Michael Luther

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.

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.

The utility of duplex scanning in infrainguinal vein graft surveillance: Results from a randomised controlled study

OBJECTIVES To evaluate the utility and efficacy of colour-coded duplex scanning as an adjunct to clinical surveillance of infrainguinal vein bypass surgery. DESIGN Prospective controlled randomised trial. METHODS The trial included 179 consecutive patients undergoing 185 primary infrainguinal vein graft reconstructions during a 3-year period. Patients alive without amputation and with open graft at 1 month were randomised to a surveillance program based on clinical examination and ankle-brachial pressure index measurement (ABI group) or additional duplex scanning (DD group). All patients were scheduled for surveillance at 1, 3, 6, 9 and 12 months after operation. RESULTS Surveillance identified four failing grafts in the ABI group and 11 in the DD group which were revised. The number of occluded grafts was seven in ABI group and 12 in DD group. At 1-year overall cumulative assisted primary patency rates in the ABI group and in the DD group were 74% and 65% respectively (p = 0.21), corresponding secondary patency rates were 84% and 71% (p = 0.04) and limb salvage rates 88% versus 81% (p = 0.23) respectively. CONCLUSIONS This study failed to show any beneficial effect of duplex scanning in a surveillance program, which was difficult to accomplish as a part of routine clinical work. However, the main difference in outcome appeared during the first postoperative month before the commencement of the surveillance program.

Postoperative delirium and health related quality of life after coronary artery bypass grafting.

Objectives. We wanted to identify determinants for postoperative delirium and its influence on health related quality of life (HRQoL) during 36-month follow-up of coronary artery bypass (CABG) patients. Design. A total of 302 patients were retrospectively analyzed. HRQoL was assessed prospectively by the15D instrument. Delirium was diagnosed clinically. Results. The incidence of delirium was 6.0%. The cumulative survival (all-cause death) in 36 months was 96.1% in patients without delirium and 77.8% in patients with delirium. Age, cerebral disease, chronic heart failure, male gender, postoperative pneumonia and low output syndrome were predictors for delirium. Delirium patients needed more resources i.e. intensive care or total duration of hospitalization and experienced no positive change in HRQoL. Moreover patients with high preoperative 15D score tended to suffer fairly severe but reversible impairment during the first 6 months after the operation. Conclusions. Preoperatively older and sicker patients with complicated postoperative course are at higher risk of developing delirium after CABG. Preoperative status and operative complications together with delirium may exert negative influence on forthcoming HRQoL, which is seen especially in patients with a relatively high preoperative level of HRQoL.

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.

Femorotibial Reconstructions for Chronic Critical Leg Ischaemia: Influence on Outcome by Diabetes, Gender and Age

OBJECTIVES To analyse the influence of risk factors on the outcome of femorotibial reconstructions for chronic critical leg ischaemia. DESIGN A longitudinal observational study of patients undergoing femorotibial reconstruction. SETTING A regional hospital and an academic referral centre. MATERIALS One hundred and eighty-eight patients undergoing 209 reconstructions to the tibial vessels for chronic critical leg ischaemia, 149 of them with in situ vein grafts. CHIEF OUTCOME MEASURES Graft patency, leg salvage and survival rates. MAIN RESULTS Severity of preoperative ischaemia influenced the immediate outcome of reconstruction. Increasing age did not influence graft patency, leg salvage or survival rates. A combination of female sex and diabetes was associated with low graft patency and leg salvage (52% and 42% at 18 months). Diabetes was associated with a decreased survival. CONCLUSIONS With proper patient selection, patency and leg salvage rates in older (> 80 years) patient groups with multiple risk factors justify an active reconstruction policy.

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.

HRQoL after coronary artery bypass grafting and percutaneous coronary intervention for stable angina

Objectives. To assess the health related quality of life (HRQoL) and the change in the NYHA class after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in the management of stable coronary artery disease (CAD). The study was non-randomized. CABG group consisted of 240 patients and 229 patients were treated with PCI. HRQoL was measured prospectively by the 15D instrument. Results. Three-year survival was 95.0 and 95.6% (NS). The HRQoL improved statistically in both groups until 6 months after treatment but deteriorated towards the end of the follow-up of 36 months. Clinically evident improvement of the HRQoL and decrease of the NYHA class took place more frequently among CABG patients. Conclusions. Despite initially more serious preoperative state and more demanding procedure CABG patients achieve equal level of HRQoL when compared with PCI patients. CABG patients may also obtain better relief from symptoms in mid-term follow-up. HRQoL cannot be the only factor to determine outcome after invasive treatment of CAD but it has to be placed in the context of the overall situation.