Effect of conservative treatment in aortoiliac occlusive disease.

Objective: To determine the effect of primary conservative treatment without revascularization in patients with proven aortoiliac occlusive disease (AIOD) presenting with intermittent claudication (IC).Background: The initial treatment of IC should focus on supervised exercise therapy (SET) and pharmacotherapy. Nowadays, primary endovascular revascularization (EVR) has become increasingly popular in patients with all types of AIOD. But in daily practice, EVR is often performed without initially extensive exercise.Method: This is a single centre retrospective study from December 2012 to September 2017. Primary outcomes were maximum walking distance (MWD) and patient satisfaction. Secondary outcomes were revascularization rate and mortality.Results: Twenty-four patients were included. Mean age was 64 years (SD: 9). Mean follow-up was 28 months (SD: 17). Nineteen patients (80%) had SET. In 18 (75%) patients, the MWD was improved compared to the initial situation. In five (21%) patients, the MWD stayed the same. The MWD of one (4%) patient decreased. Overall satisfaction rate was 87%. Three patients (13%) were not satisfied with the conservative treatment and eventually got an EVR. There was no disease related death.Conclusions: Conservative treatment, especially with SET, has acceptable subjective symptom outcomes in selected patients with AIOD. It could be a good alternative treatment for certain patients with AIOD and IC.

The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation.

BACKGROUND: Delirium in patients with critical limb ischemia (CLI) is associated with increased mortality. The main goal of this study was to investigate the association between delirium and mortality in patients undergoing major lower limb amputation for CLI. In addition, other risk factors associated with mortality were analyzed. METHODS: An observational cohort study was conducted including all patients aged ≥70 years with CLI undergoing a major lower limb amputation between January 2014 and July 2017. Delirium was scored using the Delirium Observation Screening Score in combination with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Risk factors for mortality were analyzed by calculating hazard ratios using a Cox proportional hazards model. RESULTS: In total, 95 patients were included; of which, 29 (31%) patients developed a delirium during admission. Delirium was not associated with an increased risk of mortality (hazard ratio [HR] = 0.84; 95 % confidence interval [CI]: 0.51-1.73; P = 0.84). Variables independently associated with an increased risk of mortality were age (HR 1.1; 95% CI 1.0-1.1), cardiac history (HR 3.3; 95% CI 1.8-6.1), current smoking (HR 2.9; 95% CI 1.6-5.5), preoperative anemia (HR 2.8; 95% CI 1.1-7.2), and living in a nursing home (HR 2.2; 95% CI 1.1-4.4). CONCLUSION: Delirium was not associated with an increased mortality risk in elderly patients with CLI undergoing a major lower limb amputation. Factors related to an increased mortality risk were age, cardiac history, current smoking, preoperative anemia, and living in a nursing home.

Real-time PCR Tests in Dutch Exotic Mosquito Surveys; Implementation of Aedes aegypti and Aedes albopictus Identification Tests, and the Development of Tests for the Identification of Aedes atropalpus and Aedes japonicus japonicus (Diptera: Culicidae).

Since 2009, The Netherlands Food and Consumer Product Safety Authority carries out surveys focusing on, amongst others, the presence of invasive mosquito species (IMS). Special attention is given to exotic container-breeding Aedes species Aedes aegypti (L.), Aedes albopictus (Skuse), Aedes atropalpus (Coquillett), and Aedes japonicus japonicus (Theobald). This study describes the implementation of real-time PCR tests described by Hill et al. (2008) for the identification of Ae. aegypti and Ae. albopictus, and the development of two novel real-time PCR tests for the identification of Ae. atropalpus and Ae. j. japonicus. Initial test showed that optimization of elements of the Ae. aegypti and Ae. albopictus tests was needed. Method validation tests were performed to determine if the implemented and newly developed tests are fit for routine diagnostics. Performance criteria of analytical sensitivity, analytical specificity, selectivity, repeatability, and reproducibility were determined. In addition, experiments were performed to determine the influence of environmental conditions on the usability of DNA extracted from mosquito specimens trapped in BG-Sentinel traps. The real-time PCR tests were demonstrated to be sensitive, specific, repeatable, reproducible, and are less prone to false negative results compared to partial cytochrome c oxidase I gene sequencing owing to the DNA fragmentation caused by environmental influences.

The use of iodine seed (I-125) as a marker for the localisation of lung nodules in minimal invasive pulmonary surgery.

AIM: Video assisted thoracic surgery (VATS) is an important tool in the field of thoracic pathology both for therapeutic and diagnostic purposes. The standard technique for localisation of non-visible or non-palpable lung lesions is the use of image guided insertion of a guide-wire. However, this method is associated with complications such as pneumothorax, bleeding and wire-dislocation. The aim of this study was to investigate the feasibility of using of iodine seeds (I-125) as a marker of lung lesions during VATS. METHODS: 28 consecutive patients with parenchymal lung lesions had I-125 seed localisation performed prior to VATS. After seed placement all patients underwent VATS with wedge resection. RESULTS: During surgery all lesions could be identified and radically resected. In six (21.4%) patients the seed was not placed optimally but none of these cases were associated with seed dislocation after placement. In four and in 5 patients the placement of the I-125 seed was complicated by a haematoma and pneumothorax respectively. However, in all of these patients a wait-and-see policy would have been justified. In one patient a conversion to a thoracotomy was necessary due to seed displacement. CONCLUSION: In patients with parenchymal lung lesions undergoing VATS and wedge resection I-125 seed localisation is a feasible technique. Complication rates are comparable to standard guide-wire localisation. Although I-125 seeds can be positioned under CT-guidance an optimal placement is of utmost importance for VATS wedge resection. Further research is needed to investigate the possible advantages of this technique.

Midterm results of autologous saphenous vein and ePTFE pre-cuffed bypass surgery in peripheral arterial occlusive disease.

INTRODUCTION: The graft of choice in lower limb bypass surgery is the autologous saphenous vein (ASV). However, a prosthetic graft is needed in the absence of an ASV. In such situations, we used an expanded polytetrafluoroethylene (ePTFE) pre-cuffed Dynaflo graft as supragenicular bypass or Distaflo graft as infragenicular or femorocrural bypass. In respect to the expanding possibilities of percutaneous transluminal angioplasty (PTA), the indication for bypass surgery moved toward patients with advanced stages of peripheral arterial occlusive disease. For this reason, this study analyzed the current performances of these ePTFE grafts and ASV grafts with special attention to limb salvage. METHODS: In a retrospective study all patients who underwent peripheral bypass surgery between 2004 and 2008 were included. Kaplan-Meier curves were used to express primary patency, secondary patency, and limb salvage rates at 1 and 3 years. Log-rank tests were performed to compare graft types. RESULTS: A total of 272 grafts (ePTFE/ASV: 110/162) were performed in lower limb bypass surgery. The mean follow-up was 20.3 months. The secondary 3-year patency rates were for (n=78) supragenicular grafts (ePTFE/ASV: 45%/94%)*, for (n=124) infragenicular grafts (24%/74%), and 70 for femorocrural grafts (26%/52%). Limb salvage after 3 years was 59% in the ePTFE group versus 78% in the ASV group (P < .05). CONCLUSION: In the current population of vascular patients where no PTA is possible and a peripheral bypass is necessary, the ASV remains the graft of first choice. However, the pre-cuffed ePTFE graft is a good alternative, especially in cases of critical limb ischemia, in respect to an acceptable limb salvage rate.

Incidence, nature and impact of error in surgery.

BACKGROUND: Adverse events occur in 3·8-17 per cent of hospital admissions. The purpose of this study was to analyse the incidence of medical errors and assess the feasibility of an error registry for quality improvement programmes. METHODS: Errors were recorded prospectively in a complication registry between 1 June 2005 and 31 December 2007. Events were coded according to the Trauma Registry of the American College of Surgeons; the nature of events was recorded and the severity graded using the 1992 Clavien system. Recorded events were discussed by the medical staff on a daily basis and, if by consensus judged to be errors, were saved to the registry database. RESULTS: Of 12,121 patients admitted to the surgical ward during the study interval, 2033 (16·8 per cent) had a complication and 735 (6·1 per cent) had an error documented in the registry. Of 873 recorded errors, 607 (69·5 per cent) were of little or no consequence (Clavien grade I) and 220 (25·2 per cent) required therapeutic intervention (Clavien grade IIa and IIb). Errors leading to permanent injury (Clavien grade III) occurred in 41 instances (4·7 per cent) and five patients (0·6 per cent) died (Clavien grade IV). CONCLUSION: This study shows that errors are common in surgery, and that near misses are more frequent than errors with serious consequences. It is hypothesized that registration of near misses might prevent errors with serious consequences and thus improve quality of care.

Functional status as a prognostic factor for primary revascularization for critical limb ischemia.

BACKGROUND: Lower extremity arterial revascularization (LEAR) is the gold-standard for critical lower limb ischemia (CLI). The goal of this study was twofold. First, we evaluated the long-term functional status of patients undergoing primary LEAR for CLI. Second, prognostic factors of long-term functional status and survival after primary LEAR for CLI were assessed. METHODS: All primary LEAR procedures were analyzed. Patients were stratified by preoperative functional status: ambulatory (group I) vs nonambulatory (group II). Patients were followed-up after 3 and 6 years. Adverse events (AEs) were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. Associated patient demographic/clinical data were analyzed using univariate and multivariate methods. RESULTS: There were 106 LEAR patients (group I: n = 42, 40% vs group II: n = 64, 60%). Group II patients were significantly older (75 vs 62 years; P = .00), were classified ASA 3-4 more frequently (78% vs 52%; P < .02), had more cardiac disease (n = 42, 66% vs n = 10, 24%; P = .00), renal disease (n = 26, 41% vs n = 7, 17%; P = .00), diabetes (n = 36, 56% vs n = 8, 19%; P = .00), hypertension (n = 47, 73% vs n = 13, 31%; P = .00) and severe CLI (n = 42, 66% vs n = 18, 38%; P < .01). Group II patients had a higher incidence of death (65.6% vs 14.3%; P = .00), minor AEs (n = 38, 26% vs n = 10, 22%; P = .00), surgical AEs (n = 48, 33% vs n = 12, 26%; P < .02) and systemic AEs (n = 24, 86% vs n = 4, 9%; P < .02). Also more unplanned reinterventions occurred in group II (n = 148, 76% vs n = 47, 24%; P = .00). Nonambulatory status was a multivariate independent predictor of nonambulatory status after LEAR during 6 years follow-up (odds ration [OR[: 21.47; 95% confidence interval [CI]: 2.76-166.77; P = .00). Pulmonary disease (OR: 7.49; 95% CI: 2.17-25.80; P = .00), not prescribing beta-blockers (OR: 4.67; 95% CI: 1.28-17.03; P < .02), nonambulatory status (OR: 22.99; 95% CI: 6.27-84.24; P = .00), and systemic AEs (OR: 9.66; 95% CI: 1.84-50.57; P < .01) were independent predictors of death. Functional status was not improved in group II after long-term follow-up. CONCLUSION: Nonambulatory patients suffer from extensive comorbid conditions. They are accompanied with an increased occurrence of AEs, unplanned reinterventions, and poor long-term survival rates. Successful LEAR did not improve their functional status after 6 years. This emphasizes that attempts for limb salvage must be carefully considered in these patients.

Morbidity and mortality caused by cardiac adverse events after revascularization for critical limb ischemia.

BACKGROUND: We assessed cardiac adverse events (AEs) after primary lower extremity arterial revascularization (LEAR) for critical lower limb ischemia (CLI) in order to evaluate the impact of cardiac AEs on the clinical outcome. We created an optimized care protocol concerning CLI patients' preoperative work-up as well as intra- and postoperative surveillance according to recent important literature and guidelines. METHODS: We conducted a prospective analysis of clinical outcome after LEAR using patient-related risk factors, comorbidity, surgical therapy, and AEs. This cohort was divided into patients with and without AEs. AEs were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. The consequences of AEs were reoperation, additional medication, irreversible physical damage, and early death. RESULTS: There were 106 patients (Fontaine III n=49, 46%, and Fontaine IV n=57, 56%) who underwent primary revascularization by bypass graft procedure (n=67, 63%) or balloon angioplasty (n=39, 37%). No difference in comorbidity was registered between the two groups. Eighty-four AEs were registered in 34 patients (32%). Patients experiencing AEs had significantly less antiplatelet agents (without AEs n=63, 88%, vs. with AEs n=18, 53%; p=0.000) and/or beta-blockers (without AEs n=66, 92%, vs. with AEs n=16, 47%; p=0.000) compared to patients without AEs. The two most harmful consequences of AEs were irreversible physical damage (n=3) and early death (n=8). Sixty percent (n=9) of systemic AEs were heart-related. The postprocedural mortality rate was 7.5%, with a 75% (n=6) heart-related cause of death. CONCLUSION: AEs occur in >30% of CLI patients after LEAR. The most harmful AEs on the clinical outcome of CLI patients were heart-related, causing increased morbidity and death. Significant correlations between prescription of beta-blockers and antiplatelet agents and prevention of AEs were observed. A persistent focus on the prevention of systemic AEs in order to ameliorate the outcome after LEAR for limb salvage remains of utmost importance. Therefore, we advise the implementation of an optimized care protocol by discussing patients in a strict manner according to a predetermined protocol, to optimize and standardize the preoperative work-up as well as intra- and postoperative patient surveillance.