Robert A. Pol

Standardised Frailty Indicator as Predictor for Postoperative Delirium after Vascular Surgery: A Prospective Cohort Study

OBJECTIVES To determine whether the Groningen Frailty Indicator (GFI) has a positive predictive value for postoperative delirium (POD) after vascular surgery. METHODS Between March and August 2010, 142 consecutive vascular surgery patients were prospectively evaluated. Preoperatively, the GFI was obtained and postoperatively patients were screened with the Delirium Observation Scale (DOS). Patients with a DOS-score ≥3 points were assessed by a geriatrician. Delirium was defined by the DSM-IV-TR criteria. Primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication and hospital length of stay (HLOS) (>7 days). RESULTS Ten patients (7%) developed POD. The highest incidence of POD was found after aortic surgery (17%) and amputation procedures (40%). Increased comorbidities (p = 0.006), GFI score (p = 0.03), renal insufficiency (p = 0.04), elevated C-reactive protein (p = 0.008), high American Society of Anaesthesiologists score (p = 0.05), a DOS-score of ≥3 points (p = 0.001), post-operative intensive care unit admittance (p = 0.01) and HLOS ≥7 days (p = 0.005) were risk factors for POD. The GFI score was not associated with a prolonged HLOS. A mean number of 2 ± 1 (range 0-5) complications were registered. The receiver operator characteristics (ROC) area under the curve for the GFI was 0.70. CONCLUSIONS The GFI can be helpful in the early identification of POD after vascular surgery in a select group of high-risk patients.

Thirty-day outcome and quality of life after endovascular abdominal aortic aneurysm repair in octogenarians based on the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE)

OBJECTIVE To determine 30-day outcome and quality of life after elective endovascular abdominal aortic aneurysm repair in octogenarians. METHODS From March 2009 to May 2011, 1200 patients with abdominal aortic aneurysms were treated with endovascular aneurysm repair (EVAR) using the Endurant stent graft were included in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) registry. Among these, 926 (77%) were aged <80 years, and 274 (23%) were aged ≥ 80 years. Quality of life was assessed using composite EuroQoL 5-Dimensions Questionnaire index scores. RESULTS Gender was unequally distributed, with more female patients among the octogenarians (P = .043). Octogenarians had a significantly higher American Society of Anesthesiologists classification (P < .001) and differed significantly in baseline risk factors. The younger cohort was more likely to smoke (P < .001) and be alcoholics (P = .005). Octogenarians had larger aortic aneurysm (P = .010) and left iliac artery diameters (P = .017) and greater infrarenal neck angulation (P = .01). The technical success rate was >99% for both cohorts. Octogenarians were more often operated on under general anesthesia (P = .028), had a longer procedure duration (P = .001), and an increased length of hospitalization; both total (P < .001) and postprocedure (P < .001). All-cause mortality and major adverse event rates were similar in the two groups (P = .835 and P = .186, respectively). There was no difference in the number of secondary endovascular procedures or aneurysm rupture at 30 days. At discharge, both groups had reduced health status dimensions, except anxiety/depression, when compared with baseline. At 30 days, the octogenarian group had a lower composite EuroQoL 5-Dimensions Questionnaire index compared with the younger group, indicating a slower recovery (0.83 ± 0.20 vs 0.87 ± 0.16; P = .003). CONCLUSIONS Octogenarians can be safely treated using the Endurant stent graft with a high technical rate of success, low perioperative mortality, and no reduction in quality of life. Octogenarians did, however, appear to recover more slowly than younger patients with respect to certain quality of life components. Long-term data are needed to confirm these results.

Results of 244 Consecutive Patients with Hemorrhoids Treated with Doppler-Guided Hemorrhoidal Artery Ligation

Aim: This study was designed to determine the effect of treating hemorrhoids with the Doppler-guided hemorrhoidal artery ligation (DG-HAL) procedure. Methods: From June 2005 to March 2008, 244 consecutive hemorrhoidal patients underwent hemorroidal artery ligation performed with the DG-HAL system from AMI®. All patients were evaluated postoperatively with a proctologic examination and interview. Further follow-up was performed by telephone with a standardized questionnaire. When indicated, patients revisited the clinic for further examination and treatment. Results: 244 patients were treated with DG-HAL. The mean follow-up time was 18.4 months (range 1.4–37.2). Sixty-seven percent of the patients had an improvement of symptoms after one treatment. Fifty-three patients (22%) underwent a second procedure because of persisting symptoms. Thirteen patients (25%) underwent a second DG-HAL and 40 (75%) underwent rubber band ligation. In total, 69% of the patients had a good response using the DG-HAL technique. Multivariate logistic regression analysis revealed prolapse to be an independent risk factor for persistent symptoms (OR = 2.38, 95% CI 1.10–5.15). Patients with grades 3 and 4 hemorrhoids had a higher risk of developing recurrent disease (OR = 4.94, 95% CI 0.67–36.42). Conclusion: DG-HAL seems to be an effective procedure for treating low-grade hemorrhoids. A resection procedure should be the treatment for patients with recurrent disease.

Predicting postoperative delirium after vascular surgical procedures

OBJECTIVE The objective of this study was to determine the incidence of and specific preoperative and intraoperative risk factors for postoperative delirium (POD) in electively treated vascular surgery patients. METHODS Between March 2010 and November 2013, all vascular surgery patients were included in a prospective database. Various preoperative, intraoperative, and postoperative risk factors were collected during hospitalization. The primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication, hospital length of stay, and mortality. RESULTS In total, 566 patients were prospectively evaluated; 463 patients were 60 years or older at the time of surgery and formed our study cohort. The median age was 72 years (interquartile range, 66-77), and 76.9% were male. Twenty-two patients (4.8%) developed POD. Factors that differed significantly by univariate analysis included current smoking (P = .001), increased comorbidity (P = .001), hypertension (P = .003), diabetes mellitus (P = .001), cognitive impairment (P < .001), open aortic surgery or amputation surgery (P < .001), elevated C-reactive protein level (P < .001), and blood loss (P < .001). Multivariate logistic regression analysis revealed preoperative cognitive impairment (odds ratio [OR], 16.4; 95% confidence interval [CI], 4.7-57.0), open aortic surgery or amputation surgery (OR, 14.0; 95% CI, 3.9-49.8), current smoking (OR, 10.5; 95% CI, 2.8-40.2), hypertension (OR, 7.6; 95% CI, 1.9-30.5) and age ≥80 years (OR, 7.3; 95% CI, 1.8-30.1) to be independent predictors of the occurrence of POD. The combination of these parameters allows us to predict delirium with a sensitivity of 86% and a specificity of 92%. The area under the curve of the corresponding receiver operating characteristics was 0.93. Delirium was associated with longer hospital length of stay (P < .001), more frequent and increased intensive care unit stays (P = .008 and P = .003, respectively), more surgical complications (P < .001), more postdischarge institutionalization (P < .001), and higher 1-year mortality rates (P = .0026). CONCLUSIONS In vascular surgery patients, preoperative cognitive impairment and open aortic or amputation surgery were highly significant risk factors for the occurrence of POD. In addition, POD was significantly associated with a higher mortality and more institutionalization. Patients with these risk factors should be considered for high-standard delirium care to improve these outcomes.

C-reactive protein predicts postoperative delirium following vascular surgery.

BACKGROUND The etiology of postoperative delirium (POD) following vascular surgery is generally unknown. The incidence, however, can be as high as 35%. A possible neuroinflammatory basis for delirium is likely and C-reactive protein (CRP) as a marker for inflammation can possibly play a predictive role. METHODS Between March 2010 and September 2012, 277 consecutive elective vascular surgery patients were prospectively evaluated for the diagnosis of POD. Various potential risk factors, including postoperative CRP values, were collected. RESULTS The mean age of the patients was 69 ± 11 years (range 21-92). The mean hospital length of stay was 6 ± 4 days (range 1-33). Sixteen patients (6%) developed POD during hospital stay. Univariate analysis revealed multiple comorbidities (P = 0.001), postoperative elevated CRP levels (P = 0.001), intensive care unit admittance (P = 0.01), and open aortic surgery or amputation procedures (P = 0.0001) to be significantly related to the diagnosis POD. Multivariate logistic regression analysis confirmed the relationship between an elevated CRP value and POD (odds ratio [OR] 1.01, 95% confidence interval 1.00-1.03, P = 0.04). The sensitivity analyses yielded essentially similar results. Based on OR, it can be calculated that the risk of POD is increased by approximately 35% if the CRP concentration is 50 mg/L, and by approximately 90% if the CRP concentration is 100 mg/L (compared with a CRP concentration of 5 mg/L). Thirty-one percent (5/16) of patients with POD needed a long-stay care facility after discharge (P = 0.0001). CONCLUSIONS In this study, CRP can be used as a marker for an increased risk of POD after vascular surgery. In addition, it was found that POD was associated with a 10-fold increase in the need of long-stay care after discharge.

A limited and customized follow-up seems justified after endovascular abdominal aneurysm repair in octogenarians

OBJECTIVE The objective of this study was to determine whether long-term follow-up after endovascular aneurysm repair (EVAR) is justified in octogenarians. METHODS Between September 1996 and October 2011, all patients, including octogenarians, treated for an abdominal aortic aneurysm (AAA) by EVAR were included in a prospective database. Patients older than 80 years and with a nonruptured infrarenal aneurysm treated electively or urgently were included in the study (study group [SG]). Patients with ruptured aneurysms and patients who died during surgery or within the first postoperative month were excluded from further analysis. The control group (CG) consisted of patients younger than 80 years, matched for gender and AAA diameter. All patients were evaluated 4 to 8 weeks after EVAR and then annually thereafter. Follow-up data were complemented by review of the computerized hospital registry and charts and by contact of the patients general practitioner or referring hospital. Primary outcomes were stent- or aneurysm-related complications and interventions. Secondary outcomes were additional surgical complications and patient survival. RESULTS A total number of 193 patients (SG, n = 97; CG, n = 96) were included for analysis. Median age was 80 years, and 88.6% were male. Median follow-up time was 33.6 months (interquartile range [IQR], 12.9-68.3). Stent- and procedure-related postoperative complications were comparable between groups (SG, 41.2%; CG, 39.6%; P = .82). Median time to complication was 2.3 months (IQR, 0.2-19.4) in the SG compared with 18.1 months (IQR, 6.8-50.5) in the CG. The 2-year complication-free survival rates were 58% (SG) and 60% (CG). Interventions were performed significantly less frequently in octogenarians (SG, 8.2%; CG, 19.8%; P < .05). Median time to intervention was 11.1 months (IQR, 2.0-31.0) in the SG compared with 54.3 months (IQR, 15.0-93.2) in the CG. The 2-year intervention-free survival rates were 90% (SG) and 92% (CG). During follow-up, 98 patients died (SG, n = 54; CG, n = 44); median time to death was 31.8 months (IQR, 13.3-66.0) in the SG compared with 44.4 months (IQR, 15.0-77.7) in the CG. One aneurysm-related death occurred in the CG. The 2- and 5-year survival rates were 71% and 32% for the SG compared with 77% and 66% for the CG (P < .05). CONCLUSIONS Because of the low incidence of secondary procedures and AAA-related deaths in octogenarians, long-term and frequent follow-up after EVAR seems questionable. An adapted and shortened follow-up seems warranted in this patient group.

Outcome and quality of life after endovascular abdominal aortic aneurysm repair in octogenarians

OBJECTIVE This study determined outcome and quality of life (QOL) in octogenarians, compared with patients aged <80 years, 1 year after endovascular aortic aneurysm repair (EVAR). METHODS From March 2009 until April 2011, 1263 patients in the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE) registry with an abdominal aortic aneurysm were treated with EVAR using the Endurant endograft (Medtronic Cardiovascular, Santa Rosa, Calif). The patients were grouped according to those aged ≥80 years (290 [22.9%]) and those aged <80 years (973 [77.1%]) at the time of the procedure. QOL was assessed using composite EuroQoL 5-Dimensions Questionnaire (EQ-5D) index scores. Baseline, perioperative, and follow-up data were analyzed at 1 year. RESULTS Octogenarians had poorer anatomic characteristics. The technical success rate was almost 99% for both cohorts, with no deaths. The duration of the implant procedure was significantly longer in the elderly patients (P = .002), with significant differences in overall (P < .001) and postprocedure (P < .001) hospital stays in favor of the younger group. At 1 year, there was a significant difference in all-cause mortality (P = .002) and in the number of major adverse events (P = .003), including secondary rupture (P = .01), to the detriment of octogenarians. There were no significant differences in conversion to open surgery or in overall secondary endovascular procedures. The octogenarians scored lower in their overall health care perception (P < .001) but with no significant difference in the EQ-5D index. Compared with the group aged <80 years, they had still not completely recovered their QOL after 1 year (P = .01). CONCLUSIONS Octogenarians are more difficult to treat by EVAR than younger patients due to poorer anatomic suitability and a higher incidence of complications. Recovery of QOL in octogenarians takes longer (>12 months) than expected.

Effectiveness of treatment for octogenarians with acute abdominal aortic aneurysm

OBJECTIVE To investigate whether advanced age may be a reason to refrain from treatment in patients with an acute abdominal aortic aneurysm (AAAA). METHODS This was a retrospective cohort study that took place in a tertiary care university hospital with a 45-bed intensive care unit. Two hundred seventy-one patients with manifest AAAA, admitted and treated between January 2000 and February 2008, were included. Six patients died during operation and were included in the final analysis to ensure an intention-to-treat protocol, resulting in 234 men and 37 women with a mean age of 72 ± 7.8 years (range, 54-88 years). Forty-six patients (17%) were 80 years or older. Interventions involved open or endovascular AAAA repair. RESULTS Mean follow-up was 33 ± 30.4 months (including early deaths). Mean hospital length of stay was 16.9 ± 20 days for patients younger than 80 and 13 ± 16.7 days for patients older than 80 years of age. Kaplan-Meier survival analysis revealed a significantly better survival for the younger patients (P < .05). Stratification based on urgency or type of treatment did not change the difference. Two-year actuarial survival was 70% for patients younger than 80 and 52% for those older than 80. At 5-year follow-up, these figures were 62% and 29%, respectively. Mean survival in patients older than 80 was 39.8 ± 6.8 months versus 64.5 ± 3.0 months in those younger than 80. CONCLUSIONS For octogenarians, our liberal strategy of treating patients with AAAA was associated with satisfactory short- and long-term outcome, with no difference with regard to disease- or procedure-related morbidity between the younger and older group. Assuming an integrated system for managing AAAA is in place, advanced age is not a reason to deny patients surgery.

18F-Fluorodeoxyglucose Positron Emission Tomography/CT Scanning in Diagnosing Vascular Prosthetic Graft Infection

Vascular prosthetic graft infection (VPGI) is a severe complication after vascular surgery. CT-scan is considered the diagnostic tool of choice in advanced VPGI. The incidence of a false-negative result using CT is relatively high, especially in the presence of low-grade infections. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) scanning has been suggested as an alternative for the diagnosis and assessment of infectious processes. Hybrid 18F-FDG PET/CT has established the role of 18F-FDG PET for the assessment of suspected VPGI, providing accurate anatomic localization of the site of infection. However, there are no clear guidelines for the interpretation of the uptake patterns of 18F-FDG as clinical tool for VPGI. Based on the available literature it is suggested that a linear, diffuse, and homogeneous uptake should not be regarded as an infection whereas focal or heterogeneous uptake with a projection over the vessel on CT is highly suggestive of infection. Nevertheless, 18F-FDG PET and 18F-FDG PET/CT can play an important role in the detection of VPGI and monitoring response to treatment. However an accurate uptake and pattern recognition is warranted and cut-off uptake values and patterns need to be standardized before considering the technique to be the new standard.

The relation between atherosclerosis and the occurrence of postoperative delirium in vascular surgery patients

Old and frail patients undergoing vascular surgery seem at great risk of developing postoperative delirium (POD). The aim of this review was to identify risk factors for the development of POD in vascular surgery patients. Different aetiological factors have been identified, such as increased age, excessive blood transfusion, preoperative cognitive impairment and depression. Mounting evidence supports a role for inflammation and tobacco exposure in the development of POD. Vascular surgery patients differ from the general surgical population because they suffer from both loco-regional and systemic atherosclerosis. Although current scientific evidence cannot fully link both entities, evidence is growing that suggests a relationship between systemic and cerebrovascular atherosclerosis and the development of POD.