Implementation of a fast-track-pathway including analgo-sedation with local anaesthesia for outpatient varicose vein surgery: a cohort study.

OBJECTIVE: To evaluate the clinical and economical impact of a fast-track anaesthesia protocol in the management of primary varicose vein (VV) surgery. METHODS: Over a 10-month period (from 1 December 2009 to 30 September 2011), all patients eligible for open VV surgery (N = 176) were enrolled in a fast-track clinical pathway including titrated analgo-sedation combined with local anaesthesia. This fast-track cohort was compared with a historical cohort undergoing similar procedures and receiving general anaesthesia (GA) or spinal anaesthesia (SA) (between 1 December 2009 to 30 September 2011, N = 200). The length of stay in the operating facilities and postoperative recovery areas were reported and hospital costs were estimated. In addition, the occurrence of adverse events and unplanned hospital admission were compared between the two consecutive periods. RESULTS: Patients characteristics and surgical procedure were not different in the two cohorts. After implementation of the fast-track pathway, the incidence of postoperative adverse events decreased from 41% to 2.3%, with no need for overnight hospital stay (0% versus 7%). The reduction in anaesthesia-controlled time (-47%) and in postoperative recovery time (-61%) were associated with an increased operating capacity (1 extra case per day) and with substantial cost-savings (mean reduction of €312 per case, P < 0.001). CONCLUSIONS: Implementation of a fast-track pathway for outpatient VV surgery was successful, safe and efficient. Analgo-sedation combined with infiltrative anaesthesia (instead of GA or SA) contributed to increase the operating capacity and to reduce the workload of nursing personnel.

Can bilateral varicose vein surgery be performed safely in an ambulatory setting?

OBJECTIVES: Surgery for varicose veins is still the method of choice worldwide. When varicose veins require bilateral surgery, a single procedure often is the preferred choice by the patient. Today, unilateral varicose vein surgery is frequently performed as an outpatient procedure, while in many institutions bilateral surgery is done as an in-hospital procedure. DESIGN: Retrospective comparative study. METHODS: Between 1 October 2004 and 31 October 2006, 433 patients underwent surgery for the great saphenous vein as in-patient procedure (303 unilateral and 130 bilateral), period 1. From 1 November 2006 until 31 December 2009, 825 patients had ambulatory great saphenous vein surgery (550 unilateral and 275 bilateral), period 2. We have compared unilateral and bilateral varicose vein surgery (high ligation and stripping of the great saphenous vein) and in-hospital procedures with ambulatory surgery, with regard to postoperative complications, postoperative pain and midterm follow-up. RESULTS: Operation time and total length of stay in the institution following varicose vein surgery were significantly shorter for period 2 compared with period 1 for both unilateral and bilateral surgery, without other differences between the groups. There were few postoperative complications without differences between periods, and between unilateral and bilateral surgery (wound infection 0.5%, haematoma requiring drainage 0.2%, transient paraesthesia 1.1%, superficial localised thrombophlebitis 0.6% and deep vein thrombosis in one unilaterally operated case only). CONCLUSIONS: Bilateral varicose vein surgery can be safely performed as an outpatient procedure, without increased risk of postoperative complications, increased postoperative discomfort or midterm adverse effects compared with unilateral surgery.

Subcutaneous fasciotomy and eradication of superficial venous reflux for chronic and recurrent venous ulcers: mid-term results.

OBJECTIVE: Increased intramuscular and subcutaneous tissue pressures are often found in patients with severe chronic venous insufficiency venous ulcer disease. Additional subcutaneous para-tibial fasciotomy promotes early ulcer healing. This study evaluates the mid-term effect of eradication of superficial reflux with additional fasciotomy in patients with increased tissue pressures. METHOD: Between January 2006 and June 2009, 58 patients underwent fasciotomy. Tissue pressures (intramuscular and subcutaneous) were measured. Sixty-nine limbs with 91 venous ulcers were treated. Mean duration of the venous ulcer was 3.4 years. Underlying disease was post-thrombotic syndrome (PT) in 19 patients (33%, 24 limbs, 27 ulcers) and non-post-thrombotic (non-PT) severe chronic venous insufficiency in 39 (67%, 45 limbs, 64 ulcers). All patients were C6 at the time of surgery. Preoperative tissue pressures were 23.5 ± 6.1 mmHg (intramuscularly) and 9.8 ± 3.2 mmHg (subcutaneously). RESULTS: Ninety ulcers (99%) healed postoperatively (42 with and 48 without skin grafting). Tissue pressures significantly decreased following surgery and remained low at three months postoperatively. Ten ulcers in six patients recurred six to 20 months postoperatively (11%), resulting in 86.4 actuarial freedom from venous ulcer recurrence at three years following surgery. Four patients (1 non-PT and 3 PT) had re-fasciotomy; all healed initially but two ulcers (2 patients, PT) recurred at 11 and 12 months. Those patients underwent re-fasciotomy, one healed and one recurred six months later. CONCLUSION: Eradication of superficial reflux with additional subcutaneous fasciotomy for chronic and recurrent venous ulcer improves ulcer healing or success of skin grafting. Mid-term results are excellent particularly in patients with non-PT disease. Recurrence is more frequently seen in patients with PT syndrome. In patients with ulcer recurrence and high tissue pressures, re-fasciotomy can be helpful to promote healing, particularly in patients with primary venous disease.

Popliteal venous aneurysm: a report on three cases presenting with chronic venous insufficiency without embolic events.

OBJECTIVES: Popliteal venous aneurysms (PVA) are rare, but represent a significant potential source of thromboembolus. Most often the patients present with pulmonary embolism, which can also be detected in patients presenting with chronic venous insufficiency. METHODS: Three patients without any clinical evidence of pulmonary emboli were diagnosed by venous duplex scanning during workup for superficial venous insufficiency. None of the PVAs contained thrombus. The mean diameter of the aneurysm was 30 mm. Surgery included tangential aneurysmectomy and lateral venorrhaphy. RESULTS: None of the patients had evidence of pulmonary embolism, and there were no postoperative deep venous thromboses diagnosed. All patients received anticoagulation therapy for three months postoperatively, and patency was confirmed by duplex scanning during follow-up four, nine and 12 months after surgery. CONCLUSIONS: It is recommended that PVAs should be ruled out in patients undergoing workup for chronic venous insufficiency, even in the absence of embolic events. A good quality venous duplex scanning is sufficient for diagnosis and treatment. Surgical treatment of PVAs is advocated. Tangential aneurysmectomy with lateral venorrhaphy is the surgical technique of choice. It is a safe procedure with a low complication rate.

The impact of the creation of a venous surgical centre within the department of cardiovascular surgery at a university hospital.

BACKGROUND: The establishment of specialty vein clinics has proven beneficial in terms of expansion of clinical volume. Depending on the local situation, the creation of a venous surgical centre may, in addition, result in better collaboration between various specialties, enable active participation in the development and evaluation of new treatment modalities, offer better training/education and provide venues for more complex treatment modalities such as reconstructive surgery of the deep venous system. OBJECTIVES: The aim of this study was to analyse the impact of the creation of a venous surgical centre under the auspices of a department of cardiovascular surgery at a university hospital. METHODS: A venous surgical centre was established on 1 October 2003, under the direction of one senior surgeon. The impact on clinical activity was measured in terms of patient volume, percentage distribution between venous and arterial surgery and surgical procedures performed, complications following venous surgery as well as evaluation of patient and referring physician satisfaction. Data, from the department's databank, on all patients evaluated and surgically treated for venous and arterial problems from 1 January 2000 to 30 June 2006 were analysed. Number of outpatient clinic visits and operations (patients and surgical procedures) were calculated. RESULTS: The establishment of the venous surgical centre, without additional funding, led to a significant increase in clinical volume. There was a 433% increase in vein surgical procedures and a 774% increase in outpatient clinic visits (comparing 2002 with 2004). Endovenous laser treatment of varicose veins and reconstructive surgery for the deep venous system was started, and a program for training surgeons was established. Complication rate following varicose vein surgery decreased from 5.8% to 1.2% (hematomas and groin infection). Patient and referring physician satisfaction was documented in 2004 and 2006 using questionnaires. CONCLUSIONS: The establishment of an academic venous surgical centre has proven useful in increasing clinical activity in terms of patient volume, providing more efficient and better continuity of care, ensuring less complications following varicose vein surgery, allowing the introduction of new treatment modalities, and resulting in overwhelming patient and treating physician satisfaction.

Autologous fibrin glue reinforced by platelets in surgery of ascending aorta.

OBJECTIVES: Fibrin sealants are popular for the improvement of perioperative hemostasis and reducing blood transfusion needs. Biological glues prepared from pooled human donor plasma have an inherent risk of transmission of blood-borne disease and are quite expensive to use. A system for the production of autologous fibrin sealant re-enforced by platelets has been developed. Its efficacy, safety and economic benefits have been evaluated in a prospective, randomized study. MATERIAL: 20 consecutive patients undergoing replacement of the ascending aorta by the same surgical team had local application of either Tissucol (Group A) or autologous fibrin glue (Group B) for hemostasis. RESULTS: No adverse effects of either glue were recorded. The volume of produced autologous fibrin glue was 25 cc PRP. Platelet yield was 72 %. The two groups were comparable. Efficacy was group comparable. Average cost for sealants in Group A was 470 +/- 100 Euros compared to 273 Euros in Group B, p = 0.004. CONCLUSIONS: Autologous fibrin glue re-enforced by autologous platelets can be safely produced in the operating room in a large volume, with an comparable efficacy at a lower cost than commercial sealants.

Economic impact of mitral valve plasty versus replacement for mitral valve insufficiency.

AIM: The principal techniques for surgical correction of mitral valve regurgitation (MR) were compared, with emphasis on the economic impact. METHODS: In a prospective non-randomized study 225 patients undergoing mitral valve repair were analyzed, 75 had mitral valve plasty (MVP) and 150 had mitral valve replacement (MVR). Patient demographics showed no group differences. RESULTS: Cardiopulmonary bypass time and ischemia time were shorter in the MVP-group, p<0.0001. Hospital mortality was lower after MVP, 2.0% (3/150) compared to MVR, 6.7% (5/75). ICU-stay was shorter in the MVP-group and so was length of postoperative hospital stay, p=0.014. Urgent operation was the only significant risk factor for mortality after MVP. Re-operation, endocarditis, grade IV MR, and NYHA class IV were additional risk factors in the MVR-group. Postoperative improvements of NYHA and mitral valve function were similar in both groups. MVP was more cost effective than MVR (18,050 USD or 20,430 Euro versus 24,824 USD or 28,097 Euro, p<0.001). CONCLUSION: Mitral valve plasty for MR is efficient and associated with shorter CPB and ischemia times as well as length of stay in ICU, together with a lower device cost, which makes MVP more cost effective than MVR.

Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy.

Secondary aorto-enteric fistula (AEF) is a serious, but rare, complication following surgery of the abdominal aorta. AEF occurs in 0.3-2%, but is associated with a hospital mortality between 25-90%. It is also associated with an important morbidity with a lower limb amputation rate of 9%, and a 15% risk for renewed graft infection. Nine secondary AEF were surgically treated. The hospital mortality was high,44% (4/9). Recurrent AEF was observed in 1 patient 2 years after the first operation. During follow-up 2 patients had mild infections which were resolved by antibiotic treatment. Diagnostic modalities, and recent advancements in surgical treatment as well as preventive measures are discussed.

Circumferential dissection with intimal intussusception: an unusual case of acute aortic type A dissection.

An unusual case of a type-A aortic dissection with complete circumferential dissection just above the aortic valve with intimointimal intussuseption just distal to the left subclavian artery partially obstructing the descending aorta is described. CT-scan and transesophageal echocardiography together with clinical suspicion led to the correct diagnosis. Intimointimal intussusception is an unusual type of aortic dissection in which a proximal circumferential tear causes dissection with intussusception of the torn intima downstream, which could cause confusion about the appropriate diagnosis ([1]). It is a very infrequent complication of aortic dissection with only a few cases reported in the literature ([2-6]). CT scan and transesophageal echocardiography are the most accurate diagnostic tools ([7-9]). We describe a patient with intimointimal intussusception, diagnosed by CT scan and transesophageal echocardiography.

Choice of graft material at primary CABG influences cardiac death and reintervention rates.

OBJECTIVES: To evaluate long-term survival and need for reintervention (redo CABG or percutaneous coronary artery transluminal angioplasty, PTCA) as a result of graft materials employed at the primary coronary artery bypass grafting (CABG). SUBJECTS AND METHODS: 2,327 patients who underwent primary CABG between 1980 and 1990 were followed with regard to survival and reintervention requirements for a period of 10 years. There were three groups of patients. In group 1, CABG was performed between 1980 and 1982 using veins only. Group 2 subjects had CABG done from 1983 to 1985 using veins and internal thoracic artery (ITA). Those in group 3 received two ITAs (double ITA) from 1985 to 1990. Redo CABG and PTCS were performed as needed. RESULTS: The 10-year cumulative survival figures for the groups were 92.8 % (group 1), 94.8% (group 2) and 95.4% (group 3). The difference between the groups was statistically significant (p < 0.001). Cardiac event-free survival was 74.4% (group 1), 83.5% (group 2) and 92.6% (group 3), with p < 0.0001. Myocardial infarction occurred more frequently in group 1 (4.7%) than in groups 2 or 3 (2.2 and 1.3%, respectively). The redo rates for CABG were 13.6% (group 1), 8.1% (group 2), and 1.3% (group 3). The corresponding PTCA rates for the three groups were 7.1, 3.7 and 1.6%, respectively (p < 0.0001). CONCLUSIONS: Double ITA, compared with single ITA and/or vein grafts, was the optimal graft material at the time of primary CABG because it had the lowest reintervention rate. It also did not increase postoperative morbidity.

Aortic arch replacement using a four-branched aortic arch graft.

Surgical repair for aortic arch aneurysms is associated with considerable mortality and morbidity. Adequate brain protection is essential. Experience of aortic arch repair in six patients using a four-branched arch graft is described. There were two emergency and three reoperations. One patient had ruptured aneurysm. Hypothermic cardiopulmonary bypass (18-22 degrees C) was employed. A four-branched polymer albumin-coated arch graft was used. The fourth branch of the graft was used for secondary arterial cannulation to ensure continuous brain circulation. One hospital death occurred. No permanent neurological event occurred. The four-branched arch graft facilitates fashioning arch branch anastomoses and provides better brain protection.

Pre-operative intra-aortic balloon counterpulsation in stable patients with left main coronary disease.

OBJECTIVE: To determine whether prophylactic, pre-operative, intra-aortic balloon counterpulsation (IABC) improves clinical outcome in stable patients with severe left main coronary artery disease. METHODS: A post-hoc analysis of 457 prospectively tracked, non-randomized patients undergoing coronary artery bypass graft surgery (CABG) for left main stenoses 50% and multivessel coronary disease, but without any hemodynamic compromise or ongoing angina, was conducted. Patients with heart failure, shock, ongoing ischemia or previous CABG were excluded. In 287 patients, pre-operative IABC was not used (Group 1), while IABC was initiated in 170 patients for "prophylaxis" (Group 2). RESULTS: Groups 1 and 2 were similar in age (67 +/- 10 years versus 67 +/- 11 years, respectively), sex (72% male versus 71% male, respectively), and body mass index (28 +/- 5.5 versus 27 +/- 5.1, respectively). However, more Group 1 patients had peripheral vascular disease (PVD) (25% versus 11%), but more Group 2 patients had diabetes (37% versus 29%), and a lower left ventricular ejection fraction. The unadjusted 30-day mortality was significantly higher in Group 1 [16 (5.6%) versus 2 (1.2%); p = 0.02]. Cardiopulmonary bypass time and post-operative length of stay did not differ between the two groups. After adjusting for PVD in the multivariate analysis, the p-value for the no IABP versus IABP comparison in the presence of PVD was 0.10, even though 0/18 patients with PVD and IABC died. CONCLUSION: While unadjusted mortality appears lower with prophylactic IABC, confounding variables such as PVD mandate a larger, randomized clinical trial in order to establish the role of IABC in stable patients with left main disease.

Impact of double internal thoracic artery grafts on long-term outcomes in coronary artery bypass grafting.

We performed this study to determine if bilateral internal thoracic artery grafts provide greater benefit than single internal thoracic artery grafts. Six hundred ninety-four consecutive patients who received 2 coronary grafts in a single operation during 1983-1989 were given 10 years of follow-up and then analyzed retrospectively. Group 1 (n=382) received 2 internal thoracic artery grafts, Group 2 (n= 139) received 1 internal thoracic artery graft and 1 saphenous vein graft, and Group 3 (n= 173) received 2 saphenous vein grafts. Patient demographics, preoperative angiographic findings, and operative indications were the same. Hospital mortality rates were 2.6%, 2.2%, and 2.3%, respectively. Hemorrhage, sternal wound infection, mediastinitis, sternal dehiscence, and prolonged ventilatory support showed no group differences. Follow-up over 10 years was complete in 677 survivors. Mortality rates during follow-up were 1.8%, 2.9%, and 4.7%, respectively. Cardiac-related mortality rates were 71%, 75%, and 88%, respectively (Group 1 vs Group 3, P=0.0412). Ten-year survival was better for Group 1 than for Groups 2 and 3 (P=0.0356 and P <0.0001). Cardiac-event-free survival at 10 years was 93% in Group 1, 84% in Group 2, and 74% in Group 3 (all P <0.0001). The use of 2 internal thoracic artery grafts resulted in significantly lower risk of cardiac death and re-intervention, compared with the use of 1 internal thoracic artery, which in turn was superior to the use of vein grafts. Use of double internal thoracic arteries did not increase postoperative complications.

Effective surgical management of high-risk coronary patients using preoperative intra-aortic balloon counterpulsation therapy.

The proportion of high-risk coronary patients submitted to surgical myocardial revascularization (CABG) is steadily increasing. High-risk patients utilize more hospital resources and have a higher procedural cost than low-moderate risk CABG patients. An efficient management is essential to improve outcome and reduce costs. This report entails three study periods. In an initial retrospective study coronary high-risk criteria were established. At least two of the following factors were required: redo CABG, unstable angina, left main stem stenosis greater than 70%, preoperative left ventricular ejection fraction < 0.30 and diffuse coronary artery disease. Poor preoperative cardiac performance was the major contributing factor for poor outcome. Intra-aortic balloon counterpulsation therapy (IABP) was introduced as preoperative therapy. During a second study period prospective randomized studies found preoperative IABP-therapy efficient, significantly improving both preoperative cardiac index (P < 0.0001), decreasing postoperative mortality (P < 0.0001) and morbidity, shorten intensive care unit stay as well as total hospital stay (P < 0.0001). Drug consumption was significantly reduced (P < 0.0001). Optimal timing was found to be 2 h prior to aortic cross-clamping and the therapy was found highly cost-beneficial with an average 36% reduction of the total procedural cost. During a third study period, well beyond any study protocol period, preoperative IABP therapy was again found highly effective with a close to 100% utilization rate in high-risk patients and continuous efficacy with excellent outcome, despite acceptance of sicker patients. During this post-study evaluation period 1/3 of the high-risk patients presented with 4 of the established risk factors. The use of preoperative IABP therapy is therefore highly recommended for high-risk coronary patients undergoing CABG.

Obtaining a superficial femoral artery graft in adolescents and children with the deep femoral artery transposition.

A new technique to obtain a segment of the superficial femoral artery as an arterial conduit in young patients while an unobstructed peripheral blood flow is maintained by superficial femoral artery-deep femoral artery transposition is illustrated with two clinical examples. The explanted arterial autograft requires no replacement by another graft and provides a conduit of up to 10 cm in length. Excellent results were achieved in both patients at 1 year. This technique is recommended instead of saphenous vein conduits in very young patients because of the risk for late vein degeneration.

Preoperative lipid control with simvastatin reduces the risk for graft failure already 1 year after myocardial revascularization.

Hypercholesterolemia is a recognized risk factor for development of atherosclerosis in both native coronary arteries and bypass grafts. Lipid-lowering therapy with statins is effective. Few data are available for studies on bypass grafts. The influence of hypercholesterolemia on development of bypass graft disease was studied. Clinical and angiographic follow up 1yr after CABG of patients with a preoperative cholesterol >6.2mmol/l, with a preoperative lipid control (group 2) or controls (group 1) and patients with cholesterol <4.7mmol/l (group 3) were studied. Patient demographics, angiography and operation data were the same in all the groups. Group 1 patients had significantly higher incidence of graft lesions, requiring more interventions than Group 2. Sequential vein bypass grafts showed superior features compared to single vein grafts. Preoperative lipid control with statins is strongly recommended, since uncontrolled hypercholesterolemia has a direct impact on the outcome of CABG procedure. It significantly reduces the development of vein graft obstructive disease.

Economic impact of preoperative intraaortic balloon pump therapy in high-risk coronary patients.

BACKGROUND: The efficacy of preoperative intraaortic balloon pump therapy in high-risk coronary patients has been demonstrated earlier. METHODS: This study investigates the economic aspect by a detailed cost analysis of pooled information from two previously published randomized studies and 144 consecutive low-risk coronary artery bypass graft operations. Costs for patients receiving preoperative intraaortic balloon pump therapy before aortic cross-clamping (n = 62) were compared to those in a control group (n = 50). Detailed cost analysis was based on data provided by the hospital finance department. RESULTS: The total hospital costs were as follows: low-risk coronary artery bypass graft operations cost 35,335+/-1,694 Swiss francs ($23,400+/-$1,121); high-risk coronary artery bypass graft without preoperative intraaortic balloon pump therapy cost 65,892+/-31,719 Swiss francs ($43,637+/-$21,006); and high risk coronary artery bypass graft with preoperative intraaortic balloon pump therapy cost 41,948+/-10,379 Swiss francs ($27,780+/-$6,874) (p = 0.0015). There were no significant differences in average cost among the preoperative intraaortic balloon pump therapy subgroups. CONCLUSIONS: Preoperative intraaortic balloon pump therapy in high risk coronary patients is significantly cost-beneficial, With an average saving of 24,000 Swiss francs ($16,000) on the total hospital cost, a 36% cost reduction.

Endovascular repair using vein-covered stents in the carotid artery bifurcation.

The treatment of a bleeding carotid artery pseudoaneurysm in a patient using endovascular repair is described. Vein-covered stents were successfully employed. There were no neurological complications and no recurrent bleeding during 8 months follow up and carotid artery continuity was achieved. Stents covered with saphenous vein may be considered a treatment option for endovascular repair of pseudoaneurysm of the carotid artery.