L. van der Laan

Short-Term Results of A Randomized Trial Comparing Remote Endarterectomy and Supragenicular Bypass Surgery for Long Occlusions of the Superficial Femoral Artery [The REVAS Trial]

OBJECTIVE Techniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques. DESIGN Randomized, multicenter trial. MATERIALS AND METHODS 116 patients were randomized to RSFAE (n=61) and supragenicular bypass surgery (n=55). Indications for surgery were claudication (n=77), rest pain (n=21), or tissue loss (n=18). RESULTS Median hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group (p=0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass (p=0.094). Secondary patency was 79% for both groups. Subdividing between venous (n=25) and prosthetic grafts (n=30) shows a primary patency of 89% and 63% respectively at 1-year follow-up (p=0.086). CONCLUSION RSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available. This study is registered with ClinicalTrials.gov, number NCT00566436.

Postoperative delirium in elderly after elective and acute colorectal surgery: A prospective cohort study

OBJECTIVE To assess the frailty and the incidence of delirium in elderly patients undergoing elective and acute colorectal surgery in correlation with morbidity and mortality. METHODS Patients aged 65 years and older having elective and acute colorectal surgery, between April 2013 and December 2013 were included in a prospective database. Patients diagnosed with a colorectal carcinoma or diverticulitis who were operated on were included. Factors that characterize frailty of patients were noted. The incidence rates of delirium after elective and acute surgery were recorded. Delirium was diagnosed using the Delirium Observation Screening Scale (DOSS). Preoperative evaluation, surgical outcome including morbidity, hospital stay and mortality were analyzed. RESULTS Patients ≥ 65 years were included, 83 (75%) received elective and 28 (25%) acute surgery. The overall incidence of delirium was 21%, 18% for elective and 29% for patients having urgent surgery (p = 0.24). Patients with delirium were older than the non-delirious patients (median 82 years vs. 74 years; p < 0.001). Delirious patients showed higher incidence of adverse events. Hospital stay, mortality and discharge to a nursing home were significant higher in the delirious compared to the non-delirious group (p = 0.01; 0.01; 0.02 respectively). CONCLUSION High incidence of delirium was found in both acute and elective colorectal surgery. Delirium was associated with adverse outcomes.

Reliability and reproducibility of a clinical application of a simple technique for repeated circumferential leg measurements

Objective The aim of this study is to determine the reliability and reproducibility of repeated tape measurements to assess the leg circumference during a long period. Methods A tape measure is a simple instrument that is applicable in the presence of oedema. Measurements were performed by four observers on 11 volunteers. Four measurements were done in the first week (short term), a fifth measurement at two weeks (medium term) and a sixth measurement was done at 12 weeks (long term). Results The short-, medium- and long-term intra-class correlation coefficients for repeated measurements were 0.90, 0.89 and 0.78, respectively. The short-term and long-term reproducibility indices equalled 4.4% and 6.5%. If only a single observer would be involved, the short-term intra-class correlation coefficients would improve to 0.94 (reproducibility index 3.3%). Conclusion Tape measurements have been proved to be a reliable and reproducible method to asses the lower limb circumference.

Midterm Results of Autologous Saphenous Vein and ePTFE Pre-Cuffed Bypass Surgery in Peripheral Arterial Occlusive Disease:

Introduction: The graft of choice in lower limb bypass surgery is the autologous saphenous vein (ASV). However, a prosthetic graft is needed in the absence of an ASV. In such situations, we used an expanded polytetrafluoroethylene (ePTFE) pre-cuffed Dynaflo graft as supragenicular bypass or Distaflo graft as infragenicular or femorocrural bypass. In respect to the expanding possibilities of percutaneous transluminal angioplasty (PTA), the indication for bypass surgery moved toward patients with advanced stages of peripheral arterial occlusive disease. For this reason, this study analyzed the current performances of these ePTFE grafts and ASV grafts with special attention to limb salvage. Methods: In a retrospective study all patients who underwent peripheral bypass surgery between 2004 and 2008 were included. Kaplan-Meier curves were used to express primary patency, secondary patency, and limb salvage rates at 1 and 3 years. Log-rank tests were performed to compare graft types. Results: A total of 272 grafts (ePTFE/ASV: 110/162) were performed in lower limb bypass surgery. The mean follow-up was 20.3 months. The secondary 3-year patency rates were for (n=78) supragenicular grafts (ePTFE/ASV: 45%/94%)*, for (n=124) infragenicular grafts (24%/74%)*, and 70 for femorocrural grafts (26%/52%). Limb salvage after 3 years was 59% in the ePTFE group versus 78% in the ASV group* (*P < .05). Conclusion. In the current population of vascular patients where no PTA is possible and a peripheral bypass is necessary, the ASV remains the graft of first choice. However, the pre-cuffed ePTFE graft is a good alternative, especially in cases of critical limb ischemia, in respect to an acceptable limb salvage rate.

Clinical Results after Coil Embolization of the Ovarian Vein in Patients with Primary and Recurrent Lower-Limb Varices with Respect to Vulval Varices

Objective: To study the effect of coil embolization of the insufficient ovarian vein (IOV) on varices of the lower limb (VLL). Method: From December 2005 until May 2008, we selected all patients with phlebograms that were performed in our hospital to confirm the diagnosis of insufficiency of the ovarian vein. The CEAP (clinical, aetiological, anatomical and pathological elements) classification was used to classify the lower-limb venous disease in each patient. All patients with suspected IOV in combination with VLL underwent a phlebography. If IOV was found, coil embolization of the ovarian vein(s) was performed. Results: IOV was found in 43 of 44 patients (98%). After coil embolization of the ovarian vein(s), VLL disappeared in five patients (12%) without any further treatment. Improvement in CEAP classification was measured in 13 patients (31%). In 21 (88%) of 24 patients with vulval varices, coil embolization of the ovarian vein(s) resulted in disappearance of vulval varices. Conclusions: In only 31% of the patients with IOV in combination with VLL, phlebography and coil embolization of the ovarian vein(s) did improve CEAP classification. However, coil embolization of the ovarian vein resulted in disappearance of the vulval varices in 88% of the patients.

Pathophysiology and treatment of edema following femoropopliteal bypass surgery

Substantial lower-limb edema affects the majority of patients who undergo peripheral bypass surgery. Edema has impairing effects on the microvascular and the macrovascular circulation, causes discomfort and might delay the rehabilitation process of the patient. However, the pathophysiology of this edema is not well understood. The Cochrane Library and Medline were used to retrieve literature on edema following peripheral bypass surgery. Factors other than local wound healing alone are suggested in the literature to play a role, given the severity and duration of this edema. Hyperemia, microvascular permeability, reperfusion-associated inflammation and lymphatic disruptions are likely to facilitate the development of edema. Preventive methods could be lymphatic-sparing surgery, intraoperative antioxidative therapy and postoperative elevation. Successful treatment strategies to reduce postoperative edema are based on lymph massage and external compression. In conclusion, the pathophysiology of edema following peripheral surgery is not fully understood, although reperfusion-associated inflammation and lymphatic disruptions are likely to play a crucial role. When future less-invasive techniques prove to be successful, postoperative edema might be minimized. Until then, a careful lymphatic-sparing dissection should be executed when performing a peripheral bypass reconstruction. Postoperatively, the use of compression stockings and leg elevation are currently the golden standards.

Review: Quality of life in lower limb peripheral vascular surgery

Purpose Vascular intervention studies generally consider patency and limb salvage as primary outcomes. However, quality of life is increasingly considered an important patient-oriented outcome measurement of vascular interventions. Existing literature was analyzed to determine the effect of different treatments on quality of life for patients suffering from either claudication or critical limb ischemia. Basic methods A review of the literature was undertaken in the Medline library. A search was performed on quality of life in peripheral arterial disease. Results were stratified according to treatment groups. Principal findings Twenty-one articles described quality of life in approximately 4600 patients suffering from peripheral arterial disease. Invasive treatment generally results in better quality of life scores (at a maximum of 2 years of follow-up), compared with non-invasive treatment. In patients with critical limb ischemia, successful revascularization improves quality of life scores. Only one study reported long-term results. Conclusions Increase in quality of life scores can be found for any intervention performed for peripheral arterial disease. However, there is scarce information on long-term quality of life after vascular intervention.