Iatrogenic vascular injuries with lethal outcome.

BACKGROUND: The aim was to study the nature of iatrogenic vascular injuries (IVIs) associated with postoperative death within 30 days. METHODS: Patients who had undergone vascular surgery for IVIs and were reported prospectively to the Swedish national vascular registry during 1987-2008 were identified. They were cross-checked with the national population registry. Those who died within 30 days of surgery were studied regarding case records and death certificates. RESULTS: A total of 56 patients with postoperative death within 30 days after IVI were identified. Among them, 52 case records were retrieved (93 %). In 24 cases the IVIs were caused by puncture during endovascular procedures (13 hemorrhage, 11 occlusive thrombosis), 11 by penetrating trauma during open surgery, 6 by occlusion after external compression, 6 by percutaneous accidental arterial puncture. Main symptoms were peripheral ischemia (19/52, 37 %), external bleeding (14, 27 %), and hypovolemic shock without external bleeding (10, 19 %). Main specialties involved were interventional radiology (n = 18), general surgery (n = 9), and interventional cardiology (n = 8). Overall, 22 (42 %) were avoidable, and only 13 (25 %) underwent autopsy. Within 2 weeks, 36 patients (69 %) were dead. Also, there was a higher proportion with uncertain correlation between IVI and death. CONCLUSIONS: Interventional radiology, general surgery, and cardiology are the main specialities involved in IVIs with lethal outcome. Not all fatalities after IVI are attributable to the injury itself, but almost half of the injuries were considered avoidable.

Insurance claims after vascular surgery in Sweden.

OBJECTIVES: The study aimed to estimate the incidence and causes of insurance claims (IC) after vascular surgery (VS) reported to the Swedish Medical Injury Insurance (SMII); and to validate the registration of complications in the National Vascular Registry (Swedvasc). METHODS: The medical records of all IC in VS in Sweden reported to the SMII 2002-2007 were scrutinised and cross-referenced against Swedvasc. RESULTS: There were 193 claims after VS: varicose-veins (66), lower extremity (45), aortic (31) or carotid artery (21), access (19) or other VS (11). Frequent causes of claims were peripheral nerve injury (76), wound infection (22) and cranial nerve injury (15). More than half of the patients suffered permanent injuries, three died. As many as 55 (28%) received economic compensation (an average of 45% of all ICs in SMII). The highest frequency of compensated claims (1:650 yearly procedures) was for carotid artery surgery. Of the procedures, 187 were elective. Compared with the Swedvasc, claudication was a more common indication (28% vs. 12%). Nearly one-fifth (18%) were incorrectly registered in Swedvasc. CONCLUSIONS: The most common causes of insurance claims were peripheral nerve injuries and infections. Patients raising insurance claims after vascular surgery undergo acute procedures less frequently, and are correctly registered in the Swedvasc in 82% of cases.

Iatrogenic vascular injuries in Sweden. A nationwide study 1987-2005.

OBJECTIVES: To study the epidemiology of vascular injuries, with special focus on iatrogenic vascular injuries (IVIs) and time-trends. DESIGN AND METHODS: From the Swedish national vascular registry, Swedvasc, prospectively registered data on vascular injuries during 1987-2005 were analysed and cross-referenced for mortality against the population registry. RESULTS: Of 1853 injuries, 48% were caused by iatrogenic, 29% penetrating and 23% blunt trauma. In the three groups median age was 68, 35 and 40 years, respectively. The annual incidence of procedures for vascular injuries increased from 1.2-1.6 per 100 000 inhabitants and the proportion of IVIs increased from 41 to 51%, during the period. Mortality was higher after IVI (4.9%) compared to non-IVI (2.5%). Patients with IVI also had more co-morbidities; 58% cardiac disease, 44% hypertension, and 18% renal dysfunction. Among 888 IVIs, right femoral arterial injury was the most frequent (37%). The most common vascular reconstruction was direct suture (39%) followed by by-pass or interposition graft (19%, of which prosthetics were used in over half the cases). Endovascular repair increased from 4.6% to 15% between 1987 and 2005. CONCLUSIONS: Vascular injuries, in particular iatrogenic ones, appear to be increasing. Iatrogenic injuries affect vulnerable patients with co-morbidities and are associated with a high mortality.

Popliteal artery injury during knee replacement: a population-based nationwide study.

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations.

A prognostic index of unsuccessful laparoscopic cholecystectomy for acute calculous cholecystitis.

The aim of this retrospective study was to investigate the accuracy of using preoperative data for the prediction of conversion from laparoscopic to open cholecystectomy in patients operated on for acute calculous cholecystitis. Laparoscopic cholecystectomy was scheduled in eighty-nine of 184 consecutive patients with acute calculous cholecystitis who underwent urgent or early cholecystectomy without bile duct exploration in our department between 1991 and 1998. The correlation between 11 preoperative clinical, laboratory and ultrasonographic variables, and the rate of conversion to open cholecystectomy was studied. Among the 11 variables tested, age and leukocyte count were independent factors of predictive significance. These two factors were used for constructing an additive prognostic index for conversion to open cholecystectomy. Thus, three groups of patients could be identified having a 10%, 30-70% or over 88% risk of conversion. Logistic regression analysis permits accurate preoperative identification of unsuccessful laparoscopic cholecystectomy in patients with acute calculous cholecystitis.