Editor's Choice - Epidemiology, Diagnostics, and Outcomes of Acute Occlusive Arterial Mesenteric Ischaemia: A Population Based Study.

OBJECTIVE: The exact incidence and outcomes of acute occlusive arterial mesenteric ischaemia (AMI) are unclear as most studies include only patients diagnosed correctly while alive. The aim of this study was to assess the incidence, mortality, and diagnostics of AMI by also including patients diagnosed post-mortem. METHODS: This retrospective study comprised patients diagnosed with AMI either alive or post-mortem between 2006 and 2015 within a healthcare district serving 1.6 million inhabitants. Key exclusion criteria were venous or non-obstructive ischaemia. RESULTS: A total of 470 patients were included in the study of which 137 (29%) were diagnosed post-mortem. The most common misdiagnoses on those not diagnosed alive were unspecified infection (n = 19, 17%), gastrointestinal bleeding (n = 13, 11%), and ileus (n = 13, 11%). Of those diagnosed alive (n = 333), 187 (56%) underwent active surgical or endovascular treatment. During the 2006 - 2015 period, the overall incidence of AMI was 3.05 (95% CI 2.78 - 3.34)/100 000 person years and 26.66 (95% CI 24.07 - 29.45) for those aged 70 years or more. The mean autopsy rate during the study period was 29% for the overall population (32% during 2006 - 2010 and 25% during 2011 - 2015) and 18% for those aged 70 years or more. Overall, the 90-day mortality was 83% in all patients. The ninety day mortality decreased, being 87% during the first period (2006 - 2010) and 79% during the second period (2011 - 2015) (p = .029), while at the same time the proportion of patients diagnosed alive rose from 71% to 80% (p = .030) and the number of endovascular revascularisations rose from 1% to 5% (p = .022). CONCLUSION: A significant proportion of patients with AMI are not diagnosed alive, which is reflected in the mortality rates. Post-mortem examinations and autopsy rate data continue to be key factors in epidemiological studies on AMI.

Reconstruction of the superficial femoral vessels with muscle flap coverage for soft tissue sarcomas of the proximal thigh.

BACKGROUND: Surgical resection of soft tissue sarcoma with a margin of healthy tissue may necessitate resection and reconstruction of major blood vessels together with soft tissues of the proximal thigh to preserve the limb. The long-term functional outcomes of these reconstructions remain unestablished. The aim of this report was to assess the vascular and functional outcomes of soft tissue sarcoma patients with femoral vessel reconstructions. PATIENTS AND METHODS: Patients who had undergone oncovascular reconstruction during the treatment of proximal thigh soft tissue sarcoma in 2014-2020 were reviewed for details of the vascular and soft tissue reconstructions, and the oncological and functional outcomes. This included eight patients of a median age 59 (range 19-77) years. All had a reconstruction of at least the superficial femoral artery and vein as well as soft tissue reconstruction with a muscle flap. All vessel reconstructions were done with either autologous vein (six grafts/four patients) or allograft (10 grafts/six patients). A microvascular latissimus dorsi flap, with a skin island, was incorporated to cover the vascular grafts in five patients. A pedicled sartorius or gracilis muscle flap was used to fill the defect in three patients. RESULTS: Graft patency was assessed in seven patients with a median follow-up of 48 (1-76) months. The arterial graft was patent in 6/8 and the vein graft in 2/8 patients. The gait had returned to normal in five of the six patients assessed. The median MTSS was 70 (43-87)% and the TESS 90 (75-100)%. No local recurrence of the sarcoma was detected. CONCLUSIONS: Vascular reconstruction combined with soft tissue reconstruction enables limb-sparing surgery in patients with soft tissue sarcoma involving proximal femoral vessels. Although the surgeries are complex with high early morbidity, the achieved long-term functional outcomes are worthwhile.

Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques.

OBJECTIVE: Roughly 10% - 20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction. METHODS: This was a retrospective cohort study. A total of 1 375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumour infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end to end anastomosis, or a spiral graft from the great saphenous vein was performed. Next, 90 day and long term survival and outcomes across reconstruction techniques were analysed. RESULTS: Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end to end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuro-endocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in hospital and one on post-operative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a Clavien-Dindo grade 5 complication. In addition, 50 (23%) patients had Clavien-Dindo grade 3 - 4 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected. CONCLUSION: The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections.

Multidisciplinary Oncovascular Surgery is Safe and Effective in the Treatment of Intra-abdominal and Retroperitoneal Sarcomas: A Retrospective Single Centre Cohort Study and a Comprehensive Literature Review.

OBJECTIVE: Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess surgical results of retroperitoneal or intra-abdominal sarcomas involving major blood vessels. METHODS: This was a retrospective single centre cohort study and a comprehensive review of literature. Patients with retroperitoneal or intra-abdominal sarcomas treated by the oncovascular team in Helsinki University Hospital from 2010 to 2018 were reviewed for vascular and oncological outcomes. A comprehensive literature review of vascular reconstructions in patients with retroperitoneal sarcoma was performed. RESULTS: Vascular reconstruction was performed in 17 patients, 11 of whom required arterial reconstructions. Sixteen of the operations were sarcoma resections; the post-operative diagnosis for one patient was thrombosis instead of the presumed recurrent leiomyosarcoma. Early graft thrombosis occurred in two venous and one arterial reconstruction. Late thrombosis was detected in three (18%). The median follow up was 27 (range 0-82) months. Of the patients with sarcoma resections 5 (31%) died of sarcoma and further 4 (25%) developed local recurrence or new distant metastases. The comprehensive review of literature identified 37 articles with 110 patients, 89 of whom had inferior vena cava reconstruction only. Eight arterial reconstructions were described. Late graft thrombosis occurred in 14%. The follow up was 0-181 months, during which 57% remained disease free and 7% died of sarcoma. CONCLUSION: Vascular reconstructions enable radical resection of retroperitoneal and intra-abdominal sarcomas in patients with advanced disease. The complex operations are associated with an acceptable rate of serious peri-operative complications and symptomatic thrombosis of the repaired vessel is rare. However, further studies are needed to assess the performance of the vascular reconstructions in the long term.

En bloc resection of visceral aorta and right kidney due to aortic sarcoma using temporary extracorporeal bypass grafting.

Aortic sarcomas have not been linked to Lynch syndrome in humans, although other soft tissue malignancies have been. We report the case of a 31-year-old man with Lynch syndrome, who presented with abdominal pain and severe claudication. The clinical and diagnostic workup revealed near occlusion of the infrarenal aorta due to aortic angiosarcoma. En bloc resection of the visceral and infrarenal aorta with right nephrectomy was performed, facilitated by temporary extracorporeal bypass to the visceral arteries. The aorta was reconstructed with a bifurcated Dacron graft. At the 24-month follow-up examination, the patient was free of disease but was experiencing chronic diarrhea.

Cryopreserved Venous Allografts in Supra-inguinal Reconstructions: A Single Centre Experience.

OBJECTIVE: This study introduces a novel technique for supra-inguinal arterial reconstructions with cryopreserved femoral vein and caval allografts with a low re-infection rate and an acceptable graft re-intervention rate on early mid term analysis. METHODS: Patients treated from February 2012 to March 2018 with cryopreserved venous allograft reconstructions owing to infection in the supra-inguinal area were reviewed retrospectively. The primary end points were re-infection and the treatment related mortality rate. Secondary end points were 30 and 90 day and overall mortality and graft re-intervention rate. RESULTS: Of the 23 patients treated with cryopreserved venous allografts for infection in aorto-iliac area, 21 (91%) patients underwent reconstruction with cryopreserved femoral veins and two (9%) with vena cava. Indications for treatment were aortic graft infections (n = 12 [52%]), mycotic aneurysms (n = 5 [22%]), femorofemoral prosthetic infections (n = 3 [13%]), anastomotic pseudo-aneurysms (n = 2 [9%]), and aortic thrombosis with intestinal spillage (n = 1 [4%]). In hospital and 90 day mortality were 9% (n = 2); overall treatment related mortality during the median follow up of 15 months was 13% (n = 3). During the follow up, two allografts were re-operated on owing to anastomotic dilatation and one because of re-infection, resulting in a re-intervention rate of 13% (n = 3). None of the grafts was lost and there were no amputations. At the end of follow up 17 patients (74%) were alive. Kaplan-Meier estimation for survival was 76% (95% confidence interval [CI] 57%-95%) at one year and 70% (95% CI 49%-91%) at two years. CONCLUSION: Cryopreserved venous allografts appear to be an infection resistant and reasonably safe reconstruction material in the aorto-iliac axis based upon the early mid term analysis from a single centre experience. Further research is needed to compare their performance with other biological reconstruction material.

Choice of First Emergency Room Affects the Fate of Patients With Acute Mesenteric Ischaemia: The Importance of Referral Patterns and Triage.

OBJECTIVES: Despite modern advances in diagnosis and treatment, acute arterial mesenteric ischaemia (AMI) remains a high mortality disease. One of the key modifiable factors in AMI is the first door to operation time, but the factors attributing to this parameter are largely unknown. The aim of this study was to evaluate the factors affecting delay, with special focus on the pathways to treatment. METHODS: This was a single academic centre retrospective study. Patients undergoing intervention for AMI caused by thrombosis or embolism of the superior mesenteric artery between 2006 and 2015 were identified from electronic patient records. Patients not eligible for intervention or with chronic, subacute onset, colonic only, venous, or non-occlusive mesenteric ischaemia were excluded. Patients were divided into two groups according to the first speciality examining the patient (surgical emergency room [SER], surgeon examining the patient first or non-surgical emergency room [non-SER], internist examining the patient first). The primary endpoint was first door to operation time and secondary endpoints were length of stay and 90 day mortality. RESULTS: Eighty-one patients with AMI were included. Fifty patients (62%) died during the first 30 days and 53 (65%) within 90 days. Presenting first in non-SER (vs. SER) was independently associated with a first door to operation time of over 12 h (OR 3.7 [95% CI 1.3-10.2], median time 15.2 h [IQR 10.9-21.2] vs. 10.1 h [IQR 6.9-18.5], respectively, p = .025). The length of stay was shorter (median 6.5 days [4.0-10.3] vs. 10.8 days [7.0-22.3], p = .045) and 90 day mortality was lower in the SER group (50.0% vs. 74.5%, p = .025). CONCLUSIONS: The first specialty that the patient encounters seems to be crucial for both delayed management and early survival of AMI. Developing fast/direct pathways to a unit with both gastrointestinal and vascular surgeons offers the possibility of improving the outcome of AMI.

Open Repair of Mycotic Abdominal Aortic Aneurysms With Biological Grafts: An International Multicenter Study.

BACKGROUND: The treatment of mycotic abdominal aortic aneurysm requires surgery and antimicrobial therapy. Since prosthetic reconstructions carry a considerable risk of reinfection, biological grafts are noteworthy alternatives. The current study evaluated the durability, infection resistance, and midterm outcome of biological grafts in treatment of mycotic abdominal aortic aneurysm. METHODS AND RESULTS: All patients treated with biological graft in 6 countries between 2006 and 2016 were included. Primary outcome measures were 30- and 90-day survival, treatment-related mortality, and reinfection rate. Secondary outcome measures were overall mortality and graft patency. Fifty-six patients (46 males) with median age of 69 years (range 35-85) were included. Sixteen patients were immunocompromised (29%), 24 (43%) had concomitant infection, and 12 (21%) presented with rupture. Bacterial culture was isolated from 43 (77%). In-situ aortic reconstruction was performed using autologous femoral veins in 30 patients (54%), xenopericardial tube-grafts in 12 (21%), cryopreserved arterial/venous allografts in 9 (16%), and fresh arterial allografts in 5 (9%) patients. During a median follow-up of 26 months (range 3 weeks-172 months) there were no reinfections and only 3 patients (5%) required assistance with graft patency. Thirty-day survival was 95% (n=53) and 90-day survival was 91% (n=51). Treatment-related mortality was 9% (n=5). Kaplan-Meier estimation of survival at 1 year was 83% (95% confidence interval, 73%-94%) and at 5 years was 71% (52%-89%). CONCLUSIONS: Mycotic abdominal aortic aneurysm repair with biological grafts is a durable option for patients fit for surgery presenting an excellent infection resistance and good overall survival.

A Population-Based Study of Abdominal Aortic Aneurysm Treatment in Finland 2000 to 2014.

BACKGROUND: In the event of rupture of an abdominal aortic aneurysm (AAA), mortality is very high. AAA prevalence and incidence of ruptures have been reported to be decreasing. The treatment of AAA has also undergone a change in recent decades with a shift toward endovascular aneurysm repair (EVAR). Our aim was to evaluate how these changes have affected the elective and emergency treatment of AAA and their results in Finland. METHODS: All patients treated for AAA in Finland, a country with a population of 5.5 million, during 2000 to 2014 were searched from the registry of the Finnish Institute for Health and Welfare. Data on all patients who had died of AAA during the same time period were obtained from Statistics Finland. The data were combined and analyzed. RESULTS: The annual incidence of ruptured AAA was 16.4 per 100 000 population over 50 years and decreased significantly during the study period. Over half of the 4949 patients who had a ruptured AAA died outside the hospital. Thirty-day mortality after emergency repair was 39.4%. Intact AAA repairs numbered 4956. The absolute number of annual repairs increased during the study period, and the use of EVAR became the dominant method of elective repair. Thirty-day mortality in elective AAA repair dropped significantly from 6.3% in 2000 to 2004 to 2.7% in 2010 to 2014 mostly because of the increased number of EVAR procedures with lower mortality. Long-term mortality in patients treated with EVAR was higher than in patients treated with open repair. Mortality after elective AAA repair was primarily attributable to cardiovascular causes, but there was a slightly higher proportion of AAA-related late deaths in patients treated with EVAR. CONCLUSIONS: Ruptured AAA incidence for men >65 years has declined by nearly 30% in Finland, likely because of the decrease in AAA prevalence. The treatment results have improved as well for both elective and emergency repair. Increased use of EVAR has resulted in a decrease of mortality after elective AAA repair, but results of open repair have improved as well. However, late mortality from elective EVAR is surprisingly high in comparison with open repair, which may have been exaggerated by patient selection.

Outcome of surgery for patients with renal cell carcinoma and tumour thrombus in the era of modern targeted therapy.

OBJECTIVE: This study evaluated the clinical outcome of patients with renal cell carcinoma (RCC) with tumour thrombus (TT) after surgical management. MATERIALS AND METHODS: In total, 142 consecutive RCC patients with TT who were operated on in Helsinki University Hospital between 2006 and 2014 were analysed. Eighty-eight (62%) of these patients had been operated on with radical intention and 54 (38%) with cytoreductive intention. A total of 73 patients (51%) received postoperative targeted therapy. The primary endpoint was cancer-specific survival (CSS). RESULTS: The 5 year CSS for level of involvement of TT in the renal vein, subdiaphragmatic vena cava and supradiaphragmatic vena cava was 60% (81 patients), 43% (52 patients) and 51% (nine patients), respectively (p = .42). The median CSS for lymph-node involvement was 63 months for patients with no lymph-node involvement but 10 months for patients with lymph-node involvement (p < .01). The median CSS for metastasis status was 63 months for patients with no metastases compared with 18 months for patients with metastases (p < .01). Among several factors examined, WHO performance status (p = .04), tumour necrosis (p = .05), presence of distant metastases (p = .04) and tumour histology (p = .05) were associated with CSS in the multivariate analysis. CONCLUSIONS: Operative treatment for RCC with TT is associated with good prognosis when there is no lymph-node involvement or distant metastases.

Temporary Axillorenal Bypass in Complex Aorto-Renal Surgery.

BACKGROUND: Prolonged renal ischemia during vascular surgery carries high morbidity and mortality. We report an alternative technique for maintaining renal circulation during suprarenal aortic or renal artery clamping. METHODS: Between October 2007 and May 2012, 16 patients undergoing aorto-renal surgery (13 men, 3 women) were operated using temporary axillorenal bypass. Operations were performed for supra- and juxtarenal aortic aneurysms (11), occlusive aortic disease (2), renal artery stenoses (2), and abdominal myofibroblastic tumor (1). In elective cases, axillorenal bypass was planned, when prolonged renal ischemia was expected based on preoperative information. Preoperative risk factors (renal dysfunction, hypertension, coronary disease, diabetes, smoking) and intraoperative variables (operating time, blood loss, renal ischemia time) were assessed and compared with postoperative kidney function (serum creatinine, urine output, dialysis) and in-hospital or 30-day-mortality. Even though renal blood flow was restored between clampings, the total cumulative ischemia time was used in analysis. Acute renal failure postoperatively was based on RIFLE criteria. RESULTS: Preoperatively, 44% (7) of the patients had normal renal function (S-crea ≤ 100 mmol/L). Renal function was moderately present in 50% (8) (S-crea 100-200 mmol/L) and severely in 6% (1) (S-crea ≥ 200 mmol/L). Median operation time was 393 min (251-535 min) and median renal ischemia time was 24.5 min (range 8-50 min). Transient acute renal dysfunction occurred in 6 (38%) patients, and 4 of them had renal insufficiency preoperatively. Transient renal replacement therapy was needed in 1 (6%) patient only. In 1-month control, postoperative renal function had returned to its baseline level or improved and in-hospital or 30-day mortality was zero. CONCLUSIONS: Temporary axillorenal bypass is a considerable option to minimize renal ischemia time during high-risk vascular surgery.

[Surgical treatment of soft tissue sarcomas]. / Pehmytkudossarkoomien kirurginen hoito.

Surgical excision of the tumor with a tumor-free margin is always the most important form of treatment of soft tissue sarcoma. Although a local management of the tumor would in many cases be achieved by amputation, the functional and psychological consequences would often be significant. Better knowledge of the biology of different subtypes along with the progress in the forms of treatment has improved the prognosis. Modern surgical treatment aims at functional resection with tumor-free margins and preservation of the limb, whenever possible. If necessary, the operation will be complemented with postoperative radiotherapy. Adjuvant chemotherapy or chemoradiotherapy are given in some cases.

Quality assessment of elective abdominal aortic aneurysm repair from referral to surgery.

BACKGROUND: The risk of rupture for a large (≥ 55 mm) abdominal aortic aneurysm(AAA) is significant and therefore operative treatment should take place before possible aneurysm rupture. Timing of elective AAA surgery has rarely been investigated previously. The aim of this study is to evaluate success in the elective treatment process of large AAAs from referral to surgery in Helsinki University Central Hospital. PATIENTS AND METHODS: We retrospectively analyzed all 361 patients who were assigned for elective treatment of AAA during 2005 - 2010. We divided the patients into subgroups according to size of the aneurysm: <60 mm, 61 - 70 mm and >70 mm. The main focus was set on the preoperative period and on potential factors causing delay. End points indicating failure in the treatment process were aneurysm ruptures and deaths before surgery. RESULTS: The median time from referral to surgery for the three subgroups was 112, 91 and 45 days respectively (p < 0,001). There were no significant differences between the treatment methods: open repair (OR) with 103 days and endovascular aortic repair (EVAR) with 113 days until surgery. Twenty three (6.4 %) patients were operated on emergency basis while waiting for the operation, six of them for ruptured aneurysm. There were an additional five patients with aneurysm ruptures who all died, as did four out the six operated ones. CONCLUSIONS: The whole treatment process starting from the referral should be considered in order for elective AAA treatment to succeed. Recommendations should be established for the preoperative period to guarantee rapid preoperative evaluation.

Carotid embolectomy and endarterectomy for symptomatic complete occlusion of the carotid artery as a rescue therapy in acute ischemic stroke.

Emergency endarterectomy of an occluded internal carotid artery (ICA) has not been investigated as an option of rescue therapy for severe acute ischemic stroke in the era of intravenous (IV) thrombolysis treatment neither as a primary treatment nor after failed IV thrombolysis. Data from the pre-IV thrombolysis era are conflicting and therefore emergency endarterectomy has not been recommended. The number of patients reaching the emergency room within the IV thrombolysis time window has vastly grown due to advanced acute stroke treatment protocols. The efficacy of mechanical thrombectomy as a primary or add-on to IV thrombolysis therapy option is being actively investigated. We herein report 2 cases of acute ischemic stroke with computerized tomography (CT) angiography-documented occlusion of an ICA that were treated with emergency carotid endarterectomy and embolectomy to restore cerebral blood flow. Both cases presented with severe stroke symptoms and signs not responding to IV thrombolysis and showed severe CT-perfusion deficits mainly representing ischemic penumbra. Blood flow was surgically restored after 5 h of symptom onset. Both patients achieved a favorable outcome. We conclude that timely surgical approach of acute ICA occlusion after failed thrombolysis as a rescue therapy may be a viable option in well-selected patients.

[Challenging treatment of aortic aneurysm is under change]. / Aortta-aneurysman vaativa hoito muuttumassa.

Abdominal aortic aneurysm is a common and increasing health risk. Indication for therapy in men is an aneurysm over 55 mm and in women, over 50 mm in diameter. Novel endovascular treatment procedures are nowadays suitable for a large proportion of patients and will improve patient safety, shorten the duration of therapy and speed up rehabilitation. Therapeutically very challenging problems are aneurysms affecting the renal and visceral arteries, infections of aortic prostheses as well as aneurysmal ruptures during emergency services. Managing of these problems requires experience, whereby centralizing their treatment will improve treatment outcome.

[Emergency problems in vascular surgery]. / Päivystysongelmat verisuonikirurgiassa.

The most typical emergency patient of vascular surgery is suffering from urgent lower limb ischemia, potentially threatening the viability of the limb. Life-threatening conditions requiring immediate treatment include rupture of the abdominal aorta as well as septicemia associated with necrosis of a neuropathic-ischemic leg of the diabetic patient. Stenosis of the carotid artery requires an emergency operation, if in spite of antithrombotic medication the patient exhibits persistent transient symptoms of paresis or attacks of blindness. Vascular injury should be suspected and a vascular surgeon consulted in limb injuries, if the pulse cannot be conclusively felt distally.

Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service.

Our aim was to determine whether organizational changes could improve the outcome after ruptured abdominal aortic aneurysm (RAAA). Regional centralization and quality improvement in the in-hospital chain of treatment of RAAA included strengthening of the emergency preparedness and better availability of postoperative intensive care. During the reorganization, all patients with RAAA were admitted to Helsinki University Central Hospital (HUCH) from Helsinki and Uusimaa district. RAAA patients in the hospital district of Helsinki and Uusimaa between 1996 and 2004 were identified. The study period was divided into three periods: I, control; II, change; and III, present. Of the total of 626 patients with RAAA, 352 (56%) were admitted to the HUCH, of whom 315 (90%) underwent surgery. During the study period, population-based mortality decreased from 77% to 56% (P < 0.001) and 90-day mortality, from 54% to 28% (P = 0.002). Operative 30-day mortality was 19% during the third period and lower than previously (P = 0.001). Our results seem to argue in favor of centralization of emergency vascular services with adequate manpower and operative expertise in the first line and with availability of closed-unit postoperative critical care to achieve better results as these measures were associated with a positive impact on survival.

Adjuvant arteriovenous fistula as means of rescue for infrapopliteal venous bypass with poor runoff.

OBJECTIVE: The aim of this study was to assess the outcome of infrapopliteal bypass when an adjuvant arteriovenous (AV) fistula was reconstructed as means of rescue as a result of poor runoff. The design was a retrospective multicenter case-control study. METHODS: Seventy-seven infrapopliteal vein bypasses required an adjuvant AV fistula among 1813 patients operated on for critical leg ischemia in 3 vascular centers between 1996 and 2003. The mean age was 74 years (range, 39-90 years). A total of 70% of the patients had diabetes, and 24% had undergone previous vascular surgery. In 25% of the bypasses, the distal anastomosis was in a crural artery, in 55% it was in the dorsal pedal artery, and in 20% it was in a plantar artery. An adjuvant AV fistula was reconstructed in all cases because of poor intraoperative arterial status, intraoperative angiography, or low intraoperative flow. A control group was retrieved that matched the study group according to the recipient artery and runoff score. RESULTS: The primary and secondary patency were 61% and 75%, respectively, at 1 year in the AV fistula group and 57% and 71% in the control group. The 3-year patency rates were 49% and 62% for the AV fistula group and 46% and 71% for the control group, respectively. There was a 76% leg-salvage rate at 3 years in the study group, compared with 87% in the control group. There were no major complications related to the AV fistula. Intraoperative flow was increased from a median of 20 mL/min to 115 mL/min by the AV fistula (P = .003). The graft flow was significantly higher in the AV fistula group than in the control group (P = .001). CONCLUSIONS: The adjuvant AV fistula increased graft flow significantly in a poor-outflow venous bypass. In this extreme patient group, acceptable patency and leg salvage was achieved without adverse effects. Despite this, the AV fistula did not improve the outcome.

Utility of surgery for ruptured abdominal aortic aneurysm.

Our aim was to assess the utility of surgery for ruptured abdominal aortic aneurysm (RAAA) using the number of quality-adjusted life years (QALYs) in a retrospective study with cross-sectional quality-of-life (QoL) evaluation. During a 7-year period up to 2002, 242 of 269 (90%) patients with RAAA underwent surgery. Survivors were sent the EQ-5D self-administered questionnaire to assess their long-term outcome. EQ-5D single index values were calculated for each survivor and combined with age- and sex-adjusted Finnish life tables to obtain QALY estimates. Total hospital mortality (90-day) and operative mortality (30-day) were 140 of 269 (52.0%) and 106 of 242 (43.8%), respectively. Of the 129 surviving patients, 111 were available for QoL evaluation. The response rate was 85%. The mean (range) number of QALYs after RAAA was 4.1 (0-30.9) for all and 8.5 (0.2-30.9) for hospital survivors. Young age and low Glasgow Aneurysm Score were associated with a high number of QALYs irrespective of the statistical method used for analysis. Successful repair of RAAA was able to lend considerable benefit as measured by QALYs.