G. Pedersen

SURGICAL TREATMENT OF POPLITEAL ARTERY ANEURYSMS

Objectives: To report the results of surgical treatment of popliteal aneurysms with respect to symptoms and aneurysm size. Design: A retrospective study based on prospectively registered data, in a single vascular unit. Patients and Methods: Forty-nine patients were subjected to 57 operations from May 1974 to June 2000. Patency and limb salvage rates are compared for limbs with and without symptoms of ischaemia, and for small (2 cm or less) and large (> 2 cm) aneurysms. The long-term survival rate was calculated and compared with that of an age and sex-matched population. Results: The overall 5 year graft patency was 60 %. It was 83 % for asymptomatic limbs and 49 % for limbs with ischaemic symptoms. This difference was significant (p < 0,05). The overall 5 year limb salvage rate was 76 %. It was 100 % for asymptomatic and 64 for symptomatic limbs and this difference was significant (p < 0,05). Twenty-one of the aneurysms were 2 cm or less in diameter and 85 % of these caused symptoms of ischemia. The operative mortality was 4 %. The 5-year survival rate was 57 % and significantly lower than that of a demographically matched population. Conclusion: The results of prophylactic operations for popliteal aneurysms on asymptomatic limbs are significantly better than those of operations done on limbs with ischaemic symptoms. The aneurysm size at which to recommend surgery is still not settled.

Treatment of a Hepatic Artery Aneurysm by Endovascular Stent-Grafting

Aneurysms of the visceral arteries are rare. Traditional treatment has been surgical or endovascular with coil embolization. Recently, however, reports on endovascular therapy with stent-grafts have been published. We report the case of a 61-year-old man who was successfully treated with a stent-graft for a symptomatic combined celiac/hepatic artery aneurysm.

Influence of laparoscopic cholecystectomy on the prevalence of operations for gallstones in Norway

OBJECTIVE To assess trends in the treatment of gallstone disease, by recording the number of admissions to hospital and operations; to find out if there are regional differences in the number of operations for gallstone disease; to compare these with those of other countries, and to discuss possible causative factors with special reference to introduction of laparocopic cholecystectomy. DESIGN Study of medical records. SETTING University hospital, Norway. SUBJECTS A total of 55,622 hospital stays and 28,048 operations for gallstone disease were recorded in a national registry for the 8-year period 1992-9, which comprise 99% of all admissions for gallstone disease. INTERVENTIONS Data were compared for number of admissions to hospitals for gallstone disease, incidence of different operations, and trends in treatment. Different regions in Norway were also compared. RESULTS Both the number of hospital stays and the number of gallstone operations increased slightly over the period. Compared with 1992, the open cholecystectomy rate was reduced to 25%, and laparoscopic operations increased more than four times. The incidence of endoscopic procedures showed an annual increase from 1992-9, followed by a fall in 1999 to the 1992 level. CONCLUSION Treatment trends show a pronounced increase in laparoscopic operations, and at the same time fewer open operations. The total number of operations has increased slightly in Norway. The prevalence of operations for gallstones in Norway is the lowest reported in Western Europe. The overall number of gallstone operations in Norway is relatively small. The increase in the number of operations for gallstones in Norway was mainly caused by the increase in laparoscopic cholecystectomies. After a steady rise, there was a fall in the number of endoscopic procedures for common bile duct stones during the last year. At the same time, however, magnetic resonance cholangiopancreatography was introduced in Norway. The prevalence of gallstone disease in the population studied seems to have had little influence on the incidence of operations. Many Norwegian patients with gallstone disease who could benefit from operation are probably not being offered surgical treatment today, but are treated in an expectant manner instead.

Neutrophil CD64 as a Marker for Postoperative Infection: A Pilot Study

The aim of this pilot study was to evaluate the clinical utility of quantitative CD64 measurements to differentiate between systemic inflammation in response to surgical trauma and postoperative bacterial infection. In a consecutive series of 153 patients undergoing elective vascular surgery, peripheral venous blood samples were taken preoperatively on admission and postoperatively during the first 24h. The samples were analysed for C-reactive protein (CRP), total leucocyte counts (white blood cell (WBC)), serum procalcitonin (PCT) and neutrophil CD64 expression. Of the 153 patients, the focus is on those with (1) postoperative infection alone (group 1; n=1 4); (2) pre- and postoperative infection (group 2; n=6); and (3) postoperative fever with no other signs of infection (group 3; n=29). In group 1, all four markers were significantly increased in the 24h after surgery: CD64 (p=0.001), CRP (p=0.001), WBC (p=0.002) and PCT (p=0.012); in group 2, there was no significant difference in the CD64 (p=0.116), WBC (p=0.249) and PCT (p=0.138) values, whereas a marginal significance was shown for CRP (p=0.046); and the results for group 3 were similar to those of group 1. This pilot study suggests that the role of neutrophil CD64 measurements in facilitating the diagnosis of early postoperative infection merits further investigation.

Five‐year outcomes following a randomized trial of femorofemoral and femoropopliteal bypass grafting with heparin‐bonded or standard polytetrafluoroethylene grafts

Cohort studies suggest superior long‐term patency of luminal heparin‐bonded polytetrafluoroethylene (Hb‐PTFE) bypass grafts compared with standard PTFE grafts. The aim of this study was to compare the outcomes of Hb‐PTFE grafts with those of standard PTFE grafts 5 years after a randomized trial.

Non-curative surgery for aortoenteric fistula

Abstract Graft infection with secondary aortic fistula is a rare complication following implantation of aortic prostheses, frequently occurring after emergency procedures and reoperations. The condition is associated with considerable morbidity and mortality. Curative treatment consists of explantation of the infected graft followed by fistula revision and implantation of a new graft in combination with antimicrobial therapy. Non-curative treatment with aortic stentgraft and long-term substitution treatment with antibiotics may be an option in cases where graft explantation is deemed too risky. We present an elderly patient with aortoenteric fistula following surgery for ruptured abdominal aortic aneurysm. Implantation of an aortic stentgraft and fistula revision was performed but the original aortic prosthesis was not explanted. The aortoenteric fistula recurred twice, but the patient has survived more than 12 years following non-curative surgery with good quality of life.

Arteriovenous fistula of the groin in a drug abuser with endocarditis

Abstract Intravenous drug abusers commonly develop endocarditis due to injection of particulate matter that can cause endothelial damage to the valves. The frequent need to access the venous system can result in vascular traumas with potential complications including arteriovenous (AV) fistulas. Here, we present the case of an intravenous drug abuser with endocarditis and an unusually large AV fistula in the groin. The patient was successfully operated for endocarditis. However, the AV fistula was at the time not acknowledged. The combination of ileofemoral vein thrombosis and a large AV fistula led to pulmonary septic embolism and life-threating, right-sided heart failure. Computed tomography scan did not reveal the AV fistula, but suspicion was raised. Ultrasound diagnosed and revealed the magnitude of the AV fistula, and the patient was treated with a minimally invasive percutaneous technique.

Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs.

Background: Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed. Materials and Methods: A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed. Results: Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0–2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium. Conclusions: Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.

Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is technically feasible with acceptable long-term results

OBJECTIVES To investigate the results of endovascular treatment of symptomatic, atherosclerotic lesions of the infrarenal aorta. PATIENTS AND METHOD This is a retrospective study including 30 procedures performed on 25 patients in the period from 1990 through 2003. There were 16 women (64%) and 9 men, with a mean age of 55 years (range 35-81 years). The indication was disabling intermittent claudication in all cases. Preoperative assessment was done with ankle-arm pressure measurement and angiography. The mean length of the lesions was 2.5cm (range 1-6cm). One lesion was a short occlusion and nine were >90% stenoses. The remaining 20 lesions were significant (>70%) stenoses. The procedure was done with PTA alone in 13 cases, and with additional stenting in 17. RESULTS The procedures were technically successful in 28 cases and clinically successful in all 30. In two cases, a >50% residual stenosis was not dilated further because of stretch pain. The mean observation time was 40 months (range 0-135 months). The primary 2 and 5 year patency rates calculated on basis of intention to treat were 90 and 77%. The primary assisted patency rate was 90% at 2 years and 83% at 5 years. Eight patients developed significant restenosis, of which five were treated with a new endovascular procedure. Two failures were treated conservatively and one with surgical thrombendarterectomy. CONCLUSION Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is feasible in patients with suitable anatomy. Clinical success rates are high and long-term patency is good. Complications are few and minor. The majority of failures are amenable to new endovascular treatment.