Sorjo Mätzke

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.

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.

ANKLE BRACHIAL INDEX MEASUREMENTS IN CRITICAL LEG ISCHAEMIA - THE INFLUENCE OF EXPERIENCE ON REPRODUCIBILITY

Background and Aims: While the use of ankle brachial indices (ABI) in the screening for peripheral arterial obstructive disease is widely accepted, the applicability of ABI in the identification of critical leg ischaemia (CLI) is far from settled. The aim was to assess inter-observer variability of ABI measurements in patients with CLI. Material and Methods: The study was conducted in two parts. In both parts a handheld 9.5 MHz Doppler device was used. Part A: ABI was measured by 7 measurers with variable measurement experience in 22 limbs of patients admitted to the surgical ward because of CLI. The agreement between the measurements was assessed. Part B: Inter-observer agreement in measuring ABI was assessed between 2 trained vascular technicians measuring 33 limbs in patients with CLI on the vascular outpatient clinic. Results and Conclusions: Part A: 16 % of the ABI-values differed 0.15 or more from the median and the mean coefficient of variation was 56.1. Part B: The difference between measurements did not exceed 0.14 with a mean coefficient of variation of 3.2. To obtain reproducible and quantitative measurement values the measurements have to be performed by trained personnel. Measurements performed by untrained personnel can only be regarded as qualitative.

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.

Sentinel lymph node mapping using SPECT–CT fusion imaging in patients with oral cavity squamous cell carcinoma

Lymphoscintigraphic planar imaging is commonly performed to locate the sentinel lymph nodes (SLN) preoperatively. The images are, however, obscure lacking anatomical information and only rough topographical orientation of the SLNs is possible. Image fusion of Single Photon Emission Computed Tomography (SPECT) and Computed Tomography (CT) has been suggested to be an anatomically more precise method for preoperative SLN mapping. In the present study, preoperative lymphoscintigraphic SLN mapping was performed by using a hybrid gamma-camera with CT system (SPECT–CT) in addition to conventional planar lymphoscintigraphy in 15 consecutive patients with squamous cell carcinoma (SCC) of the oral cavity. The planar images were compared to fused SPECT and CT images. SPECT–CT fusion images showed only one SLN that was not detected in planar images. Two SLNs suspected in planar images could be excluded by SPECT–CT. The location of the SLNs could be determined more accurately by SPECT–CT. SPECT–CT fusion imaging was found feasible for preoperative SLN identification in patients with oral cavity SCC. It enables more accurate localisation of the SLNs, but it rarely reveals SLNs, that are not detected on planar images.

Claudication does not always precede critical leg ischemia

Prevalence of intermittent claudication is often used to calculate the prevalence of critical leg ischemia (CLI), a more severe form of peripheral arterial disease (PAD). Although this logical course of the disease is intellectually appealing, not all patients with CLI have experienced any symptoms of previous claudication. A total of 100 consecutive patients with objective evidence of critical ischemia, as evaluated by non-invasive testing in the authors’ vascular laboratory, were subjected to a structured interview to evaluate how often peripheral arterial disease is presented with symptoms of CLI as the initial complaint. In all, 37 patients had never experienced claudication prior to the development of CLI. Furthermore, 12 of 63 patients who suffered from previous claudication did not have any claudication symptoms at the time of the development of CLI. Of the 37 patients with CLI as the first sign of PAD, 20 had diabetes - four of whom with manifest diagnosed neuropathy. The patients without previous claudication more frequently had ulcers as the initial symptom of CLI (89%) than those with claudication (59%), whose disease first progressed to rest pain. Altogether, 25 patients did not walk enough to develop symptoms of claudication. In conclusion, every patient presenting with symptoms potentially related to CLI should undergo vascular laboratory measurements regardless of whether he/she has a history of claudication or not. This is especially true in limbs with unhealed skin lesions.

Haemodynamic results of femoropopliteal percutaneous transluminal angioplasty

OBJECTIVES To determine the utility of percutaneous transluminal angioplasty (PTA) of the femoropopliteal segment in patients with claudication and critical leg ischaemia (CLI). DESIGN Longitudinal observational study. SETTING A university based vascular surgical centre. MATERIAL Ninety-five patients with stenosing or occlusive arterial lesions of the femoropopliteal segment underwent 52 primary PTA for claudication and 50 primary PTA for CLI. METHODS The procedure was considered haemodynamically successful when the increase of immediate postprocedural ABI was 0.15 or more. The criterion for haemodynamic success during follow-up was an ABI having not decreased by more than 0.15 from the immediate postprocedural level. The run-off arteries were graded according to the scoring system proposed by the SVS/ISCVS. RESULTS Among the technically successful procedures (83%), the haemodynamic success rate was 77% at 1 month, 55% after 1 year, and 51% after 2 years. The cumulative haemodynamic success rates were 83%, 66% and 61% in claudicants, and 70%, 42%, and 38% in CLI (p = 0.03). In patients with a run-off score < or = 7.5, the success rates were 84%, 67%, and 60%, respectively, whereas in those with a crural score > 7.5 these were 61%, 39%, and 39%, respectively (p = 0.04). CONCLUSIONS The haemodynamic results suggest that PTA to the femoropopliteal segment is seldom a procedure of choice for critically ischaemic legs with poor run-off. The run-off score is useful in identifying patients who may benefit from PTA.

Sentinel lymph node biopsy as an alternative to wait and see policy in patients with small T1 oral cavity squamous cell carcinoma

Conclusion. Although sentinel lymph node (SLN) biopsy is not yet validated for clinical use to replace elective neck dissection in patients with oral squamous cell carcinoma, it can be recommended for patients who do not fulfil the criteria for elective neck treatment according to current treatment protocols. Objective. To examine the benefits of SLN biopsy in oral cancer patients who have a small risk for occult metastasis and therefore are not considered candidates for elective neck treatment. Patients and methods. Thirteen consecutive patients with a small T1 oral cavity squamous cell carcinoma, clinically staged N0, and who did not meet the indications for elective neck treatment, underwent SLN biopsy. The SLNs were cut at 1–2 mm intervals and stained with haematoxylin and eosin and cytokeratin AE1/AE3. Results. Histopathological examination of SLNs revealed micrometastases in two patients. A selective neck dissection was performed on these patients and no further metastases were encountered. All patients had a minimum follow-up of 12 months and no cervical or other recurrences were encountered.

Survival of a Microvascular Muscle Flap Despite the Late Occlusion of the Inflow Artery in a Neuroischaemic Diabetic Foot

A microsurgical free rectus abdominis flap was connected to a popliteodistal vascular reconstruction because of a limb-threatening ischaemic ulcer in an 84 year old diabetic patient. After six months the inflow vessel occluded, but the flap stayed viable, apparently receiving its nutrition through newly developed collaterals.