Device-specific outcomes after endovascular abdominal aortic aneurysm repair.

Over the last decade, endovascular aneurysm repair (EVAR) has been used extensively for the elective treatment of infra-renal abdominal aneurysms. However, it remains unclear how specific devices perform and how they compare to others. We provide an overview of currently used endografts, and discuss the current evidence regarding device-specific outcomes. Published literature confirms differences in results according to endograft selection. These differences were more pronounced with older generations of devices, in comparison to newer models. Contemporary results are generally good and one should remember that no randomized data exist regarding individual device performance. Moreover, by the time there is enough follow-up to draw conclusions, the data is relatively obsolete due to constant improvements in endograft technology and design. Results from EVAR have been steadily improving and individualized device selection has shown to be valuable. It appears that patients with favorable anatomy do well with most modern endografts. Those with challenging anatomies may benefit more from a particular design, delivery and deployment feature requiring greater knowledge and experience for adequate device selection.

Endovascular treatment of traumatic ruptures of the thoracic aorta.

Rupture of the thoracic aorta after a blunt traumatic accident is a life-threatening event. This injury is instantly fatal in about 80% of the victims, and half of those who initially survive the incident will die during the first day, if left untreated. Before 1997, patients were treated with an open repair, but the conventional surgical approach carries a high mortality and morbidity rate. Graft interposition and cross-clamping of the aorta are responsible for a high paraplegia rate. Despite the fact that active distal perfusion of the aorta lowers the incidence of neurological deficit, the timing of these extensive procedures in the severely injured multi-trauma patient is difficult. The endovascular repair of a traumatic thoracic aortic rupture has gained rapid acceptance as a better alternative. This minimally invasive procedure has a median operating time of <1 h, and it can be done during the same session in which other life-threatening injuries are repaired. There is no need for a thoracotomy or single lung ventilation, blood loss is minimal and systemic heparinization is not required. So far, no spinal cord ischemia has been described for the endovascular repair. Besides numerous advantages, a few problems can be expected. The narrow aortic diameter of these young trauma-victims, combined with a steep aortic arch, makes the adaptation of the endograft along the inner curvature sometimes difficult. Because the smallest endograft usually exceeds the narrow aortic diameter, only excessively oversized devices can be used, which explains the high type I endoleak encountered in the published series. No randomized studies are yet available comparing the open with the endovascular technique, but the initial results of the endovascular repair seem promising and lower mortality and morbidity rates are documented. Long-term outcome are lacking so far, but are needed to address the durability of the procedure. Further research and development should concentrate on the problems we have seen with steep and narrow aortic arches, and devices with more flexible curves and smaller diameters should become available in the near future.

[Evaluation of the rate of autopsy and rate of disparity between autopsy results and clinical cause of death in a surgical ward, with the emphasis on necrological review]. / Een onderzoek naar het percentage obducties en naar discrepanties tussen obductiebevindingen en klinische doodsoorzaak op een heelkundige afdeling met extra aandacht voor necrologiebesprekingen.

OBJECTIVE: To determine the rate of autopsy and the rate of disparity between autopsy results and the clinically determined cause of death in a surgical ward. DESIGN: Descriptive. METHOD: A total of 12,000 patients were admitted to the surgical ward of the Red Cross Hospital, the Hague, the Netherlands, from January 1999 to December 2002. 305 (3%) died during their stay on the ward. By using our standard mortality registration system, it was possible to classify the causes of death, evaluate shortcomings in treatment, and determine the extent of agreement between pre- and post-mortem findings. RESULTS: Permission for an autopsy was obtained for 136 patients (45%). The autopsy rates in patients who died following abdominal aortic surgery, colonic surgery, peripheral artery bypass surgery, and hip surgery were 55%, 63%, 35% and 30%, respectively. In 37 patients (27%), the autopsy report revealed a disparity with the clinical cause of death. Patients who died after abdominal aortic surgery or colonic surgery had disparity rates of 33% and 21%, respectively. Patients who died after peripheral artery bypass surgery or hip surgery had disparity rates of 13% and 7%, respectively. CONCLUSION: The overall rate of autopsy was lower (45%) than in the period 1992-1998 (60%), but remained relatively high in patient groups who were previously found to have a high rate of disparity between pre- and post-mortem findings. Post-mortem examination remains an important tool that can be used to verify diagnosis and treatment and therefore assess the quality of care.

Contemporary series of morbidity and mortality after lower limb amputation.

OBJECTIVES: This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital. METHODS: All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system. RESULTS: In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years. CONCLUSIONS: An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.

Complication registration in patients after peripheral arterial bypass surgery.

The objective of this study was to describe the kinds of complications and their incidence after peripheral vascular surgery of the lower limb, coding for causes and effect on the patient. In this prospective study, a standardized complication registration system was used at the Red Cross Hospital, The Hague. All patients (n = 373) receiving an infrainguinal bypass graft during the period January 1, 1996 to December 31, 1999 were included. All postoperative complications occurring during admission were coded. In 29% of the patients 153 complications were coded. Early occlusions of the graft occurred 36 times, wound infections 21 times and postoperative hemorrhages 20 times. Postoperative retention of urine was seen most frequently of all nonspecific complications (n = 22). In 43 cases the patient needed medication or a blood transfusion for his complication. In 42 cases a re-intervention was necessary. Complications led to a prolonged stay in the hospital in 20 cases. Six patients died during admittance (mortality 1.6%). An error in surgical therapy and error in nonsurgical therapy were the cause of the complication in 108 cases (out of 153). The advantage of this complication registration is that it describes all complications, not just the specific ones. Furthermore, by categorizing all complications we force ourselves to look for errors in nonsurgical therapy and surgical technique and to describe the effect of the complication.

Mortality after colon surgery: the value of a mortality registration system.

BACKGROUND/AIMS: Postoperative mortality after colon surgery is relatively infrequent. In order to evaluate the quality of colon surgery, post-mortem evaluation is useful. This study was performed to determine the value of a mortality register used at the Department of Surgery of the Red Cross Hospital. METHODS: From 1991 to 2000, 882 colon resections were performed for both malignant and benign disorders, including elective and emergency surgery. Permission for autopsy was asked routinely. All cases were reviewed and categorized in a multidisciplinary meeting. Any discrepancy between the clinical and post-mortem diagnosis was determined by a pathologist. RESULTS: The mortality rate of colon surgery was 8.0% (n = 71), 23% for emergency surgery and 6% for elective surgery (p < 0.001). For patients under 70 years of age the mortality rate was 4.3%, for patients over 70 years of age 11.2% (p < 0.001). Autopsy was performed in 62% (n = 44) of the patients. Discrepancy between clinical and post-mortem findings was documented in 14%. CONCLUSION: Postoperative mortality after colon surgery is influenced by the timing of surgery (elective or emergency procedure) and the age of the patient. A discrepancy of 14% between clinical cause of death and post-mortem cause of death justifies the need for obtaining autopsy in this type of surgery.