Thomas Eugster

Does specialization improve outcome in abdominal aortic aneurysm surgery

Specialization and high volume are reported to be related to a better outcome after abdominal aortic aneurysm repair. The aim of this study was to compare, in patients undergoing abdominal aortic aneurysm repair, the outcomes of those whose surgery was done by general surgeons with the outcomes of those whose surgery was done by specialist vascular surgeons. All patients undergoing abdominal aortic aneurysm repair at the Basel University Hospital (referral center) from January 1990 to December 2000 were included. Patients with endovascular treatment were excluded. Operations in group A (n = 189), between January 1990 and May 1995, were done by general surgeons. Operations in group B (n = 291), between June 1995 and December 2000, were done by vascular surgeons. In-hospital mortality and local and systemic complications were assessed. In-hospital mortality rates were significantly lower for group B (with specialist surgeons) than for group A, both overall (group B, 11.7%; group A, 21.7%; p = .003) and for emergency interventions (group B, 28.1%; group A, 41.9%; p = .042). The reduction in mortality for elective surgery in group B was not statistically significant (group B, 1.1%; group A, 4.9%; p = .054). There were significantly fewer pulmonary complications in group B compared with group A (p = .000). We conclude that in patients undergoing abdominal aortic aneurysm repair, those whose surgery is done by a specialized team have a significantly better outcome than those whose surgery is done by general surgeons.

Verschluss der A. femoralis superficialis Der autologe Venenbypass zur supragenualen A. poplitea

ZusammenfassungDie Wahl des Materials zur Überbrückung einer verschlossenen A. femoralis superficialis wird bei supragenualem Anschluss kontrovers diskutiert. Wir vergleichen unsere Langzeitresultate mit autologem Venenmaterial mit Daten aus der Literatur. Patienten und Methode: von 1992–1999 haben wir bei 57 Patienten 64 femoropopliteale, supragenuale Rekonstruktionen mit autologer Vene durchgeführt. Resultate: Die primäre Offenheitsrate nach 72 Monaten betrug 82,6%, die primär assistierte 98,1%. Die perioperative Mortalität (≤30 Tage) lag bei 3,1%. Nach 72 Monaten lebten noch 80,4% der Patienten. 61% der Patienten: wurden im Stadium II operiert. Schlussfolgerung: Mit autologem Venenmaterial sind sowohl im Stadium der kritischen Ischämie wie auch im Stadium II bei supragenualem Anschluss hervorragende Resultate zu erzielen. Vergleichsstudien mit Verwendung von Kunststoff oder Bioprothesen zeigen ansprechende Kurzzeitresultate. Kurze Beobachtungszeiten und kleine Fallgruppen führen zur Überschätzung der Resultate mit Kunststoffprothesen und lassen den trügerischen Schluss zu, diese Materialen für den supragenualen Anschluss zu bevorzugen.AbstractIntroduction: The choice of material for above-knee popliteal artery bypass is still a matter of continuous debate. This study presents the results of femoropopliteal suprageniculate autologous vein bypass. The comparison with results from the current literature should help to clarify the question of the most suitable bypass material. Patients and methods: From 1992 to 1999 we analysed the results of 64 autologous bypass reconstructions to the above-knee popliteal artery. All patients entered a prospectively designed follow-up program after operation. Results: The primary cumulative patency rate was 82.6%, the primary assisted patency rate was 98.1% 72 months postoperatively. 61% of the patients suffered from claudication before treatment. The perioperative mortality (≤30 days) was 3.1% for the whole group. Conclusions: Using autologous venous material excellent results for femoropopliteal suprageniculate artery bypass reconstructions can be achieved. The interpretation of short-term studies with small groups comparing autologous, PTFE and biological materials can be misleading. These studies simulate no significant differences in patency rates between the various groups of materials due to statistical problems (Type I or Type II errors). Larger sample sizes, careful examination of bypass occlusions and long-term follow up make autologous veins to the material of choice even for reconstructions to the suprageniculate popliteal artery.

Intermediate-term outcome of single kidney grafts from pediatric donors weighing 10-14 kg in adult recipients.

Kidneys from pediatric donors weighing <10 kg are preferably transplanted en bloc, while kidneys from donors weighing >15 kg can be safely transplanted as single kidneys. However, single kidney transplantation from donors weighing 10–14 kg is controversial and has not been well investigated.

Die postoperative Betreuung nach gefäßchirurgischem Eingriff - Sekundärprophylaxe und Richtlinien für den Hausarzt

Die postoperative Betreuung des gefaschirurgischen Patienten stellt auch an den nachbehandelnden Arzt grose Anforderungen. Eine spezielle Herausforderung bietet dabei die Kontrolle der kardiovaskularen Risikofaktoren. Hier kommt dem Hausarzt eine grose Bedeutung zu. Im folgenden Artikel werden die wichtigsten gefaschirurgischen Eingriffe und deren Nachbehandlung dargestellt.

The outcome of the primary vascular access and its translation into prevalent access use rates in chronic haemodialysis patients

Background The American Fistula First Breakthrough Initiative currently aims for a 66% arterio-venous fistula (AVF) rate, while in the UK, best practice tariffs target AVF and arterio-venous graft (AVG) rates of 85%. The present study aims to assess whether these goals can be achieved. Methods We conducted a retrospective cohort study on patients who initiated haemodialysis from 1995 to 2006. Outcomes were the final failure-free survival of the first permanent access and the type of second access created. Prevalent use rates for the access types were calculated on the 1st January of each year for the second half of the study period. Results Two hundred and eleven out of 246 patients (86%) received an AVF, 16 (6%) an AVG and 19 (8%) a permanent catheter (PC) as the first permanent access. Eighty-six (35%) patients had final failure of the primary access. One- and 3-year final failure-free survival rates were 73 and 65% for AVF compared with 40 and 20% for AVG and 62 and 0% for PC, respectively. In patients with primary AVF, female sex {hazard ratio (HR) 2.20 [confidence interval (CI) 1.29–3.73]} and vascular disease [HR 2.24 (CI 1.26–3.97)] were associated with a poorer outcome. A similar trend was observed for autoimmune disease [HR 2.14 (CI 0.99–4.65)]. As second accesses AVF, AVG and PC were created in 47% (n = 40), 38% (n = 33) and 15% (n = 13). The median prevalent use rate was 80.5% for AVF, 14% for AVG and 5.5% for PC. Conclusions The vascular access targets set by initiatives from the USA and UK are feasible in unselected haemodialysis patients. High primary AVF rates, the superior survival rates of AVFs even in patient groups at higher risk of access failure and the high rate of creation of secondary AVFs contributed to these promising results.

Aktuelle diagnostische Aspekte beim asymptomatischen Bauchaortenaneurysma

ZusammenfassungEinzig die Früherkennung eines abdominalen Aortenaneurysmas (AAA) ist wesentlich, um den schicksalhaften Verlauf bis zur lebensbedrohenden Ruptur zu beeinflussen. Die Ultraschalluntersuchung des Abdomens weist ein AAA mit großer Sicherheit nach und stellt deshalb die Vorsorgeuntersuchung der Wahl dar. Die Computertomographie und in Zukunft vermehrt die Magnetresonanz sind wichtige diagnostische Hilfsmittel. Im Blut zirkulierende Zytokine oder Metalloproteinasen werden als potenzielle Marker auch für das asymptomatische AAA in Betracht gezogen. Die vorliegende Übersichtsarbeit zeigt gesicherte diagnostische Aspekte beim asymptomatischen AAA und gibt einen Ausblick auf mögliche Untersuchungsmethoden der Zukunft.AbstractThe early detection of abdominal aortic aneurysm (AAA) is crucial for the prevention of a potential life threatening rupture. The diagnosis of AAA is made by ultrasound examination of the abdomen. CT and increasingly MRI are valuable tools in AAA diagnosis and therapy. Cytokines and metalloproteinases are potential markers for asymptomatic AAA in blood samples. This overview summarises approved diagnostic approaches and discusses possible procedures in detecting AAA.

Ist die infrainguinale Rekonstruktion der arteriellen Strombahn mit autologer Vene im Stadium der limitierenden Klaudikation gerechtfertigt

Zusammenfassung Die Indikation zur infrainguinalen Rekonstruktion der arteriellen Strombahn im Sta- dium der limitierenden Klaudikation ist v. a. im angelsächsischen Raum umstritten. Die Resultate sind kritisch auszuwerten, da keine extremitätenbedrohende Ischämie vorliegt. Unsere Analyse soll Aufschluss darüber geben, ob gute Langzeitergebnisse die Indikation zur Revaskularisation auch im Stadium II der PAVK rechtfertigen. Wir haben dazu retrospektiv alle Patienten nachkontrolliert, bei denen zwischen Oktober 88 und Dezember 98 eine infrainguinale Venenbrücke angelegt wurde. Der älteste Patient war 86, der jüngste 20 Jahre alt. Insgesamt wurden 421 Brücken bei 410 Patienten angelegt. 115 Rekonstruktionen (27,2%) erfolgten wegen limitierender Klaudikation, 306 (72,8%) Brücken wurden im Stadium der kritischen Ischämie (III und IV) angelegt. Bei allen Brücken wurde autologe Vene verwendet. Die Nachkontrolle erfolgte nach festem Schema in der Gefäßsprechstunde.Die primäre Offenrate nach 84 Monaten betrug im Stadium II 64,8%, im Stadium III und IV 54,2% (p=0,344). Die primär assistierte Offenrate betrug 86,1 bzw. 79,3% (p=0,285).Alle Patienten mit limitierender Klaudikation waren postoperativ beschwerdefrei. Bei 2 Patienten mit Klaudikatio musste postoperativ die Extremität amputiert werden (1,7%), verglichen mit 26 (8,5%) im Stadium III oder IV. Beide im Stadium II amputierten Patienten litten an Diabetes mellitus und mussten bei offener Rekonstruktion infolge einer später aufgetretenen Vorfußgangrän operiert werden (3 und 5 Jahre nach Revaskularisation).Interdisziplinäres Management der Patienten mit limitierender Klaudikation durch ein spezialisiertes Team von Angiologen, Radiologen und Gefäßchirurgen, konsequente Verwendung von autologem Venenmaterial sowie regelmäßige postoperative Nachkontrollen ergeben nach unserer Erfahrung hervorragende Langzeitergebnisse. Diese rechtfertigen die Operation bei der limitierenden Klaudikation in ausgewählten Fällen.Abstract Infrainguinal arterial reconstruction for intermittent claudication has been discouraged because of fear of bypass graft failure, significant perioperative complications, and limb loss. This may be worse than the natural history of the disease. In our study, we retrospectively evaluated all infrainguinal bypass procedures performed in the past 10 years.From October 1988 to December 1998, we performed 421 infrainguinal arterial reconstructions, 115 (27.2%) for debilitating claudication and 306 (72.8%) for critical ischemia in 410 patients. The average age was 73.2 years (range 20–86 years). There were significantly more diabetics with critical ischemia (183 versus 14, P=0.000). Other risk factors (smoking, hypertension, hyperlipidemia) were evenly distributed in both groups. Follow-up was scheduled in our vascular laboratory.The primary patency rates were 64.8% for intermittent claudication and 54.2% for critical ischemia at 7 years (P value not significant), and the primary assisted patency rates were 86.1% and 79.3%, respectively (P value not significant). There were 2 patients (1.7%) with limb loss in the follow-up period (3 and 5 years after operation, respectively). Both patients were diabetics, who had to be amputated with patent grafts because of progressive forefoot gangrene. The 30-day mortality rate was 0.8% (1 patient died on the second postoperative day due to cardiac failure).In our experience, patients with debilitating claudication have to be managed by a team of angiologists, radiologists, and vascular surgeons. The use of autologous vein, intraoperative angioscopy, and a scheduled follow-up program may be the cornerstones for excellent long-term results. These results justify operation in selected cases.