Single use negative pressure wound therapy in vascular patients: clinical and economic outcomes.

OBJECTIVE: Surgical site complications (SSCs) such as dehiscence and infection are a common issue within vascular surgeries and are a key concern to payers and clinicians. It is estimated that occurrence of complications in vascular surgery can increment length of stay by 9.72 days and costs by £3776 per episode. The objective of this research was to determine the clinical and economic impact of the prophylactic use of single use negative pressure wound therapy (sNWPT) in postoperative femoral endarterectomy incisions within a single centre in the Netherlands. METHOD: Data were extracted retrospectively from the medical notes of patients consecutively treated for femoral endarterectomy between January 2013 and December 2019 in a single centre in the Netherlands. Since August 2016, patients were treated with the sNPWT device and their data were compared with that of patients treated before the introduction of the device. Data were extracted on SSCs and associated healthcare resource use, with comparisons made between the two patient groups. RESULTS: The study included a cohort of 108 patients. Data of patients treated by standard care (n=64) showed 32 (50%) patients developed complications. This reduced significantly in patients treated with the sNPWT device (n=44) of whom eight (18.2%) developed a postoperative complication (p=0.0011). Average postoperative costs per patient were €3119 for those in the standard care group and €2630 where the sNPWT device was used. CONCLUSION: sNPWT provided clinical and economic benefits over standard care in the treatment of femoral endarterectomy patients, significantly reducing rate of complication and their associated costs.

Gore Iliac Branch Endoprosthesis for treatment of bilateral common iliac artery aneurysms.

OBJECTIVE: The Gore Iliac Branch Endoprosthesis (IBE; W. L. Gore & Associates, Flagstaff, Ariz) has recently been approved by the Food and Drug Administration for treatment of common iliac artery (CIA) aneurysms. Despite early excellent results in clinical trial, none of 63 patients were treated for bilateral iliac aneurysms. The goal of this study was to examine real-world experience using the Gore IBE for bilateral CIA aneurysms. METHODS: A retrospective review of an international multicenter (16 U.S., 8 European) experience using the Gore IBE to treat bilateral CIA aneurysms was performed. Cases were limited to those occurring after Food and Drug Administration approval (February 2016) in the United States and after CE mark approval (November 2013) in Europe. Demographics of the patients, presentation, anatomic characteristics, and procedural details were captured. RESULTS: There were 47 patients (45 men; mean age, 68 years; range, 41-84 years) treated with bilateral Gore IBEs (27 U.S., 20 European). Six patients (12.7%) were symptomatic and 12 (25.5%) patients were treated primarily for CIA aneurysm (aorta <5.0 cm). Mean CIA diameter was 40.3 mm. Four patients had aneurysmal internal iliac arteries (IIAs). Two of these were sealed proximally at the IIA aneurysm neck and two required coil embolization of IIA branches to achieve seal in the largest first-order branches. Technical success was achieved in 46 patients (97.9%). No type I or type III endoleaks were noted. There was no significant perioperative morbidity or mortality. IIA branch adjunctive stenting was required in four patients (one IIA distal dissection, three kinks). On follow-up imaging available for 40 patients (85.1%; mean, 6.5 months; range, 1-36 months), 12 type II endoleaks (30%) and no type I or type III endoleaks were detected. Two of 80 (2.5%) IIA branches imaged were occluded; one was intentionally sacrificed perioperatively. CONCLUSIONS: Preservation of bilateral IIAs in repair of bilateral CIA aneurysms can be performed safely with excellent technical success and short-term patency rates using the Gore IBE device. Limb and branch occlusions are rare, usually are due to kinking, and can almost always be treated successfully with stenting.

A rare case of oesophageal rupture: Boerhaave's syndrome.

A 70-year-old patient was referred to our emergency department with severe retrosternal pain after forceful vomiting. Computed tomography (CT) scan revealed a left-sided oesophageal rupture with accompanying pneumomediastinum and bilateral pleural effusions. Conservative treatment with cessation of oral intake, intravenous broad-spectrum antibiotics, parenteral fluids and nutrition and left sided tube thoracostomy was initiated initially. After 5 days, however, the patient deteriorated. Follow-up CT scan demonstrated a mediastinal fluid collection as well as loculated pleural empyema. Open thoracotomy with mediastinal debridement and pleural drainage was performed, after which he made a slow but full recovery. Spontaneous oesophageal rupture due to an abrupt rise in intraluminal pressure caused by vomiting is also known as Boerhaave's syndrome. It is a rare but potentially life-threatening condition. Many patients present with atypical symptoms, and therefore, physicians should have a high index of suspicion in any patient presenting with vomiting and retrosternal pain. When Boerhaave's syndrome is suspected, a CT scan of the thorax and upper abdomen should be performed since treatment depends on clinical and radiological findings. Conservative management (cessation of oral intake, nasogastric decompression, administration of intravenous fluids and parenteral nutrition, intravenous broad-spectrum antibiotics and proton pump inhibitors and tube thoracostomies) may only be considered in patients with a contained rupture without systematic symptoms of infection. In these patients, endoscopic bridging of the tear with a self-expandable stent is also an option. Primary surgical repair (either by thoracotomy or by video assisted thoracoscopy (VATS)) should be considered when patients present with sepsis and/or large non-contained leaks or with severe mediastinal decontamination.