M. Heikkinen

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.

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).

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN Retrospective study. MATERIAL AND METHODS The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.

Multiple HIV-Related Aneurysms: Open and Endovascular Treatment

Purpose: To report successful endovascular repair of thoracic aortic aneurysms in 2 patients with human immunodeficiency virus (HIV). Conclusions: Endovascular and open treatment of HIV-related aneurysms is possible, with excellent long-term results. Patients with long-life expectancy should be treated according to the same guidelines as patients without HIV. Case Reports: Thoracic and abdominal aortic aneurysms (AAA) were found in a 60-year-old woman 1 year after she was diagnosed with HIV. Because of pain and risk of rupture, the AAA was repaired with conventional open techniques in February 1997, while the thoracic aneurysm was excluded in a staged procedure using a homemade endograft delivered through a 10-mm conduit sewn to the aortic tube graft. Two months later, new aneurysms were found in the superficial femoral arteries bilaterally; both were excised and replaced with vein grafts. After 7 years, the patient is well and no longer takes antiretroviral medication. Surveillance imaging shows continued patency of the stent-graft without evidence of leak or migration. In a more contemporary case, a 46-year-old man was found to have 5 focal aneurysms in the aorta; the most proximal descending thoracic aneurysm increased 2 cm in 2 weeks. The two thoracic aneurysms were successfully excluded using 2 Excluder stent-grafts. At 7 months, he was doing well, and the aneurysm had shrunk 11 mm.

The Fate of AAA Patients Referred Electively to Vascular Surgical Unit

Background: The ideal treatment of abdominal aortic aneurysms (AAA) is to operate aneurysms likely to rupture, without exposing other cases to major surgery. The purpose here was to analyse retrospectively the management of AAA in a well-defined geographical region in the 1990s. Methods: 194 new vascular surgical outpatient consultations due to AAA were done to the regional vascular centre during the years 1990, 1992, 1994, 1996 and 1998. Data were collected from case records. Statistics Finland provided causes and dates of death. Results: The mean observed annual AAA incidence was 9.0 per 100 000 inhabitants and it rose significantly (33.3 %) during the study period. The duration of follow-up varied between 0 and 129 months. The 5/8-year cumulative mortality was 37.3/50.7 %. The most common causes of death were AAA-related (31.7 %), cardiac (29.1 %) or malignancy (19.0 %). Twenty-five patients with small AAA were referred to primary health care sector for further follow-up. There were no RAAA (ruptured AAA) deaths in this group. The cumulative 5/8-year mortality was 43.2/49.9 %. One hundred patients underwent an elective aneurysm repair with in-hospital mortality of 7.0 %. The cumulative 5/8-year mortality was 23.7/35.4 %. Twelve patients refused elective treatment. The cumulative 5/8-year mortality was 45.1/63.4 % and 5/7 deaths were due to RAAA. Twenty-three patients were unfit for elective repair. The cumulative 5/8-year mortality was 87.0 %/100 % and 5/20 deaths were caused by RAAA. The cumulative 5/8-year RAAA-rate in the patients with AAA more than 5.0 cm in diameter and outside elective aneurysm-repair (n = 23) was 51.9 %/100.0 %. Conclusion: The observed incidence of AAA increased during the 1990s. Half of the patients underwent an elective procedure. Patients unfit for surgery died mainly for other reasons than RAAA. Most patients with AAA over 5.5 cm not subjected to elective procedure, died of rupture.

Ten-Year Outcomes after Endovascular Aneurysm Repair (Evar) and Magnitude of Additional Procedures

Background and Aims: With any new technology complications are possible, and problems with first-generation aortic stentgrafts have been extensively reported. The long-term outcome of this patient population and the magnitude of additional secondary procedures are, however, less well covered. Materials and Methods: Between February 1997 and November 1999, 48 patients (44 men and 4 women; mean age 70 years; range 54–85) with AAA (average 57mm, range 40–90mm) were treated with a Vanguard® endoprosthesis. Stentgrafts were sized by CT and angiography-based measurements. Results were continuously assessed using contrast-enhanced CT before discharge, 1, 3, 6 and 12 months after the procedure and thereafter annually. Since 2001 plain abdominal X-rays have been performed annually. Results: The technical implant success rate was 100%. Median follow-up was 91 months (range 7.6–120 months). None of the patients was lost during this period. Hospital mortality was 0%. There were 25 subsequent deaths (52%), the most common cause being coronary artery disease. There were ten late conversions to open surgical repair, including three emergency operations: two due to rupture and one to thrombosis. EVAR-related complications were encountered in 43 patients (90%): 12 primary endoleaks (all type II), 36 late endoleaks (16 type I, 2 type II and 18 type III), 22 migrations, 25 row separations, 20 thromboses, one endotension and 3 ruptures of the AAA. Secondary procedures were required in 39 patients (81%): 1 re-endografting by aortoiliac bifurcated graft and 3 with a uni-iliac graft; 33 limb graft repairs were performed and 19 infrarenal cuffs were placed. There were 4 late embolizations and 4 attempts, and 6 thrombolyses, four of which were successful. Further, 9 femoro-femoral crossover by-pass and 2 axillo-femoral by-pass operations and 2 amputations were carried out during the follow-up. Only one patient was alive without complications. Conclusions: The impact of long-term follow-up of patients treated with the new technology was emphasized in this patient population. A careful surveillance protocol and active endovascular treatment of complications can yield acceptable results and low AAA rupture and aneurysm mortality rates, also with the first-generation endovascular graft. A new technology, however, may involve unpredictable problems which can magnify the workload and incur high costs over several years after the initial procedure.

The Profile of Leg Symptoms, Clinical Disability and Reflux in Legs with Previously Operated Varicose Disease

Purpose: It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease. Methods: A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed. Results: The site of superficial reflux was at the groin in 58 % (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11 % (unoperated short saphenous vein). In 58 % of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74 % of the legs, sensation of oedema in 64 %, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2–3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2–3) were significantly more frequent among complicated legs (CEAP clinical class C2–3: 22% versus CEAP clinical class C4–6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7 % versus severe reflux: 48 %; p < 0.005). Conclusions: Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

Deep Venous Thrombosis

The following three factors, primarily postulated by Virchow, are most important in the pathophysiology of deep venous thrombosis (DVT)[10]: Injury of vessel wall Abnormalities of blood (coagulation disorders) Abnormalities of blood flow (stasis). There are multiple risk factors for DVT, but the inde- pendence and magnitude of each are unclear [10,11, 12,34 ]: Increasing age Cancer Coagulation disorder Smoking Obesity Oestrogen substitution Surgery (hip or knee arthroplasty,cancer surgery in the abdominopelvic area, neurosurgery) Trauma Immobilization (air-related DVT) Previous DVT. Calf veins are the most common site of thrombus [20]. Acute DVT is more frequently left-sided, and this phenomenon can be noted more clearly in proximal DVTs. Acute DVT affects vein segments from calf to iliac level in 5%of cases (iliofemoral DVT). Postoperative DVT is restricted to calf veins in 80% [21]. Propagation into more proximal veins may occur in 5–15% [16]. The annual incidence of DVT is 5 per 10,000 in the general population. The 5-year cumulative incidence of recurrent DVT is approximately 20%. Prevalence of DVT is 0.5% at age 50 years and 4.5% at age 75 years. Therisk of DVT increases twofold during each 10-year increase in age [9,11]. Without prophylaxis, the incidence of postoperative cDVT is 40–80%in patients undergoing large ortho- cpaedic surgery. The corresponding numbers in general csurgery are 20–40%. In vascular surgery, several Du- cplex or venography-based studies have shown that the crate of DVT is 18–32%after abdominal or lower limb creconstructions. Postoperative DVT has been noted in c12%of the legs after abdominal vascular surgery de- cspite medical prophylaxis [10]. Superficial thrombophlebitis may be associated with DVT. In legs with large-scale thrombophlebitis involv- ing the saphenofemoral or saphenopopliteal junction, DVT may be present in as much as 40%of cases [10].

Absent pedal pulse and impaired balance in older people: a cross-sectional and longitudinal study

Background and aims: The purpose of this study was to determine the relationship between abnormal pedal pulse status and postural balance in older people. Methods: Prospective, population-based cohort study of older residents in the city of Jyväskylä, Finland. A total of 419 individuals aged 75 or 80 at baseline, with known lower extremity pulse status and balance tests performed on a force platform, were eligible for analysis. Results: Cross-sectionally, persons with both dorsal pedal artery pulses absent were found to sway more (p=0.047 anteroposterior velocity, normal standing eyes-open position). The risk of being unable to do the full tandem stance was twofold (OR=2.20, 95% CI 1.29–3.78) for persons without palpable dorsal pedal arteries compared with those with normal pulse status. Balance deterioration was observed at five years (p<0.001for time) but without group-by-time interaction. At ten years, however, the interaction term became significant for the normal standing eyes-closed position (p=0.025 for anteroposterior velocity and p=0.026 for mediolateral velocity), indicating greater balance deterioration among those with both dorsal pedal artery pulses absent. Conclusions: According to our study, the absence of both dorsal pedal artery pulses is associated with impaired balance in older people. The association was observed both cross-sectionally and longitudinally. In addition, as diminished pedal pulses are frequently associated with impaired lower extremity circulation, our results have also produced information on the possible pathophysiological mechanisms of balance deterioration in older people, which warrant further study.