Kari Ylönen

Risk-scoring Method for Prediction of 30-Day Postoperative Outcome after Infrainguinal Surgical Revascularization for Critical Lower-limb Ischemia: a Finnvasc Registry Study

BackgroundThe aim of the present study was to develop a risk-scoring method for prediction of immediate postoperative outcome after infrainguinal surgical revascularization for critical limb ischemia.MethodsThe Finnvasc registry included data on 3,925 infrainguinal surgical revascularization procedures. This database was randomly divided into a derivation and a validation data set of similar sizes.ResultsIn the overall series, 30-day postoperative mortality and major amputation rates were 3.1% and 6.3%, respectively. The 30-day postoperative mortality and/or limb-loss rate was 9.2%. Diabetes, coronary artery disease, foot gangrene, and urgent operation were independent predictors of 30-day postoperative mortality and/or major lower-limb amputation. A risk score was developed by assigning 1 point each to the latter risk factors. In the derivation data set, the 30-day postoperative mortality/amputation rates in patients with scores of 0, 1, 2, 3, and 4 were 7.7%, 6.4%, 11.1%, 20.4%, and 27.3%, respectively, (P < 0.0001); mortality rates were 1.3%, 2.3%, 4.1%, 7.7%, and 12.1%, respectively, (P < 0.0001); and major amputation rates were 6.4%, 4.3%, 7.1%, 12.7%, and 18.2%, respectively, (P < 0.0001). In the validation data set, the 30-day postoperative mortality/amputation rates in patients with scores of 0, 1, 2, 3, and 4 were 4.8%, 7.5%, 10.1%, 15.9%, and 22.2%, respectively, (P < 0.0001); mortality rates were 0.7%, 2.3%, 4.2%, 5.5%, and 14.8%, respectively, (P < 0.0001); and major amputation rates were 4.6%, 5.3%, 6.4%, 11.0%, and 14.0%, respectively (P = 0.011).ConclusionsThis simple risk-scoring method can be useful to stratify the immediate postoperative outcome of patients undergoing infrainguinal surgical revascularization for critical lower-limb ischemia.

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.

Glasgow Aneurysm Score as a predictor of immediate outcome after surgery for ruptured abdominal aortic aneurysm

The aim of the study was to assess the value of the Glasgow Aneurysm Score in predicting postoperative death after repair of a ruptured abdominal aortic aneurysm (AAA).

Long-term Outcome after Isolated Endarterectomy of the Femoral Bifurcation

BackgroundLong-term outcome after endarterectomy of the femoral bifurcation has not been widely investigated, and the aim of this study was to assess its late results from a community-wide perspective.Patients and MethodsBetween 1983 and 2006 111 isolated endarterectomies of the common femoral artery and/or the proximal part of the superficial femoral artery or profunda femoris were performed in 90 patients at the Oulu University Hospital, Oulu, Finland. A total of 77 limbs were treated surgically for claudication and 34 others for critical limb ischemia. Angiographic findings of 100 extremities were evaluated.ResultsThe in-hospital mortality rate was 1.8%. The mean follow-up period was 5.9 years. At 5-, 10-, and 15-year follow-up the overall survival was 60.5%, 32.7%, and 17.6%, respectively (S.E < 0.05). A C-reactive protein value ≥ 10 mg/l was predictive of poor late survival (p = 0.008). Limb salvage rates after isolated femoral endarterectomy at 5-, 10-, and 15-year follow-up were 93.7%, 93.7%, and 85.2%, respectively (S.E. < 0.08). Critical limb ischemia (p = 0.006) and current smoking (p = 0.027) were independent predictors of major lower limb amputation. A total of 41 limbs were subjected to ipsilateral vascular procedures after femoral endarterectomy, only one of which was re-endarterectomy. Freedom from any ipsilateral revascularization procedure at 5-, 10-, and 15-year follow-up was calculated at 68.0%, 50.6%, and 42.5%, respectively (S.E. < 0.08). The overall linearized rate of reintervention on the ipsilateral limb was 0.16 ± 0.44/year. The linearized rate among patients who had any ipsilateral vascular reintervention was 0.43 ± 0.66/year.ConclusionsIsolated femoral endarterectomy is a rather low-risk and durable procedure. However, a significant number of reinterventions distal or proximal to the endarterectomized site can be expected in one third of patients.

Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm.

This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long‐term outcome after elective open repair of abdominal aortic aneurysm (AAA).

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.

Inferior Mesenteric Artery Embolization before Endovascular Repair of an Abdominal Aortic Aneurysm: Effect on Type II Endoleak and Aneurysm Shrinkage

PURPOSE To evaluate the value of preoperative embolization of the inferior mesenteric artery (IMA) before endovascular repair of an abdominal aortic aneurysm. MATERIALS AND METHODS From January 2000 to October 2006, 79 patients (mean age, 72.3 years; 69 men) scheduled for endovascular aneurysm repair (EVAR) were found to have a patent IMA at computed tomography. Coil embolization of the patent IMA was performed in 40 patients at Kuopio University Hospital, and their outcome was compared with that of 39 patients with a patent IMA who underwent EVAR at Oulu University Hospital without preoperative IMA embolization (control group). All patients were treated with a Zenith stent-graft. The mean follow-up time was 3.4 years +/- 1.7 (median, 3.1 years; range, 0-7.6 years). RESULTS There were significantly fewer type II endoleaks in the IMA embolization group than in the control group (25% vs 59%, respectively; P = .002). Preoperative IMA embolization did not correlate with aneurysm size change. The overall linearized aneurysm shrinkage rate per year was 1.4 mm per year +/- 3.8 in the IMA embolization group and 1.7 mm per year +/- 2.4 in the control group (P = .72). CONCLUSIONS Preoperative coil embolization of the IMA reduced the frequency of type II endoleaks after EVAR, but the authors failed to show any influence on late postoperative aneurysm shrinkage.

Validation of the Finnvasc Score in Infrainguinal Percutaneous Transluminal Angioplasty for Critical Lower Limb Ischemia

The aim of the present study was to validate the Finnvasc score for prediction of immediate outcome after infrainguinal percutaneous transluminal angioplasty (PTA) for critical lower limb ischemia (CLI). Our registry included prospective data on 512 patients who underwent isolated infrainguinal PTA revascularization procedures for CLI. The Finnvasc score herein evaluated was calculated by assigning one point each to diabetes, coronary artery disease, foot gangrene, and urgent operation. Early mortality and major limb amputation rates after PTA revascularization were 2.5% and 12.3%, respectively. Seventy-two patients (14.1%) died and/or had lower limb amputation. Diabetes (p = 0.001), foot gangrene (p = 0.047), urgent operation (p < 0.0001), and preoperative renal failure (p = 0.001) were independent predictors of postoperative mortality and/or major limb amputation. Finnvasc score was predictive of major lower limb amputation (p = 0.003), mortality (p < 0.0001), and mortality and/or major amputation (p < 0.0001) after PTA. Mortality, major lower limb amputation, and combined end point rates in patients with a Finnvasc score of 3-4 were 12.8%, 25.6%, and 35.9%, respectively. The Finnvasc score is a simple risk scoring method which can be useful to estimate the risk of immediate postprocedural mortality and/or major lower limb amputation also in patients undergoing infrainguinal PTA for CLI.

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature.

Objective To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition. Patients and methods Forty-two patients underwent emergency repair for symptomatic, unruptured AAA. Results Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA. Conclusion Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.