worse long-term patency, although it did not preclude technical success.

Routine Inferior Mesenteric Artery Embolisation is Unnecessary Before Endovascular Aneurysm Repair.

OBJECTIVE: A type II endoleak is the most common complication during surveillance after endovascular aneurysm repair (EVAR), and a patent inferior mesenteric artery (IMA) is a known risk factor for an endoleak. The effect of routine IMA embolisation prior to EVAR on overall outcome is unknown. The aim of the study was to compare two strategies: routine attempted IMA embolisation prior to EVAR (strategy in centre A) and leaving the IMA untouched (strategy in centre B). METHODS: Patients were treated with EVAR in two centres during the period 2005 - 2015, and the data were reviewed retrospectively. The primary endpoints were re-intervention rate due to type II endoleaks and the late IMA embolisation rate. Secondary endpoints included EVAR related re-intervention, sac enlargement, aneurysm rupture, and open conversion rates. RESULTS: Strategy A was used to treat 395 patients. The IMA was patent in 268 (67.8%) patients, and embolisation was performed in 164 (41.5%). The corresponding figures for strategy B were 337 patients with 279 (82.8%) patent IMAs, two (0.6%) of which were embolised. The mean duration of follow up was 70 months for strategy A and 68.2 months for strategy B. The re-intervention rates due to a type II endoleak were 12.9% and 10.4%, respectively (p = .29), with no significant difference in the rate of re-interventions to occlude a patent IMA (2.0% and 4.7%, respectively; p = .039). The EVAR related re-intervention rate was similar, regardless of strategy (24.1% and 24.6%, respectively; p = .93). Significant sac enlargement was seen in 20.3% of cases treated with strategy A and in 19.6% treated with strategy B (p = .82). The rupture and conversion rates were 2.5% and 2.1% (p = .69) and 1.0% and 1.5% (p = .40), respectively. CONCLUSION: The strategy of routinely embolising the IMA does not seem to yield any significant clinical benefit and should therefore be abandoned.

A Population-Based Study of Abdominal Aortic Aneurysm Treatment in Finland 2000 to 2014.

BACKGROUND: In the event of rupture of an abdominal aortic aneurysm (AAA), mortality is very high. AAA prevalence and incidence of ruptures have been reported to be decreasing. The treatment of AAA has also undergone a change in recent decades with a shift toward endovascular aneurysm repair (EVAR). Our aim was to evaluate how these changes have affected the elective and emergency treatment of AAA and their results in Finland. METHODS: All patients treated for AAA in Finland, a country with a population of 5.5 million, during 2000 to 2014 were searched from the registry of the Finnish Institute for Health and Welfare. Data on all patients who had died of AAA during the same time period were obtained from Statistics Finland. The data were combined and analyzed. RESULTS: The annual incidence of ruptured AAA was 16.4 per 100 000 population over 50 years and decreased significantly during the study period. Over half of the 4949 patients who had a ruptured AAA died outside the hospital. Thirty-day mortality after emergency repair was 39.4%. Intact AAA repairs numbered 4956. The absolute number of annual repairs increased during the study period, and the use of EVAR became the dominant method of elective repair. Thirty-day mortality in elective AAA repair dropped significantly from 6.3% in 2000 to 2004 to 2.7% in 2010 to 2014 mostly because of the increased number of EVAR procedures with lower mortality. Long-term mortality in patients treated with EVAR was higher than in patients treated with open repair. Mortality after elective AAA repair was primarily attributable to cardiovascular causes, but there was a slightly higher proportion of AAA-related late deaths in patients treated with EVAR. CONCLUSIONS: Ruptured AAA incidence for men >65 years has declined by nearly 30% in Finland, likely because of the decrease in AAA prevalence. The treatment results have improved as well for both elective and emergency repair. Increased use of EVAR has resulted in a decrease of mortality after elective AAA repair, but results of open repair have improved as well. However, late mortality from elective EVAR is surprisingly high in comparison with open repair, which may have been exaggerated by patient selection.

Magnetic Resonance Imaging of Internal Jugular Veins in Multiple Sclerosis: Interobserver Agreement and Comparison with Doppler Ultrasound Examination.

BACKGROUND: Doppler ultrasound (US) has been widely used to evaluate the cervical venous system of multiple sclerosis patients according to the hypothesis of chronic cerebrospinal venous insufficiency with contradictory results. Venous anatomy and pathology can be examined with less operator-dependent magnetic resonance imaging (MRI). Our aim is to assess the interobserver agreement in measuring internal jugular vein (IJV) cross-sectional area (CSA) in MR images and to explore the agreement between US and MRI in the detection of calibers of ≤0.3 cm2 in the IJV CSA in the prospective study. METHODS: Thirty-seven multiple sclerosis patients underwent MRI of the cervical venous system. Two independent neuroradiologists measured the CSA of IJV at the mid-thyroid level. Furthermore, the time from contrast enhancement of common carotid arteries to that of each IJV (transit time in seconds) was assessed, and recorded whether IJV or the vertebral plexus visualized first during the contrast passage. US examination had been performed earlier. RESULTS: Interobserver agreement for assessing IJV CSA in MR images was substantial: the measurements differed >0.5 cm2 between the examiners in only 5 IJVs (7%), Cohen's kappa 0.79. Transit times from common carotid artery to IJV varied between 5.1 and 14.1 sec. Fifteen patients had left-to-right asymmetry in the speed of IJV contrast filling. IJV CSA ≤ 0.3 cm2 was found in 51 IJVs on the basis of US. Ten of these IJVs (19.6%) showed IJV CSA ≤ 0.3 cm2 also in MRI. All IJVs defined as CSA ≤ 0.3 cm2 in MRI met this caliber criterion also in US. CONCLUSIONS: Interobserver agreement at the thyroid level of the IJV was good at MRI measurements. The US defines more IJVs as narrow (CSA ≤ 0.3 cm2) than MRI. The US measurements for IJV CSA are not comparable with these methods. The US seems too sensitive in terms of finding venous stenosis.

Quality assessment of elective abdominal aortic aneurysm repair from referral to surgery.

BACKGROUND: The risk of rupture for a large (≥ 55 mm) abdominal aortic aneurysm(AAA) is significant and therefore operative treatment should take place before possible aneurysm rupture. Timing of elective AAA surgery has rarely been investigated previously. The aim of this study is to evaluate success in the elective treatment process of large AAAs from referral to surgery in Helsinki University Central Hospital. PATIENTS AND METHODS: We retrospectively analyzed all 361 patients who were assigned for elective treatment of AAA during 2005 - 2010. We divided the patients into subgroups according to size of the aneurysm: <60 mm, 61 - 70 mm and >70 mm. The main focus was set on the preoperative period and on potential factors causing delay. End points indicating failure in the treatment process were aneurysm ruptures and deaths before surgery. RESULTS: The median time from referral to surgery for the three subgroups was 112, 91 and 45 days respectively (p < 0,001). There were no significant differences between the treatment methods: open repair (OR) with 103 days and endovascular aortic repair (EVAR) with 113 days until surgery. Twenty three (6.4 %) patients were operated on emergency basis while waiting for the operation, six of them for ruptured aneurysm. There were an additional five patients with aneurysm ruptures who all died, as did four out the six operated ones. CONCLUSIONS: The whole treatment process starting from the referral should be considered in order for elective AAA treatment to succeed. Recommendations should be established for the preoperative period to guarantee rapid preoperative evaluation.

[Should we start AAA screening in Finland?]. / Onko vatsa-aortan aneurysman seulontaan aihetta suomessa?

Abdominal aortic aneurysms (AAA) are usually asymptomatic before rupture. Through ultrasound screening AAA can be found before rupture. In Europe England and Sweden have started one-time ultrasound screening for men at age 65. Many studies around Europe have shown that screening is cost-effective. In a recent Finnish study one-time screening for men at age 65 would be a more effective option than the current practice where no screening is offered. Screening for abdominal aortic aneurysm among 65-year-old women would entail less additional costs but fewer life years gained than screening for men. Starting the screening would require additional resources in the Finnish health care system as compared to the current policy.

Outcome after open repair of ruptured abdominal aortic aneurysm in patients>80 years old: a systematic review and meta-analysis.

BACKGROUND: The role of open repair in the management of ruptured abdominal aortic aneurysm (RAAA) in patients>80 years old is questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies. METHODS: Studies on open repair of RAAA in patients>80 years old were identified in July 2010. The immediate and intermediate results were expressed as pooled proportions with 95% confidence interval (95% CI). Linear regression and meta-regression were performed to evaluate the impact of variables on the immediate postoperative mortality. RESULTS: Pooled analysis of 29 studies showed that the risk of immediate postoperative mortality in patients>80 years old was significantly higher than in younger patients (risk ratio 1.440, 95%CI 1.365-1.519, I2 36.8%, P=0.002; risk difference 19.4%, 95% CI 16.4-22.4%, I2 38.8%, P=0.019). Pooled analysis of 36 studies showed an immediate postoperative mortality rate of 59.2% (95% CI 55.7-62.5, I2 35.62). Immediate postoperative mortality in patients<80 years old positively correlated with that of patients>80 years old (rho: 0.686, P<0.0001). Intermediate survival data of 111 operative survivors were available from six studies, and their pooled survival rates at 1-, 2-, and 3-year were 82.4, 75.6, and 68.7%, respectively. CONCLUSIONS: Immediate and intermediate survival rates of patients>80 years old after open repair of RAAA are acceptable. These findings suggest a more confident approach toward emergency repair of RAAA in the very elderly.

Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service.

Our aim was to determine whether organizational changes could improve the outcome after ruptured abdominal aortic aneurysm (RAAA). Regional centralization and quality improvement in the in-hospital chain of treatment of RAAA included strengthening of the emergency preparedness and better availability of postoperative intensive care. During the reorganization, all patients with RAAA were admitted to Helsinki University Central Hospital (HUCH) from Helsinki and Uusimaa district. RAAA patients in the hospital district of Helsinki and Uusimaa between 1996 and 2004 were identified. The study period was divided into three periods: I, control; II, change; and III, present. Of the total of 626 patients with RAAA, 352 (56%) were admitted to the HUCH, of whom 315 (90%) underwent surgery. During the study period, population-based mortality decreased from 77% to 56% (P < 0.001) and 90-day mortality, from 54% to 28% (P = 0.002). Operative 30-day mortality was 19% during the third period and lower than previously (P = 0.001). Our results seem to argue in favor of centralization of emergency vascular services with adequate manpower and operative expertise in the first line and with availability of closed-unit postoperative critical care to achieve better results as these measures were associated with a positive impact on survival.

Utility of surgery for ruptured abdominal aortic aneurysm.

Our aim was to assess the utility of surgery for ruptured abdominal aortic aneurysm (RAAA) using the number of quality-adjusted life years (QALYs) in a retrospective study with cross-sectional quality-of-life (QoL) evaluation. During a 7-year period up to 2002, 242 of 269 (90%) patients with RAAA underwent surgery. Survivors were sent the EQ-5D self-administered questionnaire to assess their long-term outcome. EQ-5D single index values were calculated for each survivor and combined with age- and sex-adjusted Finnish life tables to obtain QALY estimates. Total hospital mortality (90-day) and operative mortality (30-day) were 140 of 269 (52.0%) and 106 of 242 (43.8%), respectively. Of the 129 surviving patients, 111 were available for QoL evaluation. The response rate was 85%. The mean (range) number of QALYs after RAAA was 4.1 (0-30.9) for all and 8.5 (0.2-30.9) for hospital survivors. Young age and low Glasgow Aneurysm Score were associated with a high number of QALYs irrespective of the statistical method used for analysis. Successful repair of RAAA was able to lend considerable benefit as measured by QALYs.