van den Johannes Dungen

Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience.

OBJECTIVES To present an 8-year clinical experience in the endovascular treatment of short-necked and juxtarenal abdominal aortic aneurysm (AAA) with fenestrated stent grafts. METHODS At our tertiary referral centre, all patients treated with fenestrated and branched stent grafts have been enrolled in an investigational device protocol database. Patients with short-necked or juxtarenal AAA managed with fenestrated endovascular aneurysm repair (F-EVAR) between November 2001 and April 2009 were retrospectively reviewed. Patients treated at other hospitals under the supervision of the main author were excluded from the study. Patients treated for suprarenal or thoraco-abdominal aneurysms were also excluded. All stent grafts used were customised based on the Zenith system. Indications for repair, operative and postoperative mortality and morbidity were evaluated. Differences between groups were determined using analysis of variance with P < 0.05 considered significant. RESULTS One hundred patients (87 males/13 females) with a median age of 73 years (range, 50-91 years) were treated during the study period; this included 16 patients after previous open surgery or EVAR. Thirty-day mortality was 1%. Intra-operative conversion to open repair was needed in one patient. Operative visceral vessel perfusion rate was 98.9% (272/275). Median follow-up was 24 months (range, 1-87 months). Twenty-two patients died during follow-up, all aneurysm unrelated. No aneurysm ruptured. Estimated survival rates at 1, 2 and 5 years were 90.3 +/- 3.1%, 84.4 +/- 4.0% and 58.5 +/- 8.1%, respectively. Cumulative visceral branch patency was 93.3 +/- 1.9% at 5 years. Visceral artery stent occlusions all occurred within the first 2 postoperative years. Four renal artery stent fractures were observed, of which three were associated with occlusion. Twenty-five patients had an increase of serum creatinine of more than 30%; two of them required dialysis. In general, mean aneurysm sac size decreased significantly during follow-up (P < 0.05). CONCLUSIONS Fenestrated stent grafting for short-necked and juxtarenal abdominal aortic aneurysm appears safe and effective on the longer term. Renal function deterioration, however, is a major concern.

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.

Results of streamlined regional ambulance transport and subsequent treatment of acute abdominal aortic aneurysms

Objective: To describe the triage of patients operated for non-ruptured and ruptured abdominal aortic aneurysms (AAAs) before the endovascular era. Design: Retrospective single-centre cohort study. Methods: All patients treated for an acute AAA between 1998 and 2001 and admitted to our hospital were evaluated in the emergency department for urgent AAA surgery. All time intervals, from the telephone call from the patient to the ambulance department, to the arrival of the patient in the operating theatre, were analysed. Intraoperative, hospital and 1-year survival were determined. Results: 160 patients with an acute AAA were transported to our hospital. Mean (SD) age was 71 (8) years, and 138 (86%) were men. 34 (21%) of these patients had symptomatic, non-ruptured AAA (sAAA) and 126 patients had ruptured AAA (rAAA). All patients with sAAA and 98% of patients with rAAA were operated upon. For the patients with rAAA, median time from telephone call to arrival at the hospital was 43 min (interquartile range 33–53 min) and median time from arrival at the hospital to arrival at the operating room was 25 min (interquartile range 11–50 min). Intraoperative mortality was 0% for sAAA and 11% for rAAA (p = 0.042), and hospital mortality was 12% and 33%, respectively (p = 0.014). Conclusions: A multidisciplinary unified strategy resulted in a rapid throughput of patients with acute AAA. Rapid transport, diagnosis and surgery resulted in favourable hospital mortality. Despite the fact that nearly all the patients were operated upon, survival was favourable compared with published data.

Amputation for Long-Standing, Therapy-Resistant Type-I Complex Regional Pain Syndrome

BACKGROUND Some patients with long-standing, therapy-resistant type-I complex regional pain syndrome consider an amputation. There is a lack of evidence regarding the risk of recurrence of the pain syndrome and patient outcomes after amputation. The goal of the present study was to evaluate the impact of an amputation on pain, participation in daily life activities, and quality of life as well as the use of a prosthesis and the risk of recurrence of the pain syndrome in patients with long-standing, therapy-resistant type-I complex regional pain syndrome. METHODS From May 2000 to October 2008, twenty-two patients underwent an amputation of a nonfunctional limb at our institution because of long-standing, therapy-resistant type-I complex regional pain syndrome. Twenty-one of these patients were included in our study. The median age was forty-six years (interquartile range [IQR], thirty-seven to fifty-one years), the median duration of the complex regional pain syndrome was six years (IQR, two to ten years), and the median interval between the amputation and the study was five years (IQR, three to seven years). A semistructured interview was conducted, physical examination of the residual limb was performed, and the patients completed two questionnaires. RESULTS Twenty patients (95%) reported an improvement in their lives. Nineteen patients (90%) reported a reduction in pain, seventeen patients (81%) reported an improvement in mobility, and fourteen (67%) reported an improvement in sleep. Eighteen of the twenty-one patients stated that they would choose to undergo an amputation again under the same circumstances. Ten of the fifteen patients with a lower-limb amputation and one of the six with an upper-limb amputation regularly used a prosthesis. The type-I complex regional pain syndrome recurred in the residual limb of three patients (14%) and symptoms recurred in another limb in two patients (10%). CONCLUSIONS Amputation may positively contribute to the lives of patients with long-standing, therapy-resistant type-I complex regional pain syndrome. Patients were likely to use a prosthesis after a lower-limb amputation. The risk of recurrence of the type-I complex regional pain syndrome was 24%.

Results of Endovascular Abdominal Aortic Aneurysm Repair with the Zenith stent-graft

OBJECTIVE To evaluate single center results of the Zenith stent-graft for elective abdominal aortic aneurysm repair. METHODS Data from all patients treated with a Zenith graft between March 1999 and December 2006 were retrospectively analyzed from a prospective database. Outcome measures were technical success, all-cause and aneurysm related mortality, late complications, and re-interventions. RESULTS A total of 234 patients were included, of which 216 were male. Mean age was 72.1+/-6.9 years. Mean diameter of the aneurysm was 60.9+/-10mm. Technical success rate was 98.3%. Thirty day mortality was 1.7%. Median follow-up was 26.9 months (range, 1-104). Overall survival was 92.2+/-1.8% at 1 year, 87.2+/-2.3% at 2 years, and 69.9+/-4.6% at 5 years. During follow-up, one aneurysm ruptured due to limb disconnection, which was treated by bridging stent-grafting. Re-interventions were performed in 9.2% of the patients, with 79% by endovascular means. There was no mortality related to re-intervention. CONCLUSIONS Endovascular abdominal aortic aneurysm repair with the Zenith device provides excellent results with a low risk for aneurysm-related death and rupture, and a low re-intervention rate in the mid-term.

ANEURYSM FORMATION IN MODIFIED HUMAN UMBILICAL VEIN GRAFTS

OBJECTIVES Aneurysm formation in Human Umbilical Vein Grafts has been reported to be as high as 65% after 5 years. One of the causes might be the structure of the Biograft-wall and in 1985 a new method of processing the graft was begun. In Groningen this new improved Biograft has been used since late 1986. DESIGN Duplex scanning was used to examine the frequency of aneurysm formation in the new improved Biograft. MATERIALS Sixty-nine patent Biografts have been examined in a period up to 6 years after implantation. MAIN RESULTS Aneurysms were found in only 17% of grafts although the frequency increased with time. Dilatation was common but may be due to a more elastic graft. CONCLUSION These findings justify the continued use of the new Biograft as a substitute for arterial femoropopliteal reconstructions.

Relationship between epicardial adipose tissue and subclinical coronary artery disease in patients with extra‐cardiac arterial disease

Epicardial adipose tissue (EAT) and mediastinal adipose tissue (MAT) are linked to coronary artery disease (CAD). The association between EAT, MAT, and severity of CAD in known extra‐cardiac arterial disease was investigated.

Imaging the vulnerable carotid artery plaque.

Abstract Imaging plays a key role in the selection of patients for carotid artery surgery. Indication for carotid endarterectomy or stenting is based on symptomatology and degree of stenosis as determined by angiography, duplex ultrasonography or computed tomographic angiography. Degree of stenosis has long time been assumed the most reliable predictor of stroke-risk in patients with carotid artery stenosis and accordingly, traditional imaging methods were focused on luminal stenosis. There is, however, growing evidence that other factors than degree of stenosis determine whether a carotid plaque will result in acute neurologic events or not. Various morphological characteristics and molecular processes have proven to be highly related to carotid plaque instability and symptomatology. As a result, the focus of imaging techniques in carotid artery disease is more and more shifting towards identification of the vulnerable plaque rather than the high-grade stenosis. In traditional imaging modalities, new insights of imaging beyond degree of stenosis have been explored and may be able to detect morphological characteristics of plaque vulnerability. In addition, advanced molecular imaging methods have been developed and are able to identify molecular and cellular processes in the vulnerable carotid artery plaque. It is clear that recent developments in carotid imaging are of great potential in the identification of the vulnerable carotid plaque.

The use of the gastroepiploic artery for peripheral revascularisation. A study in pigs

OBJECTIVES To use the autologous gastroepiploic artery (GEA) as arterial bypass graft for peripheral revascularisation. We compared the development of intimal hyperplasia and nitric oxide (NO) capacity in GEA and internal jugular vein (IJV) implanted as peripheral grafts. MATERIALS AND METHODS In pigs the GEA was implanted into the right peripheral circulation as a femoropopliteal bypass graft. In the left peripheral circulation the IJV was implanted as a femoropopliteal graft. After 21 days all grafts were harvested. Vascular rings of each graft before and after operation were studied for NO capacity. The distal half of each graft was prepared for histomorphometric studies. RESULTS Administration of bradykinin to IJV and GEA induced relaxation. After implantation bradykinin resulted in contraction in IJV grafts, whereas in GEA grafts relaxation was reduced. In IJV grafts extensive intimal hyperplasia was formed, whereas in GEA grafts only small areas of intimal hyperplasia were formed. CONCLUSIONS The functional studies lost NO capacity in IJV grafts, whereas NO capacity in GEA grafts remained intact. Intimal hyperplasia in IJV grafts was extensive, whereas GEA grafts demonstrated preservation of pre-existent intimal architecture. These results may encourage the application of the human GEA as bypass graft for reconstruction of arteries in the lower limb or foot.