Risk Factors for Complications after Peripheral Vascular Surgery in 3,202 Patient Procedures.

BACKGROUND: Complications after open vascular surgery are a major health challenge for the healthcare system and the patients. Infrainguinal vascular surgery is often perceived as less risky than aortic surgery and the aim of this study was to identify which risk factors correlated with postoperative complications after open vascular surgery for infrainguinal occlusive disease in an 8-year cohort using the Danish National Vascular Registry (Karbase), which gathers information on all vascular procedures in Denmark. METHODS: This study is a retrospective cohort study. The Karbase was searched for the predefined procedures from January 1, 2005 through December 31, 2012 at our 2 vascular departments. Both elective and urgent surgeries were included. Complications were defined as wound, surgical, or general complication according to Karbase. RESULTS: Three thousand two hundred two procedures were identified. Median age was 70 years and 21% were octogenarians. Sixty percent were male. There was an overall complication rate of 30%, with 19% being wound complications, 6% surgical, and 10% general complications. The greatest risk factors for developing a complication were high age, cardiac and renal disease, high American Society of Anesthesiologists score, and general anesthetics. The 30-day mortality was 5% (1% for claudicants and 8% for acute ischemia) and the 30-day amputation rate was 7% (0.5% for claudicants and 21% for gangrene). CONCLUSIONS: There is a high risk of complication in peripheral vascular surgery. Risk factors are modifiable or nonmodifiable. It is important to identify the risk factors and treat and optimize the patient cardiac and renal status before surgery if time allows, and also to perform surgery in local or regional anesthesia whenever possible, to reduce the risk of postoperative complications.

Mortality and complications after aortic bifurcated bypass procedures for chronic aortoiliac occlusive disease.

OBJECTIVE: Open surgery has given way to endovascular grafting in patients with aortoiliac occlusive disease. The growing use of endovascular grafts means that fewer patients with aortoiliac occlusive disease have open surgery. The declining open surgery caseload challenges the surgeon's operative skills, particularly because open surgery is increasingly used in those patients who are unsuitable for endovascular repair and hence technically more demanding. We assessed the early outcome after aortic bifurcated bypass procedures during two decades of growing endovascular activity and identified preoperative risk factors. METHODS: Data on patients with chronic limb ischemia were prospectively collected during a 20-year period (1993 to 2012). The data were obtained from the Danish Vascular Registry, assessed, and merged with data from The Danish Civil Registration System. RESULTS: We identified 3623 aortobifemoral and 144 aortobiiliac bypass procedures. The annual caseload fell from 323 to 106 during the study period, but the 30-day mortality at 3.6% (95% confidence interval [CI], 3.0-4.1) and the 30-day major complication rate remained constant at 20% (95% CI, 18-21). Gangrene (odds ratio [OR], 3.3; 95% CI, 1.7-6.5; P = .005) was the most significant risk factor for 30-day mortality, followed by renal insufficiency (OR, 2.5; 95% CI, 1.1-5.8; P = .035) and cardiac disease (OR, 2.1; 95% CI, 1.4-3.1; P < .001). Multiorgan failure, mesenteric ischemia, need for dialysis, and cardiac complications were the most lethal complications, with mortality rates of 94%, 44%, 38%, and 34%, respectively. CONCLUSIONS: Aortic bifurcated bypass is a high-risk procedure. Although open surgery has increasingly given way to endovascular repair, 30-day outcomes have remained stable during the past decade. Thus, it is still acceptable to consider an aortic bifurcated bypass whenever endovascular management is not feasible.

Reducing delay of carotid endarterectomy in acute ischemic stroke patients: a nationwide initiative.

BACKGROUND AND PURPOSE: Guidelines recommend carotid endarterectomy (CEA) within 2 weeks from an ischemic event. However, previous studies have shown that only a minority of patients undergo CEA within this period. The aim of this study was to examine the effect of a multidisciplinary nationwide initiative aimed at reducing time to CEA after acute ischemic stroke. METHODS: We examined a historic population-based observational cohort based on individual patient-level records from the Danish Stroke Registry and the Danish Vascular Registry. The implementation of early ultrasound examination of the carotids (within 4 days from admission) in medical departments coupled with fast CEA after referral to a department of vascular surgery were monitored and audited systematically from 2008 and onward. RESULTS: A total of 813 acute ischemic stroke patients underwent CEA during 2007-2010. The percentage of patients undergoing CEA within 2 weeks increased from 13% in 2007 to 47% in 2010 (adjusted odds ratio, 5.8 [95% CI, 3.4-10.1]). The overall median time decreased from 31 days to 16 days. The percentage of relevant acute ischemic stroke patients receiving early ultrasound examination of the carotids increased from 41% in 2008 to 72% in 2010. The time from referral to operation at a vascular department was reduced by ≈40%. CONCLUSIONS: Establishing time limits of 4 days to ultrasound examination of the carotids and of 2 weeks to CEA from onset of stroke followed by a systematic multidisciplinary monitoring and auditing of processes was associated with a substantial increase in the proportion of acute ischemic stroke patients who undergo CEA within 2 weeks in Denmark.

Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis.

BACKGROUND: Postthrombotic syndrome (PTS) is a common complication after iliofemoral venous thrombosis, often resulting in poor quality of life (QOL) among the affected patients. This study assessed development of PTS and its effect on QOL among patients treated for iliofemoral venous thrombosis by catheter-directed thrombolysis. METHODS: Patients admitted with an iliofemoral venous thrombosis and treated with catheter-directed thrombolysis at Gentofte University Hospital from 1999 to 2008 were invited to participate. Duplex ultrasound imaging was used to assess venous patency and valve function. Each patient completed the generic Short-Form 36-item (SF-36) health survey assessment, producing physical component (PCS) and mental component summary (MCS) scores, and the disease-specific Venous Insufficiency Epidemiological and Economic Study (VEINES)-Quality of Life (QOL)/Symptoms (Sym), questionnaires to assess QOL. PTS was assessed using the Villalta scale. RESULTS: The study included 109 patients. Median follow-up was 71 months. PTS developed in 18 patients (16.5%) and of those, initial thrombolysis was successful in 13. Patients with PTS had significantly worse mean ± standard deviation scores than patients without PTS on VEINES-QOL (34.2 ± 9.6 vs 53.1 ± 6.6; P < .0001), VEINES-Sym (34.0 ± 8.8 vs 53.2 ± 6.6; P < .0001), SF-36 MCS (44.2 ± 15.5 vs 52.3 ± 11.0; P = .005), and SF-36 PCS (42.3 ± 9.1 vs 53.5 ± 7.8; P < .0001) subscales. Patients with reflux or chronic occlusions, or both, had significantly lower mean ± SD scores than patients with patent veins without reflux on VEINES-QOL (43.5 ± 14.3 vs 51.0 ± 8.8; P = .044) and SF-36 PCS (47.2 ± 10.9 vs 52.4 ± 8.5; P = .049) scales. CONCLUSION: PTS was associated with worse QOL, although only a few patients developed PTS after catheter-directed thrombolysis of iliofemoral venous thrombosis. Patients with patent veins and sufficient valves have higher QOL scores than patients with reflux and occluded veins.

Patients and physicians agree only partially in symptoms and clinical findings before and after treatment for varicose veins.

Objective Quality improvement in surgery has mainly been based on clinical database outcomes. This study compared variables from the patient-reported Aberdeen Varicose Vein Questionnaire with the Danish Clinical Vein Database, in order to reveal agreements and differences in symptoms and clinical findings. Methods In the period January-March 2011, 379 legs in 287 patients treated for varicose veins were registered in the Danish Clinical Vein Database and compared to the Aberdeen Varicose Vein Questionnaire. Results Patients and physicians agreed in reduction of symptoms after intervention with one or more complaints still present in 128 (93%) patients according to Aberdeen Varicose Vein Questionnaire compared to the Danish Clinical Vein Database with only 64 (47%) patients. Patients reported cosmetic complaints and teleangiectasies both before and after treatment (p < 0.001) more often than doctors. Conclusion The Aberdeen Varicose Vein Questionnaire has added valuable information to the dialogue between the doctor and patient on which symptoms expecting to improve and which not.

[Clinical indicators and quality databases--a review]. / Kliniske indikatorer og kvalitetsdatabaser--en oversigt.

This review states the work which has been done in Denmark on clinical indicators and large databases containing clinical data with nationwide coverage. The aim of the work was to obtain valid and reliable information on clinical quality to be used by clinicians, leaders, and the public. Nationally we have: 1) The needed experience related to identification and development of clinical indicators and construction of databases. 2) The necessary partners (scientific societies, hospital owners, primary care sector, and health authorities) are motivated and involved in a collaborative organisation. Nationally we lack: 1) Experience with implementation and use of clinical indicators. 2) An overview of the needed investments to ensure coverage of all important diseases, continuity in patient care, and improvement of the existing databases. 3) Fully integrated information systems.

[Vascular reconstruction of venous occlusion in the lower extremities. Experiences in 12 patients]. / Karkirurgisk rekonstruktion ved venøs okklusion i underekstremiteterne. Erfaringer fra 12 patienter.

INTRODUCTION: This paper describes the late results after surgical reconstruction for deep venous occlusion in the lower extremities. MATERIAL AND METHODS: Twelve patients were treated, two women and 10 men (median age 46, range 17-66 years) over a 6-year period. Seven patients had chronic venous occlusion with venous claudication or ulcer, two had DVT with severely affected limbs, and three were reconstructed, because of tumour involvement. Externally supported ePTFE grafts were used in 11 patients and vein material in the last patient. The median follow-up period was 18 months (range 1-96 months). Evaluation of patency included clinical examination and duplex ultrasound or phlebography. RESULTS: One patient died three weeks postoperatively of multiorgan failure. Another died one year postoperatively of pulmonary metastases from a leiomyosarcoma of the common femoral vein. At follow-up, 50% of the reconstructions had remained open for a median period of five years. DISCUSSION: The results are comparable with those of the literature. The selection of patients requires, in addition to anatomic visualisation of the occluded segment, a haemodynamic demonstration of venous obstruction, i.e. by a pressure gradient across the occluded segment. Surgical reconstruction is possible in the case of a strong indication.

[Distribution of colonic surgery among surgeons in the city of Copenhagen]. / Fordeling af colonkirurgi på operatører i hovedstadsområdet.

INTRODUCTION: The outcome of some surgical procedures is related to the surgeon's experience. We examined how much experience surgeons in 12 hospitals in the region of Copenhagen gained in colon surgery in 1999. MATERIAL AND METHODS: The Ministry of Health identified the number of colon patients operated on in the region of Copenhagen in 1999. The departments were asked to validate the lists of patients and to fill in a questionnaire describing the surgeon's experience in that year. RESULTS: Eleven of 12 departments answered the questionnaire (92%). One hundred and two senior surgeons operated on 674 patients. Forty of the surgeons operated on one to four patients in 1999, and only five performed 15 or more operations. More than 50% of the surgical procedures were carried out by surgeons who performed fewer than 10 colon operations in 1999. Most of the low-volume surgeons' operations were performed during calls. DISCUSSION: Colon surgery in the region of Copenhagen was performed by a large number of surgeons in many hospitals in 1999. Hospital volume was not associated with surgeon volume.

[IT systems for clinical databases--status and perspectives]. / It-systemer til kliniske kvalitetsdatabaser--status og perspektiver.

Generally, the use of clinical databases for quality development in the hospital sector has not been satisfactory. A substantial problem attaches to the IT systems used hitherto. This article describes a number of requirements which the National Indicator Project has specified for a forthcoming second generation of clinical database system. Besides, the second generation system Clinical Performance Measurements which is used in the Copenhagen Hospital Corporation for several disease areas and for The Danish Vascular Registry is described. This experience emphasizes the need for central management of development initiatives within clinical quality databases. The management must allow for coordination, rational management and experience-based further development of IT systems for the clinical databases and integration with present and forthcoming systems including electronic patient record systems. The management should also allow for the decisive interaction between clinical quality development and medical informatics.

[Local thrombolysis in proximal deep venous thrombosis of the lower extremity]. / Lokal trombolyse ved proksimal dyb venetrombose i underekstremiteten.

INTRODUCTION: Deep venous thrombosis (DVT) often leads to chronic venous insufficiency and the present study was conducted in order to investigate the effectiveness of catheter-directed thrombolysis in patients with proximal DVT of the lower extremity (iliac vein involved), with respect to recanalisation and maintenance of venous valve function. MATERIAL AND METHODS: A prospective clinical investigation was carried out with puncture of the popliteal vein for continuous infusion of r-alteplase. Twelve patients suffering from recent proximal DVT were treated: In 10 patients the left extremity was affected, in two the right. Three of the 12 patients had factor V Leiden mutation in the heterozygote form, one of whom also had prothrombin mutation in heterozygote form. RESULTS: Ten of the 12 had their venous thrombosis successfully lysed and were discharged with an open venous system in the affected limb. The lysed venous segments remained patent in all ten, with normal venous valve function, as evaluated by Doppler reflux testing. The median follow-up time was five months (range 0-9 months). In one patient, the proximal thrombus (iliac) was lysed successfully, but the femoral vein could not be opened, probably because of an old thrombus remaining from a previous DVT episode. In the other patient, the venous thrombus was lysed successfully, but the vein rethrombosed after one day. DISCUSSION: Catheter-directed thrombolysis appears feasible in patients with recent proximal DVT and the short-term results are good in terms of venous patency and valve function. A randomised trial is necessary to test whether this treatment modality is superior to conventional anticoagulation therapy.

Treatment of chronic upper limb ischaemia is safe and results are good.

INTRODUCTION: Chronic ischaemia of the upper extremity is rare, and only a few small studies are published on results after revascularisation. We found it of interest to present this larger population-based registry-study of patients treated for chronic ischaemia of the upper limb by open or endovascular procedures. MATERIAL AND METHODS: A total of 101,725 primary arterial vascular procedures in the Danish National Vascular Registry (Karbase) were recorded from 1.1.1993 to 31.12.2011. Of these, a total of 453 (0.4%) procedures were performed for chronic stenotic disease of the proximal arteries of the upper limb, 233 endovascularly and 220 by open surgery. RESULTS: Open reconstructions: Two patients died within 30 days, which is equivalent to a mortality rate of 0.9%. Six (2.7%) reconstructions occluded before discharge. Complications were observed in 41 patients (19%); the complications were predominantly related to surgical wound. At follow-up, 74 (70%) had no symptoms. Endovascular reconstructions: There were six deaths within the first 30 days, which is equivalent to an early mortality rate of 2.6%. Four (2%) reconstructions occluded before discharge. Complications were observed for 23 (10%) patients; the complications were predominantly of neurovascular origin. At follow-up, 90 (74%) had no symptoms. The one-year survival was 95% with no difference between the two groups. CONCLUSION: Chronic ischaemia of the upper limb can be treated both with open surgery and endovascularly with acceptable results. There was an excellent one-year patency rate for the patients who showed up for follow-up; the patency rate was comparable to that reported in the literature. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Cone pathway function in relation to asymmetric carotid artery stenosis: correlation to blood pressure.

PURPOSE: To examine retinal function in relation to retinal perfusion pressure in patients with carotid artery stenosis. METHODS: Thirteen patients with carotid artery stenosis without clinical eye disease underwent assessment of ophthalmic artery systolic blood pressure (OSP) by ocular pneumoplethysmography, carotid artery obstructive disease by ultrasonography, intraocular pressure by applanation tonometry, retinal perfusion by fluorescein angiography and retinal function by multifocal electroretinography (mfERG). Data analysis compared the eye on the most stenotic side with the fellow eye in the same patient. RESULTS: Ophthalmic systolic pressure was 95.8 ± 13.1 mmHg on the side with the highest degree of carotid artery stenosis (mean 94.0%) and 111.7 ± 10.3 mmHg in the fellow eyes on the side with the lesser degree of stenosis (mean 33.9%). Summed mfERG implicit times (N1 and P1) were 3.4% and 2.0% longer (p = 0.013 and 0.021), and N1 and P1 amplitudes were 18.0% and 16.0% (p = 0.0041 and 0.020) lower in eyes on the side with the higher stenosis compared with the contralateral eyes. Shorter implicit times and higher amplitudes were correlated with higher brachial systolic arterial blood pressure (p = 0.0028, 0.011, 0.041 for N1, P1, N2 implicit times, respectively, and p = 0.0086, 0.016, 0.040 for N1, P1, N2 for amplitudes, respectively, corrected for OSP). CONCLUSION: Cone function deviation was observed in clinically healthy eyes on the side with highest degree of carotid artery stenosis and was found correlated to arterial blood pressure.

Retinal angiographic blood flowmetry is reduced in the ocular ischaemic syndrome.

INTRODUCTION: The aim of this study was to examine the use of quantitative fluorescein angiographic analysis as a means of estimating rates of perfusion of the retina in eyes with a circulatory deficit secondary to carotid artery stenosis. MATERIAL AND METHODS: The study included 21 eyes with ocular ischaemic syndrome (OIS) and 20 control eyes from subjects with carotid artery stenosis but without signs of ocular ischaemia. Analyses of video fluorescein angiograms extracting time intervals for the time delay between specific phases of the angiogram were performed. Time delay was compared between groups and in relation to degree of carotid artery stenosis and ocular systolic blood pressure. RESULTS: Among the three flow indices of retinal perfusion (arteriovenous passage time 1 (AVP1), arteriovenous passage time 2 (AVP2) and venous filling time (VP)), those including the venous filling phase were significantly prolonged in the OIS group. Furthermore, AVP2 was delayed by 3 sec. in OIS eyes (16.6 sec. versus 13.6 sec. in controls). VP was 2.4 sec. longer in OIS eyes (11.5 sec. versus 9.1 sec.). We found a significant correlation between AVP2 and ocular perfusion pressure, but no correlation between the degree of carotid artery stenosis and any of the flow indices. CONCLUSION: In a patient population spanning a wide ocular systolic blood pressure range, angiography-based quantitative flowmetry demonstrated a difference between carotid artery stenosis patients with and without OIS and a correlation between flow and ocular perfusion pressure. While angiographic flowmetry proved effective in discriminating between groups of individuals, it can only be used to support the diagnosis of the ocular ischaemic syndrome in patients with extreme flow reduction.

[Endovascular and open repair of abdominal aortic aneurysm are still both warranted--a systematic review]. / Fortsat behov for både endovaskulær og åben kirurgisk behandling af abdominalt aortaaneurisme.

Abdominal aortic aneurysm can be treated by open surgical repair or by endovascular repair (EVAR) - a less invasive procedure, with lower 30-day mortality and morbidity rates. Twelve studies have been evaluated. The results indicate that for large aneurysms > 5.5 cm, EVAR can be recommended for patients with intermediate to high operative risk. For younger patients, with low operative risk, OR is the preferred method, in light of the continued small risk of rupture after EVAR and the need for lifelong surveillance.

Prolonged multifocal electroretinographic implicit times in the ocular ischemic syndrome.

Purpose. To examine retinal function in chronic ocular ischemia using multifocal electroretinography (mfERG). Methods. Thirteen patients with unilateral ocular ischemic syndrome (OIS) underwent assessment of ophthalmic systolic blood pressure by ocular pneumoplethysmography, carotid artery patency by ultrasonography, intraocular pressure (IOP) by applanation tonometry, retinal perfusion by fluorescein angiography, and retinal function by mfERG. Results. Ophthalmic systolic blood pressure was 67.0 +/- 11.6 mm Hg in eyes with OIS and 106.1 +/- 18.0 mm Hg in fellow eyes, whereas IOP was 13.8 +/- 3.2 and 14.4 +/- 1.7 mm Hg, respectively. Summed mfERG implicit times (N1, P1, N2) were prolonged in eyes with OIS, by 7.6%, 6.2%, and 7.5%, respectively, compared with fellow eyes (P < or = 0.0048). The retardation of retinal function was significant outside the macula, whereas the assessment of responses from the central retina was limited by high variance. Second-order kernel (first slice) summed implicit times (N1, P1, N2) were also prolonged in OIS, by 6.6%, 7.3%, and 6.8%, respectively (P < or = 0.0058). Of the amplitudes, only the second-order N2 amplitude was significantly abnormal, being reduced by 23.2% in OIS (P = 0.011). Conclusions. The function of the outer and middle layers of the retina was found to be suppressed in chronic ocular hypoperfusion. The moderate delay in retinal function does not appear to explain the prominent photopic symptom of diffuse glare in bright light, and the delay could be evidence of a functional adaptation that serves to maintain and optimize signaling under conditions of compromised perfusion. (ClinicalTrials.gov number, NCT00403195.).

[A hybrid approach to surgery for thoracic aortic aneurysm]. / Hybridoperation af torakalt aortaaneurisme.

A 57-year-old male, previously treated surgically with insertion of grafts for type A and B aortic dissection, presented with a pulsatile mass in the jugular fossa. Further examination verified a pseudoaneurysm the inlet of which was located at the proximal anastomotic site of the descending aortic graft and a newly developed aneurysm of the aortic arch. Using a left lateral thoracotomy to avoid manipulation of the pseudoaneurysm, we adopted a hybrid approach by first debranching the subclavian and carotid arteries from the descending aorta followed by endoluminal grafting of the aortic arch. The pseudoaneurysm was successfully excluded.

[Carotid endarterectomy. Experiences with shortening of interval between symptom and operation]. / Subakut carotisendarterektomi. Erfaringer med afkortning af tidsrummet mellem symptom og operation.

INTRODUCTION: Carotid endarterectomy (CEA) prevents transient ischemic attack and stroke in patients with symptomatic high-grade carotid stenosis. In 2004 Rothwell et al showed that maximal benefit is gained if CEA is performed less than three weeks after the onset of the symptom. With the aim of observing this recommendation, in 2005 the Department of Vascular Surgery, Gentofte Hospital, introduced an accelerated course of examinations, a fast track, prior to CEA. MATERIALS AND METHODS: A retrospective study of the course of all patients operated with CEA during the period from June 2003 through September 2006. RESULTS: A total of 147 CEAs were performed on 145 patients, 51 before and 96 after the introduction of fast track. The period between the first symptom and CEA was reduced after the introduction of fast track to 31 days. It was easiest to reduce the time up to CEA in our own department and in the neurological departments. The stroke and death rate was unchanged, 4% and 3% before and after fast track respectively. CONCLUSION: The time between symptom and CEA can be shortened by means of a fast track after thorough information and reorganization of the work involving these patients. In order to bring the length of the period below the recommended three weeks, initiatives must be taken especially among specialist outside hospitals and among departments of general internal medicine.

[Modern treatment of type B dissections]. / Moderne behandling af type B-aortadissektion.

Rapid classification is essential in the management of aortic dissections, as Type A dissections require surgery, while the optimal treatment of Type B dissections is controversial. Medical treatment with antihypertensive medication and analgesics has so far been the main treatment of uncomplicated Type B dissections, while surgery has been reserved for complications and persistent pain in spite of medical treatment. Endovascular techniques are less invasive than open repair and show promising early results.

[Bilateral deep venous thrombosis and vena cava aplasia treated with local thrombolysis]. / Bilateral dyb venøs trombose og vena cava-aplasi behandlet med lokal trombolyse.

In this case report the treatment of a young man with bilateral iliaco-femoral DVT and vena cava aplasia is presented. The patient was treated with catheter-directed thrombolysis; the catheters were introduced in the thrombus of both legs via v. popliteae. The treatment led to almost complete thrombus resolution and no valvular incompetence at three months follow-up. In our opinion this treatment should be offered even in complex cases of acute proximal deep venous thrombosis.