Thomas Troëng

Abdominal aortic aneurysm with perianeurysmal fibrosis: Experience from 11 Swedish vascular centers ☆ ☆☆

Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Variation in Clinical Practice in Carotid Surgery in Nine Countries 2005–2010. Lessons from VASCUNET and Recommendations for the Future of National Clinical Audit

OBJECTIVES The aim of the study was to analyse variation in carotid surgical practice, results and effectiveness in nine countries. PATIENTS AND METHODS A total of 48,185 carotid endarterectomies (CEAs) and 4602 carotid artery stenting (CAS) procedures were included in the comparison. A theoretical effectiveness of CEA provision for each country was estimated. RESULTS 92.6% of the CEAs were performed according to the inclusion criteria based on the current European recommendations and had a theoretical benefit for the patient. The indication for surgery was symptomatic stenosis in 60.1% and this proportion varied between 31.4% in Italy and 100% in Denmark. The overall combined stroke and death rate in symptomatic patients was 2.3%. This varied between rates of 0.9% in Italy and 3.8% in Norway. The overall combined stroke and death rate in asymptomatic patients was 0.9%. It was lowest in Italy at 0.5%, and highest in Sweden at 2.7%. We estimated that the stroke prevention rate per 1000 CEAs varied from 72.9 in Italy to 130.8 in Denmark. CONCLUSIONS There is significant variation in clinical practice across the participating countries. The theoretical stroke prevention potential of CEA seems to vary between participating countries due to differences in the inclusion criteria.

Outcome of the Swedish Nationwide Abdominal Aortic Aneurysm Screening Program

Background: A general abdominal aortic aneurysm (AAA) screening program, targeting 65-year-old men, has gradually been introduced in Sweden since 2006 and reached nationwide coverage in 2015. The aim of this study was to determine the outcome of this program. Methods: Data on the number of invited and examined men, screening-detected AAAs, AAAs operated on, and surgical outcome were retrieved from all 21 Swedish counties for the years 2006 through 2014. AAA-specific mortality data were retrieved from the Swedish Cause of Death Registry. A linear regression analysis was used to estimate the effect on AAA-specific mortality among all men ≥65 years of age for the observed time period. The long-term effects were projected by using a validated Markov model. Results: Of 302 957 men aged 65 years invited, 84% attended. The prevalence of screening-detected AAA was 1.5%. After a mean of 4.5 years, 29% of patients with AAA had been operated on, with a 30-day mortality rate of 0.9% (1.3% after open repair and 0.3% after endovascular repair, P<0.001). The introduction of screening was associated with a significant reduction in AAA-specific mortality (mean, 4.0% per year of screening, P=0.020). The number needed to screen and the number needed to operate on to prevent 1 premature death were 667 and 1.5, respectively. With a total population of 9.5 million, the Swedish national AAA-screening program was predicted to annually prevent 90 premature deaths from AAA and to gain 577 quality-adjusted life-years. The incremental cost-efficiency ratio was estimated to be &OV0556;7770 per quality-adjusted life-years. Conclusions: Screening 65-year-old men for AAA is an effective preventive health measure and is highly cost-effective in a contemporary setting. These findings confirm the results from earlier randomized controlled trials and model studies in a large population-based setting of the importance for future healthcare decision making.

Auditing surgical outcome: ten years with the Swedish vascular registry—Swedvasc

Auditing surgical outcome: ten years with the Swedish VascularRegistry--Swedvasc. The Steering Committee of Swedvasc.

Vascular surgical audit during a 5-year period

UNLABELLED The objective was to explore possible time trends in the indications for peripheral vascular surgery in Sweden. DESIGN Analysis of data from the Swedvasc vascular registry 1987-1991. SETTING Routine vascular surgery in university, county and district hospitals within the Swedish public hospital system. The registry is independent of local administration, run by the surgeons themselves and financed by national authorities. MATERIALS 4950 procedures registered in the 17 original centres 1987-91 and 1892 procedures registered in 16 new centres 1991. CHIEF OUTCOME MEASURES Distribution of indications, mortality within 30 days and clinical outcome at one year. MAIN RESULTS During the first 5 years of the registry (1987 to 1991) the proportion of procedures performed for acute ischaemia significantly decreased from 20% to 14.3%. Simultaneously procedures for critical leg ischaemia significantly increased from 24.8 to 30.3%. Changes in the proportions treated for aortic aneurysms, carotid artery stenosis, claudication, vascular access or other indications were less striking or nonsignificant. The 30-day mortality decreased in patients operated on for acute ischaemia but did not change in other groups. The proportion of elective/emergency operation for aortic aneurysm changed from 1.2 to 2.0 leading to a minimal decrease in overall aneurysm mortality. The proportion of patients treated for claudication who were alive and improved at one year changed from 77.2% to 72.9% which was not statistically significant, while the proportion of patients treated for critical ischaemia who were alive with an intact leg after one year increased from 65.2% to 80.2% which was a significant improvement. CONCLUSIONS Decision making among vascular surgeons in Sweden appears to have improved as proportionally fewer patients are operated on for acute ischaemia, more for critical ischaemia with possibly an improved outcome.

International Variations in Infrainguinal Bypass Surgery – A VASCUNET Report

OBJECTIVES To compare practice in lower limb bypass surgery in nine countries. DESIGN A prospective study amalgamating and analysing data from national and regional vascular registries. METHODS A table of data fields and definitions was agreed by all member countries of the Vascunet Collaboration. Data from January 2005 to December 2009 was submitted to a central database. RESULTS 32,084 cases of infrainguinal bypass (IIB) in nine countries were analysed. Procedures per 100,000 population varied between 2.3 in the UK and 24.6 in Finland. The proportion of women varied from 25% to 43.5%. The median age for all countries was 70 for men and 76 for women. Hungary treated the youngest patients. IIB was performed for claudication for between 15.7% and 40.8% of all procedures. Vein grafts were used in patients operated on for claudication (52.9%), for rest pain (66.7%) and tissue loss (74.1%). Italy had the highest use of synthetic grafts. Among claudicants 45% of bypasses were performed to the below knee popliteal artery or more distally. Graft patency at 30 days varied between 86% and 99%. CONCLUSIONS Significant variations in practice between countries were demonstrated. These results should be interpreted alongside the known limitations of such registry data with respect to quality and completeness of the data. Variation in data completeness and data validation between countries needs to be improved for useful international comparison of outcomes.

Vascular surgery in Southern Sweden—the first year experience of a vascular registry

A vascular registry was set up in southern Sweden covering all peripheral vascular procedures performed in a population of almost 2 million. During the first year 1569 procedures were registered including 30-day follow-up, making a frequency of 84 per 100,000 inhabitants with a considerable variation between counties, from 42 to 146 procedures per 100,000 inhabitants. The operations were performed by 127 different surgeons, but only nine surgeons performed more than 50 operations each. These surgeons participated in 52.6% of all procedures. The frequency of re-operation differed from 4.0 to 17.9% between hospitals. One month postoperatively 70% of the patients had returned home while 13.2% were still in hospital. Median length of stay was 8 days. Overall mortality was 7.9%. The outcome at 30 days for various procedures was comparable with that of other recent reports from specialised centres.

Editor's Choice: Contemporary Treatment of Popliteal Artery Aneurysm in Eight Countries: A Report from the Vascunet Collaboration of Registries

OBJECTIVES To study contemporary popliteal artery aneurysm (PA) repair. METHODS Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland). RESULTS From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture. CONCLUSIONS Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.

Urgent Carotid Surgery and Stenting May Be Safe After Systemic Thrombolysis for Stroke

Background and Purpose— Early carotid surgery or stenting after thrombolytic treatment for stroke has become more common during recent years. It is unclear whether this carries an increased risk of postoperative complications and death. The aim of this nationwide population-based study was, therefore, to investigate the safety of urgently performed carotid procedures in patients treated with thrombolysis for stroke. Methods— Using the national Vascular and Stroke registries, we identified 3998 patients who had undergone carotid endarterectomy or carotid artery stenting for symptomatic carotid stenosis between May 2008 and December 2012. Among these, 2% (79 of 3998) had undergone previous thrombolysis for stroke. We conducted a retrospective review of registry data and individual case records with regard to postoperative complications, including surgical-site bleeding, stroke, and death. The outcome was compared with the results for the remaining patient cohort (3919 of 3998) undergoing carotid surgery and stenting during the study period. Results— The median time between thrombolysis and the carotid procedure was 10 days. Seventy-one patients underwent carotid endarterectomy, and 6 patients underwent carotid artery stenting. The 30-day death and stroke rate for the thrombolysis cohort was 2.5% (2 of 79), and for the whole cohort, it was 3.8% (139 of 3626; P=0.55). The postoperative bleeding rates requiring reoperation were not significantly different between the groups (3.8% [3 of 79] in the thrombolysis group versus 3.3% [119 of 3626] in the whole cohort; P=0.79). There was no correlation between time from lysis to surgery or stenting and complications at 30 days postoperatively. Conclusions— Urgent carotid endarterectomy or carotid artery stenting after thrombolysis for stroke may be safe without increased risk of serious complications.

Editor's Choice - Safety of Carotid Endarterectomy After Intravenous Thrombolysis for Acute Ischaemic Stroke: A Case-Controlled Multicentre Registry Study

OBJECTIVE Few studies have been published on the safety of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT). Registry reports have been recommended in order to gather large study groups. DESIGN A retrospective, registry based, case controlled study on prospectively gathered data from Sweden, the capital region of Finland, and from Denmark, including 30 days of follow up. METHODS The study group was a consecutive series of 5526 patients who had CEA for symptomatic carotid artery stenosis during a 4.5 year period. Among these, 202 (4%) had IVT prior to surgery, including 117 having CEA within 14 days, and 59 within 7 days of thrombolysis. IVT as well as CEA were performed following established guidelines. The median time from index symptom to CEA was 12 days (range 0-130, IQR 7-21). RESULTS The 30 day combined stroke and death rate was 3.5% (95% CI 1.69-6.99) for those having IVT + CEA, 4.1% (95% CI 3.46-4.39) for those having CEA without previous IVT (odds ratio 0.84 [95% CI 0.39-1.81]), 3.4% (95% CI 1.33-8.39) for those having IVT + CEA within 14 days, and 5.1% (95% CI 1.74-13.91) for those having IVT + CEA within 7 days. CONCLUSION Data on the time from symptoms to CEA in patients not having IVT, Rankin score, degree of stenosis, and cerebral imaging were not available. Despite its weaknesses, this study reasserts that CEA can be performed within the recommended 2 weeks of the onset of symptoms and IVT without increasing the risk of peri-operative stroke or death. Centres and vascular registries are recommended to continue monitoring changes in patient characteristics, lead times, and major complications after CEA in general, with a special focus on those who have undergone a prior thrombolysis.