I. Kantonen

Mortality in Abdominal Aortic Aneurysm Surgery - The Effect of Hospital Volume, Patient Mix and Surgeon's Case Load

OBJECTIVE Assessment of mortality in abdominal aortic aneurysm surgery. DESIGN A 4-year cross sectional study based on a nationwide vascular registry: Finnvasc. MATERIAL AND METHODS A total of 17,465 vascular interventions included 929 elective repairs for abdominal aortic aneurysms (AAA), and 610 emergency cases with 454 ruptures. Fifty-three percent of the operations were done in university hospitals, 44% in central hospitals and 3% in district hospitals. RESULTS The 30-day mortality rate for AAA repair was 5.1% in elective and 46% in ruptured cases. A clear dependence of operative mortality on surgeons experience in AAA surgery was observed, both regarding the surgeons total vascular case load (p < 0.01) and the number of operated elective aneurysms (p < 0.01), but not the number of operated ruptured aneurysms. However, no association was found between hospital volume and mortality in AAA surgery. CONCLUSIONS Vascular surgical experience clearly improves the results of elective aneurysm surgery.

Factors affecting the results of surgery for chronic critical leg ischemia—a nationwide survey

PURPOSE To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeons caseload and hospital volume. METHODS The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994. RESULTS The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeons annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure. CONCLUSIONS A surgeons caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia.

Influence of surgical experience on the results of carotid surgery

OBJECTIVE To assess the 30-day mortality and morbidity rates related to carotid endarterectomy on a nation-wide basis. DESIGN Retrospective cross-sectional study based on vascular registry Finnvasc. MATERIALS AND METHODS A total of 17,465 recorded vascular and endovascular procedures included exactly 1600 carotid endarterectomies performed by 104 surgeons in 23 hospitals. Fourteen per cent of the patients were operated on for asymptomatic carotid stenosis. RESULTS The combined mortality and permanent stroke rate was 3.3%, without any difference between operations done on symptomatic or asymptomatic patients. There was a clear inverse association between surgeons carotid case load and poor outcomes in carotid surgery (p < 0.005), the critical patient mass per surgeon and year being 10 operations. There was no association between outcome after carotid surgery and hospital volume of carotid operations. CONCLUSIONS Surgeons experience in carotid surgery clearly improves the results of carotid surgery.

Limits of Infrapopliteal Bypass Surgery for Critical Leg Ischemia: When Not to Reconstruct

Abstract. The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical leg ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p= 0.03), postoperative cardiac complications (p= 0.02), leg salvage (p= 0.009), amputation with patent graft (p= 0.009), and patients who survived with a salvaged leg (p= 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on leg salvage (p= 0.02) and on patients alive with salvaged leg rates (p= 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical leg ischemia, as these patients are at high risk for early postoperative leg or life loss.

AUDITING A NATIONWIDE VASCULAR REGISTRY : THE 4-YEAR FINNVASC EXPERIENCE

OBJECTIVE To assess the validity of a national vascular registry. MATERIALS AND METHODS 17,465 vascular and endovascular procedures, immediate reoperations excluded, registered in the Finnvasc registry from 26 centres during the years 1991-1994. CHIEF OUTCOME MEASURES Comparison of the number of registered procedures with hospital records, comparison of initial registrations with a random sample of re-registration and comparison of the 1-year local data input of one major centre to the same data input of the central unit. RESULTS The rate of missing registrations was 19% ranging from 0-47%. The data of the re-registered forms were in agreement with the original data in 93% of all data points, the range being from 81-100%. There was a difference of 1.5% in the data between the major centre and the central unit. CONCLUSIONS The Finnvasc registry makes it possible to audit vascular surgery nationally, although a potential limitation is centres with low registration rates.

Rupture of Abdominal Aortic Aneurysms in Patients Under Screening Age and Elective Repair Threshold

OBJECTIVES The objective of this study was to identify the proportion of abdominal aortic aneurysm ruptures that occur before the screening age or threshold diameter for operative repair is reached. METHODS The study was a retrospective analysis of RAAA patients including all RAAA patients admitted to Helsinki (HUH) and Tampere University Hospitals (TaUH) during 2002-2013. The data for age, gender, and comorbidities were collected from vascular registry and patient records. Computed tomography images taken at the time of admission were used for the measurement of maximum anteroposterior (AP) aneurysm diameter at the time of rupture. Age and diameter data were compared with risk factors. RESULTS A total of 585 patients diagnosed with RAAA were admitted to the two hospitals during the 12 year period. The mean age at the time of rupture was 73.6 years (SD 9.5, range 42-96 years). 18.3% of patients were under 65: 21.4% of men and 3.0% of women. Men were on average 8 years younger than women. The odds ratio (OR) for rupture before 65 years of age for smokers was 2.1 compared with non-smokers, and 28.4% of smokers were under 65 at the time of rupture. Of all RAAA patients, 327 had a computed tomography scan confirming rupture. The mean AP diameter of the aneurysm was 75.6 mm (SD 15.8, range 32-155 mm). The mean size was significantly lower in women than in men (70.5 vs. 76.8, p = .005). CONCLUSIONS The data from this study show that a fifth of men would not make it to the screening age of 65 before AAA rupture, the proportion being even larger in active smokers. The data from this study also supports the previous finding that aneurysm size at the time of rupture is significantly smaller in women.

Haemodynamic results of femoropopliteal percutaneous transluminal angioplasty

OBJECTIVES To determine the utility of percutaneous transluminal angioplasty (PTA) of the femoropopliteal segment in patients with claudication and critical leg ischaemia (CLI). DESIGN Longitudinal observational study. SETTING A university based vascular surgical centre. MATERIAL Ninety-five patients with stenosing or occlusive arterial lesions of the femoropopliteal segment underwent 52 primary PTA for claudication and 50 primary PTA for CLI. METHODS The procedure was considered haemodynamically successful when the increase of immediate postprocedural ABI was 0.15 or more. The criterion for haemodynamic success during follow-up was an ABI having not decreased by more than 0.15 from the immediate postprocedural level. The run-off arteries were graded according to the scoring system proposed by the SVS/ISCVS. RESULTS Among the technically successful procedures (83%), the haemodynamic success rate was 77% at 1 month, 55% after 1 year, and 51% after 2 years. The cumulative haemodynamic success rates were 83%, 66% and 61% in claudicants, and 70%, 42%, and 38% in CLI (p = 0.03). In patients with a run-off score < or = 7.5, the success rates were 84%, 67%, and 60%, respectively, whereas in those with a crural score > 7.5 these were 61%, 39%, and 39%, respectively (p = 0.04). CONCLUSIONS The haemodynamic results suggest that PTA to the femoropopliteal segment is seldom a procedure of choice for critically ischaemic legs with poor run-off. The run-off score is useful in identifying patients who may benefit from PTA.

Editor's Choice – Treatment of Aortic Prosthesis Infections by Graft Removal and In Situ Replacement with Autologous Femoral Veins and Fascial Strengthening

INTRODUCTION Aortic prosthetic graft infection (AGI) is a major challenge in vascular surgery. Eradicating the infection requires prosthetic material removal, debridement, and lower limb revascularization. For the past 15 years, we have used femoral veins for aorto-iliac reconstruction and tensor fascia lata to strengthen the upper anastomosis. OBJECTIVE The purpose of this single institution retrospective study is to present results regarding in situ replacement of infected aortic grafts with autologous femoral veins (FVs). METHODS From October 2000 to March 2013, patients treated for AGI with graft removal and autologous FV reconstruction at Helsinki University Hospital were included. Primary outcome measures were 30 day mortality, long-term treatment related mortality, and re-infection rate. Secondary outcome measures were long-term all cause mortality and event free survival (graft rupture, re-intervention, major amputation). RESULTS During a 13 year period 55 patients (42 male, 13 female) were operated on using a venous neo-aorto-iliac system for AGI. The mean follow up was 32 months (1-157 months). The 30 day mortality rate was 9% (5) and overall treatment related mortality 18% (10). All cause mortality during follow up was 22 (40%) and overall Kaplan-Meier survival was 90.7% at 30 days, 81.5% at 1 year, and 59.3% at 5 years. Graft rupture occurred in three (5%) cases, two of which were caused by graft re-infection (4%). Four patients required major amputation, one of them on arrival and three (5%) during the post-operative period. Nine (16%) patients needed interventions for the vein graft, and two graft limbs occluded during follow up. CONCLUSION In situ reconstruction for aortic graft infection with autologous FV presents acceptable rates of morbidity and mortality, and remains the treatment of choice for AGI at Helsinki University Hospital.

The natural course of abdominal aortic aneurysms that meet the treatment criteria but not the operative requirements.

INTRODUCTION Abdominal aortic aneurysms (AAAs) of 55 mm diameter or growth >5 mm in 6 months are commonly accepted treatment criteria. The aim of this study was to establish the outcome of aneurysms that met the treatment criteria but not the operative requirements. MATERIAL AND METHODS Patients (n = 154) who were declined from operative care of AAA in Helsinki University Central Hospital (HUCH) during 2000-2010 were retrospectively analysed. Reasons for exclusion were identified. The follow-up period extended until the end of April 2012. The rupture rate and mortality were determined. The patients were analysed according to the aneurysm diameter: 55-60, 61-70 and >70 mm. RESULTS The reasons for exclusion from operative treatment were cardiorespiratory co-morbidities in 33%, cancer in 8%, overall condition in 33% and patients choice in 21% of the patients. Regardless of the size of the aneurysm, the cause of death was aneurysm rupture in 43%, which was confirmed either in hospital or in autopsy for 76% of the patients. Of the ruptured aneurysms, 12 were operated of which five survived. CONCLUSIONS A ruptured aneurysm is the most common cause of death among patients unfit for surgery; this should be considered in the preoperative evaluation process, especially since 5 of the 12 patients survived the ruptured AAA (RAAA) operation.

Population-based study of ruptured abdominal aortic aneurysm.

The incidence of abdominal aortic aneurysms (AAAs) and their rupture has been reported to be decreasing. The aim was to evaluate trends in ruptured AAA (rAAA) incidence in the hospital district of Helsinki and Uusimaa (HUS) in southern Finland. This was a population‐based retrospective review of all patients with rAAA in this well defined geographical area during 2003–2013.