Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.

Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥ 45 mmHg) and transcutaneous pressure of oxygen (TcPO2 ) ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ankle brachial index (ABI) < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation.

Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review.

Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus are important to estimate the risk of amputation, ulceration, wound healing and the presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another and to evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction angiography and colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies instrument. Of the 6629 studies identified, ten met the criteria for inclusion. In these studies, the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy, the NLR of the ABI was generally higher (two out of three studies), indicating poorer performance, and ranged between 0.3 and 0.5. A toe brachial index <0.75 was associated with a median positive likelihood ratio and NLRs of 3 and ≤ 0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies, pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with diabetes mellitus is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that toe brachial index, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There were insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies.

Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review.

Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Predictors of 1-Year Survival After Endovascular Aneurysm Repair.

OBJECTIVE/BACKGROUND: The purpose of this study was to determine the preoperative variables that best predict 1-year survival following elective endovascular aneurysm repair (EVAR), a period of time that would suggest the patient had benefited from the procedure. Most EVAR survival studies focus on early and late survival; scant information is available for 1-year survival. METHODS: Data from two Australian audits of EVAR (1999-2001 and 2009-13) were combined (n = 1,647). Preoperative variables included routine demographic data, clinical health assessments, computed tomography-derived anatomical data, and all-cause mortality. Univariate and multivariate logistic regressions determined which variables best predicted 1-year survival. RESULTS: One-year survival after EVAR was 93.7% (1,544/1,647) and 30-day survival was 98.4% (1,620/1,647). Univariate analyses found that nine preoperative variables were significantly associated with 1-year survival. Five variables were included in the final multivariate model: American Society of Anesthesiologists physical status, aneurysm diameter, creatinine, respiratory assessment, and severity of iliac artery calcification (receiver-operator curve 0.717, R(2) = .117). Predicted 1-year survival ranged from 98.6% to 68.0%, based on differences in aneurysm size and patient comorbidities. CONCLUSION: Personalised 1-year survival risk enables surgeons and patients to consider seriously the risks and benefits of EVAR prior to surgery.

Development of an automated measure of iliac artery tortuosity that successfully predicts early graft-related complications associated with endovascular aneurysm repair.

OBJECTIVES: Iliac artery tortuosity has been linked to the likelihood of complications following endovascular aneurysm repair (EVAR). Measures of tortuosity can be established from CT images; however, the reproducibility of existing scoring techniques has not been clearly established. It remains unclear whether it is tortuosity at focal locations or for the vessel as a whole that is most relevant to adverse events. The two aims of this study were to develop an automated measure of iliac artery tortuosity to assist with surgical planning by providing an objective assessment of procedural difficulty, and to correlate this measure with early postoperative outcomes. DESIGN AND METHODS: Unlike existing approaches, the present measure of tortuosity considers spatial scale, which incorporates the effects of local anatomy. A computerized imaging algorithm was used to segment vasculature and establish a medial line and vascular boundary from contrast enhanced CT scans of 150 patients undergoing EVAR. Two tortuosity measures were examined: curvature and vessel to straight-line length (L1/L2-ratio). For a given spatial scale, the maximum tortuosity was computed on both iliac arteries and the artery with the lower maximum was selected for analysis. Correlation of tortuosity with early (<30 day) and longer-term graft-related complications was assessed. RESULTS: Maximal tortuosity at a 10 mm scale was a significant predictor of early (<30 day) complications (p = .016 for curvature and p = .006 for L1/L2-ratio), but not of long-term complications. Aneurysmal diameter was independent of tortuosity (Pearson's r value = -.006). CONCLUSION: The results demonstrate that, at a local scale, tortuosity measures are correlated with early outcomes. The spatial scale at which tortuosity is measured is important. The optimal scale of 10 mm implies that adverse events could be linked to a focal anatomical location.

Venous ulceration contaminated by multi-resistant organisms: larval therapy and debridement.

A 72-year-old female with venous insufficiency presented to a hospital-based multidisciplinary wound clinic after 20 years of recurrent episodes of venous leg ulcers. Examination showed bilateral leg ulcers with no evidence of arterial insufficiency, but complicated by considerable devitalised tissue, abnormally high bacterial load and the presence of multi-resistant organisms. The ulcers were initially treated with larvae to aid debridement and reduce the bacterial load, prior to skin grafting. Although ulcer free for a period of 4 months, further debridement was required when the skin condition deteriorated. Surgical intervention was chosen as the preferred method by the surgeons for a second acute care admission using hydrosugery, along with supplementary skin grafts and compression. Ongoing management, consisting of regular debridement, skin care and compression therapy, continues.

Should we develop a core international curriculum for Vascular and Endovascular Surgery?

Vascular and endovascular surgery has undergone a period of extraordinary change during the last 20 years. This is in part due to changes in patient profiles, the development of new, potent drugs and the technological advances in imaging and interventional products. These changes have effectively resulted in the development of an independent specialty, which has needed to define the competencies required for specialist recognition and credentialing. This paper discusses the key aspects of contemporary training in Vascular and Endovascular Surgery, and raises the possibility of developing an agreed core international curriculum.

Personalised predictions of endovascular aneurysm repair success rates: validating the ERA model with UK Vascular Institute data.

OBJECTIVE: The objective of this study was to externally validate the existing Australian Endovascular aneurysm repair Risk Assessment (ERA) Model using data from a major vascular centre in the United Kingdom. METHODS: Data collected from 312 endovascular abdominal aortic aneurysm repair patients at St George's Vascular Institute, London, UK were fitted to the ERA Model. RESULTS: Despite St George's patients being sicker (p < 0.001), having larger aneurysms (p < 0.001) and being more likely to die (p < 0.05) than the Australian patients, their data fitted the ERA Model well for the risk factors early death, aneurysm-related death, three-year survival and type I endoleaks as evidenced by higher area under ROC curves and/or higher R(2) goodness of fit statistics than the Australian data. CONCLUSIONS: The first external validation of the ERA Model using data from St George's Vascular Institute suggests that this tool can be used in different countries and hospital settings. The authors believe the ERA Model is robust and allows valid personalised predictions of outcomes by surgeons treating routine aneurysms as well as those in tertiary referral practices with more adverse outcomes.

Rationale and design of the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE): interim analysis at 30 days of the first 180 patients enrolled.

AIM: The Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1200-patient multicenter prospective study initiated to augment the knowledge base (poolable and comparable) about endovascular aortic repair (EVAR) in a real-world population implanted with a single latest-generation stent graft system (Endurant). With enrollment ongoing at 80 high-volume sites, the registry has limited inclusion/exclusion criteria or procedural specification. Technical and clinical data will be reported through 5 years. METHODS: An interim analysis was performed on investigator-reported data for the first 180 patients enrolled. These patients were asymptomatic elderly males (92.1%) with considerable comorbidities. For 47.3% of the patients, the American Society of Anesthesiologists risk class was either III or IV. The Endurant stent graft was successfully deployed in 99.4% of patients for elective treatment of abdominal aortic aneurysm. RESULTS: Through 30 days, the rate of all-cause mortality was 1.7% (N=3), with all 3 deaths classified as procedure-related but not device-related. The rate of secondary endovascular procedures was 1.1%, and the rate of conversion to open repair was 0.6%. At postprocedure and at 30-day follow-up, there were no type I or type III endoleaks and no instances of stent graft kinking, thrombosis, or occlusion. ENGAGE represents the largest real-world registry for any single EVAR stent graft. CONCLUSION: The interim results through 30 days of the first 180 patients enrolled are promising. Longer-term follow-up for more patients will be reported.

A model to predict outcomes for endovascular aneurysm repair using preoperative variables.

PURPOSE: Models have been developed to predict the likely outcomes of endovascular aneurysm repair (EVAR) for patients, based on a longitudinal Australian audit. METHODOLOGY: Mid-term progress of 961 Australian patients who underwent EVAR has been collected and used to develop predictive models for 17 outcomes. Stepwise forward logistic regressions determined the significant preoperative patient variables to be included in each outcome model. An interactive program was subsequently developed to allow surgeons to review the predicted success rates for patients about to undergo the procedure. Each model was assessed using a global goodness of fit test and was internally validated using bootstrapping. RESULTS: Eight pre-operative variables were included in the interactive model for 17 outcomes. The eight variables used were aneurysm size, age, ASA, gender, creatinine, aortic neck angle, infrarenal neck diameter and infrarenal neck length. The outcomes predicted included perioperative mortality, perioperative morbidity, mid-term survival and reintervention rates. All outcome models achieved reasonable goodness of fit, with the exception of the model for conversion to open repair (p=0.04). With respect to validation, survival, aneurysm related deaths, migrations, ruptures and conversions to open repair performed best in terms of predictive discrimination. Models for survival, migrations and conversions to open repairs performed best in terms of bias corrected R-squared index. The models with the smallest calibration error were 3 and 5 year survival, early deaths and mid-term type I endoleaks. CONCLUSIONS: An interactive model is available, which can assist vascular surgeons to evaluate the expected outcomes for a particular patient undergoing EVAR. The validated model is useful for counselling and pre-operative decision making.

Simvastatin plus nitric oxide synthase inhibition modulates remote organ damage following skeletal muscle ischemia-reperfusion injury.

UNLABELLED: Ischemia-reperfusion injury (IRI) to the lower extremities causes both local damage and serious dysfunction to remote organs, including lungs and kidneys. However, effective therapies are not available. This study aims to determine if simvastatin reduced the severity of remote damage following IRI. METHODS: Rats were given simvastatin before hind limb IRI. Lung and kidney tissues were assessed for neutrophil infiltration using myeloperoxidase assays and basement membrane damage by quantitative immunohistochemical measurement of collagen IV. The effect of nitric oxide synthase (NOS) inhibition on remote damage after IRI and simvastatin was assessed using the NOS inhibitor, L-NIO. RESULTS: Simvastatin (2 mg/kg) protected kidneys against IRI-induced neutrophil infiltration. Simvastatin also inhibited the IRI-induced activation of MMP-9 in the lungs. However, paradoxically, simvastatin exacerbated IRI-induced neutrophil infiltration into the lungs. IRI induced collagen IV degradation in the lungs but not in the kidneys. The degree of collagen breakdown in the lungs was significantly ameliorated by 2 mg/kg simvastatin. NOS inhibition markedly protected both the lungs and the kidneys against IRI-induced neutrophil infiltration but did not alter collagen IV degradation. Administration of simvastatin to L-Nio-treated animals enhanced the degree of protection against IRI-induced neutrophil infiltration in the kidneys but not in the lungs. CONCLUSIONS: Simvastatin protects against remote IRI-induced damage in the lungs and kidneys, suggesting statins may reduce the severity of IRI during major vascular surgery.

Predictors of success following endovascular aneurysm repair: mid-term results.

OBJECTIVE: Australian cases of endovascular aneurysm repair (EVAR) performed between 1999 and 2001 have been evaluated to determine the mid-term (6 months to 5 years) safety and efficacy of the procedure. This study looks at predictors of success, based on mid-term follow-up data. DESIGN OF STUDY: This study uses results obtained from a prospective semi-voluntary register (audit) of Australian data obtained from surgeons in the private and public sector. RESULTS: Peri-operative mortality for patients enrolled in the audit was 1.8%. Ninety-three percent of procedures were technically successful (890/961). Nearly 13% of patients have had re-interventions (mostly endoluminal) at follow-up. Analysis of audit data shows that the likelihood of experiencing post-operative complications or requiring additional procedures increases with ASA rating, increasing age, large pre-operative aneurysm size, aneurysm angle >45 degrees and number of co-morbid conditions diagnosed. CONCLUSIONS: This study confirms satisfactory mid-term results in a, national rather than unit specific, setting. Predictors of clinical failure or need for re-intervention include large aneurysm size, neck angulation >or=45 degrees and short infrarenal neck.

Effect of healing on the expression of transforming growth factor beta(s) and their receptors in chronic venous leg ulcers.

The transforming growth factor betas are of major importance in the wound repair process; however, no studies to date have investigated the role of the transforming growth factor beta receptors in chronic venous leg ulcers or what effect healing has on these proteins. To determine whether the transforming growth factor beta peptides and their receptors are expressed in chronic venous wounds, we used immunofluorescent analysis and quantitative competitive reverse transcription polymerase chain reaction to identify the protein and mRNA expression, respectively. Biopsy samples from wounds and normal skin were collected from 12 patients with chronic venous leg ulcers and three patients undergoing reconstructive surgery, respectively. Additionally four of the chronic venous leg ulcer patients were re-biopsied between 2 and 8 wk after the first biopsy when the wounds had entered the healing phase. The tissue excised from the ulcers included the surrounding intact skin, the ulcer edge, and the ulcer base. Immunofluorescent staining for transforming growth factors beta1, beta2, and beta3 was observed within the epidermis of the skin surrounding the chronic venous ulcers and in fibroblasts and inflammatory cells of the dermis, although this staining was not as strong as that seen in normal unwounded skin. Very little staining could be seen within the ulcers for any of the ligands, however. In contrast the transforming growth factor beta type I receptor was observed throughout the ulcers and the normal unwounded skin biopsies, particularly in the basal epidermal cells. No immunofluorescence for the type II transforming growth factor beta receptor was observed in any of the ulcer biopsies investigated, although it was observed throughout the epidermis and in fibroblasts and inflammatory cells in the surrounding skin. Quantitative, competitive reverse transcription polymerase chain reaction was used to analyze mRNA expression for transforming growth factor beta1 and the type II receptor in the nonhealing ulcers and normal unwounded skin biopsies. These studies revealed that transforming growth factor beta1 and transforming growth factor beta receptor II mRNA was expressed in all the chronic nonhealing ulcers albeit at very low levels for the type II receptor. In marked contrast to the staining observed in nonhealing chronic ulcers, positive immunostaining was observed for the transforming growth factor betas and both the type I and type II receptors in healing ulcers. These results suggest that the absence of a viable receptor complex for the transforming growth factor betas in nonhealing chronic venous ulcers may contribute to wound chronicity.

Time course of the acetazolamide effect in patients with extracranial carotid artery disease.

The acetazolamide test of cerebrovascular reserve is performed as a two-point transcranial Doppler (TCD) measurement of the flow velocity in the middle cerebral artery (MCA) before and 15 to 20 minutes after injection of the carbonic anhydrase inhibitor. The time course was evaluated by bilateral TCD monitoring over 45 minutes in 51 patients with extracranial carotid artery disease. Twenty-nine patients in Group 1 showed a unilateral and 22 patients in Group 2, a bilateral stenosis of the internal carotid artery (ICA). Thirty-one normal hemispheres in 18 normal subjects provided baseline control values. The most useful parameter for the description of the time course was the integral of the mean flow velocity. In both groups integral of the mean flow velocity was significantly reduced compared to that in normal persons (Group 1: 587.2 +/- 538.3 cm, p < 0.01; Group 2: 728.9 +/- 397.1 cm, p < 0.01; normal persons: 967.8 +/- 350.0 cm). The maximal increase of mean flow velocity in a two-point measurement also was significantly lower in the patient groups, but did not reach the same level of significance in Group 2 (Group 1: 19.6 +/- 12.3 cm/sec, p < 0.01; Group 2: 24.2 +/- 10.4 cm/sec, p < 0.05). Thirty-four of 73 hemispheres had reduced integral of the mean flow velocity, but only 29 had a reduced maximal increase. These data indicate that continuous monitoring and evaluation of the time course of the acetazolamide effect provide additional information on cerebrovascular reserve and help to detect an increased number of patients with impaired cerebrovascular reserve.

Time course of acetazolamide effect in normal persons.

The intravenous injection of the carbonic anhydrase inhibitor acetazolamide causes a sustained increase of blood flow velocity in the middle cerebral artery. This effect is used in the acetazolamide test of the so-called cerebrovascular reserve capacity. The acetazolamide test is performed routinely as a two-point measurement of the blood flow velocity by transcranial Doppler before and 15 to 20 minutes after drug injection. Based on the assumption that evaluation of the time course will more sensitively detect an impaired cerebrovascular reserve capacity, suitable parameters for description of the time course were developed and normal values were established from 18 healthy persons (31 hemispheres). The mean value for the maximal increase of the mean flow velocity (MFV) was 29.7 +/- 8.3 cm/sec (as percentage of increase, 62.0 +/- 17.3%) and the time of the maximal increase was 15.35 +/- 8.46 seconds. Also calculated were the velocity of the MFV rise to the maximal value (3.0 +/- 3.2 cm/sec/min), the mean of the changes of the continuously measured MFV to the baseline value (21.0 +/- 7.4 cm/sec), and the integral of MFV represented by the plane under the MFV curve (967.8 +/- 350.0 cm). The best parameter for the description of the time dependency of the acetazolamide effect is the integral of MFV.

Acute superficial venous thrombophlebitis: does emergency surgery have a role?

BACKGROUND: Superficial venous thrombophlebitis (SVT) of the long saphenous vein (LSV) has been shown to be associated with thrombus propagation into the common femoral vein in up to 44% of cases. Conservative management can thus result in deep vein thrombosis (DVT), deep vein insufficiency or fatal pulmonary embolism (PE). To examine the effects of emergency division of the sapheno-femoral junction (SFJ) on the deep venous system in SVT of the LSV we used pre- and postoperative venous duplex ultrasound. METHODS: Emergency division of the SFJ was performed in 17 patients presenting with acute superficial venous thrombophlebitis. All patients had duplex ultrasound, which demonstrated thrombus of the above knee long saphenous vein together with a normal deep venous system. A follow-up duplex ultrasound scan was arranged on discharge and at 2 months. RESULTS: No patient had propagation of thrombus into the deep venous system or a PE. One patient developed a non-occlusive clot in the popliteal vein at 2 months follow-up. All patients were discharged at 48 hours. CONCLUSIONS: Using duplex ultrasound it has been shown that emergency division of the SFJ is a safe and effective way of preventing serious complications caused by thrombus in above knee LSV SVT.

Worldwide experience with the Endurant Stent graft: review of the literature.

The Endurant Stent-graft System (Medtronic Vascular, Santa Rosa, CA) is a next-generation device intended to expand the applicability of endovascular aortic repair (EVAR). To date, the Endurant has been evaluated in 9 short- and intermediate-term studies, several in patients presenting with challenging aneurysm anatomies. Consistently, the device in these studies has been shown to be safe and effective, with an excellent rate of deployment success and with very low rates of type I/III endoleaks and reinterventions. Single center experience with Endurant in challenging anatomies with short kinked necks and calcified angulated iliac arteries in patients unfit for open repair and challenging anatomies show promising early results with no difference in mortality, morbidity and reintervention rates, but need cautious application for EVAR outside of the device-specific IFU. The Endurant Stent-graft Natural Selection Global Postmarket Registry (ENGAGE) is a long-term 1266-patient 80-site worldwide prospective postmarket study initiated to augment the knowledge base (poolable and comparable) about EVAR in a real-world population implanted with the Endurant. Technical and clinical data for ENGAGE patients will be reported through the expected completion of 5-year follow-up for all ENGAGE registry patients in 2018. We discuss the evolving challenges for EVAR that the Endurant and other next-generation stent-grafts are designed to address and review outcomes published with the Endurant since the CE marking of the device in July 2008.

Factors affecting survival after endovascular aneurysm repair: results from a population based audit.

OBJECTIVES: To determine the effect of pre-operative factors on mid-term survival of patients enrolled in an Australian audit of endovascular aneurysm repair (EVAR). DESIGN: Prospective longitudinal national register (audit) of patients undergoing EVAR. METHODS: 961 individuals who had elective or semi-urgent EVAR of abdominal aortic aneurysms were enrolled in the audit between November 1999 and May 2001. Data was contributed by 81 surgeons from 64 hospitals. Kaplan-Meier survival analysis was used to determine survival rates and factors significantly influencing survival. Parametric survival analysis with log-exponential distribution was used to estimate expected 3 and 5 year survival for different ages, ASA, creatinine and aneurysm sizes. RESULTS: Overall survival was 93% at 1 year, 80% at 3 years and 67% at five years. Survival rates were found to be statistically associated with ASA, age, aneurysm size and creatinine levels. ASA has the largest effect. Five year survival rates for aneurysms >or=65 mm and <55 mm were 54% and 76% respectively. Pre-operative creatinine levels >or=160 micromol/L lowered the survival rate from 71% to 40%. CONCLUSIONS: Survival for EVAR patients is strongly correlated with a number of pre-operative factors. This survival analysis provides a useful decision-making tool for surgeons particularly for individuals with smaller aneurysms.

Preoperative nutritional status predicts the severity of the systemic inflammatory response syndrome (SIRS) following major vascular surgery.

OBJECTIVES: This study examined the relationship between pre-operative nutritional status and systemic inflammatory response syndrome (SIRS) or sepsis following major vascular surgery. DESIGN AND METHODS: Subjects undergoing open AAA repair, EVAR or lower limb revascularisation were studied prospectively. Pre-operative nutrition was assessed clinically using Mini-Nutritional Assessment (MNA) and body composition was measured by dual energy X-ray absorptiometry (DEXA) scanning. SIRS severity was assessed for 5 post-operative days and sepsis noted within 30 days of surgery. RESULTS: Using MNA, neither SIRS severity nor sepsis occurrence differed significantly between 'well-nourished' subjects and those 'at risk of malnutrition'. Using DEXA, negative associations existed between body mass index and both SIRS score and SIRS duration. Fat free mass (FFM) was negatively associated with SIRS score and duration. Negative associations also existed between skeletal muscle mass (SMM) and SIRS score and duration. SMM was also negatively correlated with post-operative length of stay in hospital. There were no significant correlations between sepsis and any nutritional indices. CONCLUSIONS: Lower pre-operative nutritional indices, indicating protein energy malnutrition, were associated with more severe systemic inflammatory responses following major vascular surgery.