Adverse events after treatment of patients with acute limb ischemia.

BACKGROUND: To assess the outcome and the occurrence and consequences of adverse events (AEs) after treatment of acute limb ischemia (ALI). METHODS: Retrospective analysis on intra-arterial thrombolysis (group I) and thromboembolectomy (group II). Outcome measures were primary patency and limb salvage rates. AEs and consequences were registered during admission and 30 days after discharge. RESULTS: A total of 238 procedures were included (group I, 173 vs. group II, 65). The primary patency (P = 0.144) and limb salvage rates (P = 0.166) were not significantly different between both groups. A total of 195 AEs were registered. Most AEs were procedure related and resulted in surgical reintervention (77% vs. 76%). Some AEs resulted in irreversible physical damage (15% vs. 25%) and death (6% vs. 12%). CONCLUSIONS: Both, intra-arterial thrombolysis and thromboembolectomies are adequate therapies; however, they result in a wide variety of AEs resulting in serious morbidity and even death.

First experience of a novel femorocrural expanded polytetrafluoroethylene bypass graft.

BACKGROUND: This study aims to evaluate early results of a precuffed expanded polytetrafluoroethylene (ePTFE) Distaflo® Mini-Cuff Bypass Graft versus autologous saphenous vein (ASV) grafting in patients with peripheral arterial obstructive disease (PAOD). METHODS: This retrospective single-center study analyzed 42 patients who received a femorocrural bypass graft because of PAOD using an ASV graft (n = 28) or Distaflo Mini-Cuff graft (n = 14). RESULTS: Primary patency rates in the ASV and Distaflo Mini-Cuff groups were 81% and 69%, respectively, after 6 months. Secondary patency rates were 81% and 35%, respectively, after 12 months. The limb salvage rate was 81% in the ASV group vs 65% and 35%, respectively, in the Distaflo Mini-Cuff group after 6 months and 1 year. CONCLUSIONS: The ePTFE Distaflo Mini-Cuff is an option for revascularization in the absence of a suitable ASV. However, the performance of this novel graft is not better than that of current ePTFE bypass grafts.

Patient and procedure-related risk factors for adverse events after infrainguinal bypass.

BACKGROUND: Current medical practice urges individual health care facilities and medical professionals to obtain and provide detailed insight in quality of care with the possibility of comparing data between institutions. Adverse event (AE) analysis serves as a mainstay in quality assessment in vascular surgery, but the comparison of AE data between facilities can be complex. The aim of the present study was to assess independent risk factors for AE occurrence: patient, disease and operation characteristics besides general differences between health care facilities. METHODS: All AEs after infrainguinal bypass graft procedures (BGPs) in three health care facilities in the Netherlands were evaluated. AEs were defined identically in the facilities. RESULTS: Of 601 BGPs performed, 662 AEs were registered. Independent predictors of AEs were female gender (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.39-3.26; P < .01), age >or=60 years (OR, 0.57; 95% CI, 0.34-0.95; P = .03), American Society of Anesthesiologists classification 3-4 (OR, 1.79; 95% CI, 1.01-3.17; P = .05), comorbidities of pulmonary disease (OR, 2.99; 95% CI, 1.67-5.34; P < .01) and diabetes mellitus (OR, 2.49; 95% CI, 1.58-3.94; P < .01), distal anastomosis level at below knee femoropopliteal BGP (OR, 2.01; 95% CI, 1.26-3.22; P < .01), femorotibial BGP (OR, 2.40; 95% CI, 1.37-4.19; P < .01), and popliteopedal BGP (OR, 92.39; 95% CI, 11.13-766.98; P < .01). One health care facility had significantly fewer AEs than the other two (OR, 0.21; 95% CI, 0.13-0.35; P < .01). CONCLUSION: Age, gender, comorbidity, and type of surgery are all independent predictors of AE occurrence in vascular surgery. After adjustment for differences in these factors, one health care facility still had lower AE occurrence, which needs to be examined further.

Standard outpatient re-evaluation for patients not admitted to the hospital after emergency department evaluation for acute abdominal pain.

BACKGROUND: The aim of the present study was to investigate the efficacy and safety of standard outpatient re-evaluation for patients who are not admitted to the hospital after emergency department surgical consultation for acute abdominal pain. METHODS: All patients seen at the emergency department between June 2005 and July 2006 for acute abdominal pain were included in a prospective study using a structured diagnosis and management flowchart. Patients not admitted to the hospital were given appointments for re-evaluation at the outpatient clinic within 24 h. All clinical parameters, radiological results, diagnostic considerations, and management proposals were scored prospectively. RESULTS: Five-hundred patients were included in this analysis. For 148 patients (30%), the final diagnosis was different from the diagnosis after initial evaluation. Eighty-five patients (17%) had a change in management after re-evaluation, and 20 of them (4%) were admitted to the hospital for an operation. Only 6 patients (1.2%) had a delay in diagnosis and treatment, which did not cause extra morbidity. CONCLUSIONS: Standard outpatient re-evaluation is a safe and effective means of improving diagnostic accuracy and helps to adapt management for patients that are not admitted to the hospital after surgical consultation for acute abdominal pain at the emergency department.

A prospective study of incidence of saphenous nerve injury after total great saphenous vein stripping.

BACKGROUND AND OBJECTIVES: Total stripping of the great saphenous vein (GSV) is a validated surgical strategy of treating patients with primary varicose veins (PVV). An often cited, but not well documented and studied, complication of total stripping is postoperative damage of the saphenous nerve (SN). OBJECTIVE: The objective was to evaluate the incidence of SN damage and to assess the therapeutic efficacy after total stripping of the GSV. MATERIALS AND METHODS: Patients undergoing total stripping of the GSV because of PVV in the entire lower limb were enrolled. Pre- and postoperative neurologic examination was performed to identify potential sensory neurologic deficits. RESULTS: Total stripping of the GSV in 69 limbs occurred because of pain (9%) or a tired feeling in the limbs (77%) or for cosmetic reasons (14%). The overall incidence of postoperative sensory neurologic deficits was 7 and 6%, respectively, after 6-week follow-up and both 3% after 3-month follow-up. In 99% of the patients, total stripping of the GSV resulted in reduction of the primary signs and symptoms. CONCLUSION: The incidence of SN damage after total stripping of the GSV is low. Thus, total stripping of the GSV resulted in improvement of the primary complaint in almost all patients. Total stripping of the GSV is an effective surgical strategy in treating PVV.

Outcome of elective treatment of abdominal aortic aneurysm in elderly patients.

INTRODUCTION: Optimal management of an abdominal aortic aneurysm (AAA) in the elderly is not straightforward. We evaluated treatment results of elderly patients with asymptomatic abdominal aortic aneurysm that met the treatment criteria in our clinic. METHODS: Hospital charts between January 2005-December 2012 were reviewed of all patients 70 years and older diagnosed with AAA with a diameter that met the treatment criteria. Patients were stratified by age (group I: 70-79 years, group II: 80 years or older) and treatment. Outcome was measured in terms of survival and complications. RESULTS: In total 283 patients (240 (85%) men, median age 77.4 years) were included, 211 (75%) in group I and 72 (25%) in group II. There was an overall significantly higher mortality rate in the octogenarians (p < 0.01). This difference was not seen in the groups treated conservatively and with OPEN repair. However, in the EVAR group there was a significantly higher mortality rate in octogenarians (p < 0.01). CONCLUSION: Long-term outcome after EVAR procedures results in higher mortality rates for the population older than 80 years as compared to the group aged 70-79 years.

Long-term outcome of ruptured abdominal aortic aneurysm: impact of treatment and age.

BACKGROUND: Despite advances in operative repair, ruptured abdominal aortic aneurysm (rAAA) remains associated with high mortality and morbidity rates, especially in elderly patients. The purpose of this study was to evaluate the outcomes of emergency endovascular aneurysm repair (eEVAR), conventional open repair (OPEN), and conservative treatment in elderly patients with rAAA. METHODS: We conducted a retrospective study of all rAAA patients treated with OPEN or eEVAR between January 2005 and December 2011 in the vascular surgery department at Amphia Hospital, the Netherlands. The outcome in patients treated for rAAA by eEVAR or OPEN repair was investigated. Special attention was paid to patients who were admitted and did not receive operative intervention due to serious comorbidity, extremely advanced age, or poor physical condition. We calculated the 30-day rAAA-related mortality for all rAAA patients admitted to our hospital. RESULTS: Twelve patients did not receive operative emergency repair due to extreme fragility (mean age 87 years, median time to mortality 27 hours). Twenty-three patients had eEVAR and 82 had OPEN surgery. The 30-day mortality rate in operated patients was 30% (7/23) in the eEVAR group versus 26% (21/82) in the OPEN group (P=0.64). No difference in mortality was noted between eEVAR and OPEN over 5 years of follow-up. There were more cardiac adverse events in the OPEN group (n=25, 31%) than in the eEVAR group (n=2, 9%; P=0.035). Reintervention after discharge was more frequent in patients who received eEVAR (35%) than in patients who had OPEN (6%, P<0.001). Advancing age was associated with increasing mortality (hazard ratio 1.05 [95% confidence interval 1.01-1.09]) per year for patients who received operative repair, with a 67%, 76%, and 100% 5-year mortality rate in the 34 patients aged <70 years, 59 patients aged 70-79 years, and 12 octogenarians, respectively; 30-day rAAA-related mortality was also associated with increasing age (21%, 30%, and 61%, respectively; P=0.008). CONCLUSION: The 30-day and 5-year mortality in patients who survived rAAA was equal between the treatment options of eEVAR and OPEN. Particularly fragile and very elderly patients did not receive operative repair. The decision to intervene in rAAA should not be made on the basis of patient age alone, but also in relation to comorbidity and patient preference.