Jørgen E. Lorentzen

Clinical and pharmacokinetic evaluation of gentamycin containing collagen in groin wound infections after vascular reconstruction

Fourteen patients with localised groin wound graft infection after vascular reconstruction were included in this study to evaluate the clinical effect and the pharmacokinetic profile of gentamycin containing collagen for local antibiotic treatment. All patients were treated by surgical revision and the implantation of one collagen sponge containing 130 mg gentamycin in addition to systemic antibiotics. At follow-up (median 10 months, range 6-15 months), 13 of the 14 patients were cured with a patent reconstruction, giving a success rate in this series of 93%. The pharmacokinetic study showed a very high initial gentamycin concentration in wound fluid, which neatly exceeded the MIC values for most bacteria normally considered resistant to gentamycin. These high MIC values were sustained for 2 to 3 days. In conclusion, this study demonstrated a good clinical effect of gentamycin containing collagen with a high cure rate. In the wound fluid an initial high concentration of gentamycin was achieved which lasted for 2-3 days.

Revascularisation of Atherosclerotic Mesenteric Arteries: Experience in 90 Consecutive Patients*

OBJECTIVES Visceral artery surgery is well known to vascular surgeons, but most have limited personal experience. We report our experience with 90 patients treated for atherosclerotic lesions of the visceral arteries during a 25-year period 1968-1993. DESIGN Retrospective study. SETTING Department of Vascular Surgery, University Hospital Rigshospitalet, Copenhagen, Denmark. MATERIALS 54 women and 36 men, aged 56 (median; range: 34-78 years) underwent 109 consecutive mesenteric reconstructions. The indication in 90 primary procedures was acute mesenteric ischaemia of non-embolic origin in 25 patients, chronic ischaemia in 53 and prophylactic reconstruction in connection with aortic surgery in 12 patients. The superior mesenteric artery (SMA) was revascularised in 87 patients and the coeliac axis or common hepatic artery in six. Thus, only three patients had both territories revascularised. Thromboendarterectomy was performed in 15 patients, transposition of the SMA directly into the infrarenal aorta in 30 and bypass in 48 patients. CHIEF OUTCOME MEASURES Cumulative symptom-free and survival rates. MAIN RESULTS The overall perioperative (30 days) mortality rate was 13%, mainly caused by the high mortality rate of 44% (11 patients) in the acutely operated, as the mortality was 0% in patients operated on electively and only one out of 12 patients (8%) died after a prophylactic operation. Nine of the twelve deaths were due to progressive mesenteric infarction. Cumulated survival rates were 81, 60 and 35% after 5, 10 and 20 years, respectively which indicated a mortality rate three times that of an age- and sex-matched Danish population. During follow-up symptoms recurred in 30 patients, more often following emergency surgery and SMA transposition. CONCLUSIONS Mesenteric revascularisation may yield long lasting results. However, surgery for acute ischaemia carries a high mortality rate, emphasising the importance of early surgery.

Natural history of abdominal aortic aneurysm: A survey of 63 patients treated nonoperatively

During a 10-year period in which 735 patients presented with abdominal aortic aneurysms to our clinic, 63 were not offered operative treatment. The primary reason for choosing conservative treatment was concomitant diseases that increased the risk of operation. After 2 years of follow-up, half of the patients died, and the cumulative 5-year survival rate was 15%. Aneurysm rupture was the primary cause of death. The cumulative 5-year mortality hazard rate from rupture was 0.36, corresponding to an annual risk of rupture of 7%. The cumulative 5-year hazard rate of death from all other causes was 1.53, corresponding to an annual risk of 30%. Diameter of the aneurysm was found to be the only factor with a significant impact on the rate of rupture. The cumulative 5-year hazard rate of rupture among patients with aneurysms <6 cm and ≥6 cm was 0.2 and 0.6, respectively, corresponding to an annual risk of rupture of less than 5% and 10% to 15%, respectively. However, neither diameter nor other risk factors had significant influence on the time of rupture. In our opinion, once the diagnosis is confirmed the patient should be offered aneurysm resection if the general health status permits anesthesia.

Long-term results after arterial surgery for arteriosclerosis of the lower limbs in young adults.

Ninety-nine patients, with a mean age of 40 years, underwent surgery for arteriosclerosis of the lower limbs during 1975-81. The main indication for surgery was claudication and the median observation time 102 months (range 54-138 months). Twenty patients died during the follow-up period and fifteen of these could be related to arteriosclerotic disease. At follow-up, 43 patients had claudication, while 34 patients had developed other arteriosclerotic manifestations. Amputation was performed in 17 patients. At follow-up the number of patients at work remained almost unchanged, whereas the number of patients receiving disablement pension increased. This study shows that younger patients with arteriosclerosis of the lower limbs had a mortality of approximately 20%, during the period of observation of this study. However, many patients became asymptomatic after surgery suggesting that a conservative attitude to arterial surgery in these patients cannot be justified.

Renal Failure after Operation for Abdominal Aortic Aneurysm

Among 656 patients undergoing surgery for abdominal aortic aneurysm, 81 patients (12%) developed postoperative renal failure. Before operation hypotension and shock occurred in 88% of the patients with ruptured aneurysm, whereas none of the patients operated electively were hypotensive. Dialysis was performed in 32 patients, while the remaining 49 patients were managed without dialysis. Within 30 days after the operation 47 patients (58%) had died. There was no difference in mortality between patients in dialysis and patients managed without dialysis. Thirteen patients died during follow-up. In six cases the death was caused by renal failure only or in combination with failure of other organs. Analysis of the cumulative survival shows that, if the patients survive the postoperative period, their life expectancy is comparable to that of patients without renal complications.

Real Time B-mode Mapping of the Greater Saphenous Vein

Real time ultrasound mapping of the greater saphenous vein (GSV) was performed in 30 consecutive patients admitted for in situ femoro-crural revascularisation. The overall accuracy in predicting the adequacy of the GSV for in situ bypass was 90%. The predictive value of finding the vein usable was 96%, whereas the predictive value of judging the vein inadequate was 50%. The scanning procedure provided morphologic information about the GSVs, including size, tributaries, varicosities, and double segments, which may prevent unnecessary dissection and may further shorten the duration of surgery. In our opinion the technique is sufficiently accurate to replace phlebography for the routine preoperative assessment of GSV in patients considered for in situ bypass. Veins judged inadequate at scanning, however, should be further evaluated.

Inflammatory aortic aneurysms: Regression of fibrosis after aneurysm surgery

OBJECTIVES To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery. METHODS In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group. RESULTS Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls. CONCLUSION This study supports the findings that PF tends to regress after repair of the abdominal aortic aneurysm.

In Situ Saphenous Vein Bypass Surgery in Diabetic Patients

From 1986 through to 1990 a total of 483 consecutive in situ infra-inguinal vein bypass procedures were performed in 444 patients, of whom 112 (25%) were diabetics (57 insulin dependent diabetes mellitus and 55 non-insulin-dependent diabetes mellitus). Based on a prospective vascular data registry this material was analysed to determine the influence of diabetes on the outcome. Preoperative risk factors were equally distributed among diabetic and non-diabetic patients, except for smoking habits (diabetics: 48%; non-diabetics: 64%, p = 0.002) and cardiac disease (diabetics: 45%; non-diabetics: 29%, p = 0.005). Indication for surgery was gangrene or ulceration in 57% of diabetics, as opposed to 36% in non-diabetic patients (p = 0.0002). A femoro-popliteal bypass was performed in 18% of patients, whereas 82% received an infrapopliteal procedure, of which 42% were to the distal third of the calf or foot. Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.0001). The overall 3-year primary and secondary patency rates were 58 and 64%, respectively, with no differences between non-diabetics, non-insulin-dependent diabetics and insulin-dependent diabetics. Neither did limb survival differ among the three groups. However, the rate of minor amputations was significantly higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetic patients (p less than 0.00001). A markedly decreased survival rate was found in diabetics (p less than 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of arteriovenous fistulas on in situ saphenous vein bypasses

Intraoperative identification and later development of arteriovenous fistulas were investigated prospectively in 70 in situ saphenous vein bypass procedures. Surveillance was performed by completion arteriography and intra- and postoperative continuous wave Doppler examination. The intraoperative Doppler examination identified 89% of those branches with sufficient flow to opacify the deep venous system on completion arteriogram. Half of the missed fistulas underwent spontaneous thrombosis, and in only one case did the arteriovenous fistula lead to hemodynamic symptoms demanding surgical closure of the fistula. Pursuing a policy of selectively ligating fistulas that only fill the deep venous system on completion arteriography led to an additional nine arteriovenous fistulas. Developed over an average follow-up of six months, four patients presented symptoms of edema and swelling and were relieved upon closure of the fistulas. The incidence of bypass thrombosis did not differ significantly among patients with remaining arteriovenous fistulas, patients who developed fistulas during follow-up, and patients who had no signs of arteriovenous fistulas. It seems justified to continue selective intraoperative ligation of arteriovenous fistulas based on continuous wave Doppler.

Abdominal aortic aneurysm surgery: Survival and quality of life in patients requiring prolonged postoperative intensive therapy

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.