Predictive Factors of Operative Need in Medically Managed Type B Aortic Dissections.

BACKGROUND: Aneurysmal degeneration of medically managed type B aortic dissection (TBAD) can be a life-threatening condition. Preventive thoracic endovascular aorta repair (TEVAR) in patients at risk could potentially be beneficial. The aim of this study was to examine the predictors for late aneurysmal dilatation after TBAD. METHODS: A retrospective study was conducted on 82 patients with medically managed acute TBAD for a minimum of 14 days. Relevant demographic, biochemical, and radiographic variables at presentation were studied. The aortic dissection risk calculator tool developed by Sailer et al., predicting the risk of adverse events after aortic dissection based on demographic and radiographic variables at presentation, was tested retrospectively. RESULTS: With a median follow-up of 36 months (range 13-68), 25 (30.5%) patients underwent surgery (92% TEVAR). A larger initial aortic and false lumen diameter as well as a greater distal extension of the dissection was associated with higher need for surgery (respectively, P = 0.003, P = 0.004, and P = 0.001). We observed higher growth rates of maximum aortic diameter in patients with a greater distal extension of the dissection, larger false lumen diameters and false lumen outflow, and entry tears located at the inner aortic arch (respectively, P = 0.001, P = 0.005, P = 0.001 and P = 0.014). No significant correlations could be found for the risks provided by the calculator tool. CONCLUSIONS: The initial maximum aortic diameter of TBAD is a key predictor for aortic growth. Furthermore, the distal extension of the dissection also seems to play an important role in late aneurysmal degeneration. However, we were not able to confirm the added value of the risk calculator tool in our study group.

Is open acute Achilles tendon rupture repair still justified? A single center experience and critical appraisal of the literature.

INTRODUCTION: Acute Achilles tendon ruptures are injuries with multiple treatment strategies with possibly far reaching consequences. Open repair is associated with a high complication rate, whereas percutaneous techniques are associated with higher re-rupture rates. The goal of this study was to evaluate the clinical outcome and economic burden of open surgical repair and define a medically and economically sound treatment protocol for acute Achilles tendon ruptures. METHODS: Between June 2012 and December 2016 one hundred and five patients with an acute Achilles tendon rupture, treated in an open surgical manner, were studied retrospectively. All demographic, clinical and hospital-related costs were retrieved from the electronic patient database. ATRS questionnaires were sent to assess the functional outcome. A response rate of 70.5% was achieved. RESULTS: We recorded a complication rate of 40%, respectively sural nerve hypoesthesia (14.3%), delayed wound healing (28.6%), infection (20.9%) and re-rupture (4.8%). Surgical resident, as primary operating surgeon was associated with a higher complication rate (p = 0.042). Overall, a median functional ATRS score of 17 (IQR 6.5-39.5) was recorded. Infection was associated with significantly higher total healthcare costs per patient as compared to re-rupture (€17,435 vs. €4,537, p = 0.013). The total cost for surgical debridement (n = 6) was approximately 5-times higher than for re-rupture (n = 5), €108,382 vs. €22,272. The median ATRS score for surgical debridement after infection and re-rupture did not differ significantly from the overall ATRS score, respectively 32 (IQR 21-63) and 28 (IQR 15-28). Nevertheless, a difference of 10 points is considered clinically relevant. CONCLUSION: The overall functional outcome of open repair of Achilles tendon ruptures is rather good, however associated with a high complication rate, mainly due to wound problems and infection. Although several risk factors were identified, only the operating surgeon is modifiable. Considering the high total costs for surgical debridement in the context of infection compared to re-rupture surgery, despite equal functional outcome,we decided to change clinical practice to reduce the complication rate and healthcare costs. The outcome and precise costs for percutaneous repair will be addressed.