Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

Cluster-randomized crossover trial of chlorhexidine-alcohol versus iodine-alcohol for prevention of surgical-site infection (SKINFECT trial)

Background

Surgical-site infection (SSI) is a serious surgical complication that can be prevented by preoperative skin disinfection. In Western European countries, preoperative disinfection is commonly performed with either chlorhexidine or iodine in an alcohol-based solution. This study aimed to investigate whether there is superiority of chlorhexidine-alcohol over iodine-alcohol for preventing SSI.

Methods

This prospective cluster-randomized crossover trial was conducted in five teaching hospitals. All patients who underwent breast, vascular, colorectal, gallbladder or orthopaedic surgery between July 2013 and June 2015 were included. SSI data were reported routinely to the Dutch National Nosocomial Surveillance Network (PREZIES). Participating hospitals were assigned randomly to perform preoperative skin disinfection using either chlorhexidine-alcohol (0·5 per cent/70 per cent) or iodine-alcohol (1 per cent/70 per cent) for the first 3 months of the study; every 3 months thereafter, they switched to using the other antiseptic agent, for a total of 2 years. The primary endpoint was the development of SSI.

Results

A total of 3665 patients were included; 1835 and 1830 of these patients received preoperative skin disinfection with chlorhexidine-alcohol or iodine-alcohol respectively. The overall incidence of SSI was 3·8 per cent among patients in the chlorhexidine-alcohol group and 4·0 per cent among those in the iodine-alcohol group (odds ratio 0·96, 95 per cent c.i. 0·69 to 1·35).

Conclusion

Preoperative skin disinfection with chlorhexidine-alcohol is similar to that for iodine-alcohol with respect to reducing the risk of developing an SSI.

Patient- and procedure-specific risk factors for postoperative complications in peripheral vascular surgery

BACKGROUND

Interest in measuring the quality of surgical care has grown over the past decades. As complications after vascular surgery may be used as a quality indicator of care, analysis of these adverse events remains essential.

OBJECTIVE

The goal of this study was to identify patient and procedure specific risk factors of postoperative complications following infrainguinal vascular surgery and to describe the incidence, cause and consequence of all complications in this group.

PATIENTS AND METHODS

This study included all 296 patients undergoing infrainguinal arterial bypass surgery at our institution over a 5-year period. All complications occurring during these patients' admission were registered in a prospective standardised complication registration and analysed.

RESULTS

Seventy-three of 296 (25%) procedures in 247 patients were followed by 129 complications. The mean patient age was 70 years. Factors associated with a significantly higher complication risk were diabetes, critical ischaemia with rest pain or gangrene, a cardiac medical history, acute surgery and a former cerebrovascular accident (CVA). Independent risk factors in multivariate analysis were a former CVA and acute surgery. Postoperative haemorrhage (n = 19), early occlusion of the graft (n = 15) and surgical site infection (n = 10) were the most frequently registered surgery-related complications. The most common consequence of a complication was blood transfusion or treatment with additional medication (33%). In 16% of all complications, a reoperation was necessary. Twelve patients died during admission (mortality 5%).

CONCLUSION

A former CVA and acute surgery were independent risk factors of postoperative complications. Identifying the cause and consequence of each complication is essential in a complication registration. When using complications as an indicator of quality of care in this population, an adjustment should be made for patient comorbidity and surgical indication.

Assessing the quality of surgical care in vascular surgery; moving from outcome towards structural and process measures

OBJECTIVES

This study presents a review of studies reporting on quality of care in vascular surgery. The aim of this study was to provide insight in quality improvement initiatives in vascular surgery.

DESIGN

Original data were collected from MEDLINE and EMBASE databases. Inclusion criteria were: description of one of the three factors of quality of care, e.g. process, outcome or structure and prospectively described. All articles identified were ascribed to a domain of quality of care.

RESULTS

57 prospective articles were included, drawn from 859 eligible reports. Structure as an indicator of quality of care was described in 19 reports, process in 7 reports and outcome in 31 reports. Most studies based on structural measures considered the introduction of a clinical pathway or a registration system. Reports based on process measures showed promising results. Outcome as clinical indicator mainly focussed on identifying risk factors for morbidity, mortality or failure of treatment.

CONCLUSIONS

Structure and process indicators are evaluated scarcely in vascular surgery. Many studies in vascular surgery have been focussed on outcomes as indicator of quality of care, but a shift towards process measures should be considered as focus of attention in the future.

[Diagnostic image (308). A man with dyspnoea after a soccer accident]

During a soccer match, the foot of a goal keeper collided with the right thoracoabdominal area of a player, who afterwards suffered from dyspnoea caused by a ruptured liver.

Contemporary Series of Morbidity and Mortality after Lower Limb Amputation

OBJECTIVES

This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital.

METHODS

All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system.

RESULTS

In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years.

CONCLUSIONS

An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.