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.

Antibiotic concentrations in the groin wound after vascular prosthetic implantation

The kinetics of systemically and locally administered cefuroxime or ceftazidime in wound fluid were investigated in the period after vascular prosthetic implantation. Cefuroxime or ceftazidime was administered intravenously in patients. Simultaneously 250 mg ceftazidime or cefuroxime was added to preclotted blood. Locally administered antibiotics could not be detected in our samples. In groin fluid samples 24-48 h after the operation the average concentration of cefuroxime was 8.3 and of ceftazidime 5.0 mg/l. The decline of the concentration of cefuroxime or ceftazidime in groin fluid seems to be much slower than one would expect from the half-lives of the antibiotics. We conclude that cefuroxime and to a lesser extent ceftazidime are suitable as prophylactic agents in arterial reconstruction.

The correlation of peroperative outflow resistance measurements with patency 109 infrainguinal arterial reconstructions

The predictive value of outflow resistance measurements for the patency of femoro-popliteal and femoro-crural bypass grafts was analysed. Peroperative outflow resistance measurements were performed in 109 infrainguinal arterial reconstructions. Outflow resistance was significantly higher in occluded bypasses compared with those which remained open (P less than 0.01), but there was a considerable overlap of values in both groups. Statistical analysis of the correlation between outflow resistance and patency rates at 3 months revealed a marginal correlation in the femoro-popliteal bypass group (R = -0.25), which was not significant (P = 0.064). In the femorocrural bypass group there was again only a marginal correlation (R = -0.27) but this was statistically significant (P = 0.05). These data demonstrate that intraoperative outflow resistance measurements are only of limited value for predicting bypass patency in individual cases.

Treatment of complicated or infected pilonidal sinus disease by local application of phenol

This article reports on the results of conservative treatment of 48 patients with complicated pilonidal sinus disease. The treatment consisted of an injection of phenol 80% into the sinus tract after the patients had undergone depilation and excavation while under local anesthesia. The number of phenol injections in each patient varied from one to nine (mean: two injections). Patients were considered cured if no signs of recurrent pilonidal sinus disease occurred within 1 year after treatment. The mean follow-up period after cure was 3 years (range: 1 to 6 years). The recurrence rate was 6.3% (a 95% confidence interval of 1.3% to 17.2%), which was one of the lowest reported for different methods of treatment for pilonidal sinus disease. The good results in this study justify continuation of conservative treatment of pilonidal sinus disease, especially in view of the low costs and the high degree of patient comfort. Sclerosing therapy with phenol is thus recommended as a successful treatment for complicated pilonidal sinus disease.

Tracheal reconstruction with hydroxyapatite tracheal prosthesis

A porous hydroxyapatite tracheal prosthesis was implanted in rabbits after resection of a 15 mm circular segment of the cervical trachea. Postoperatively the animals were followed by radiography, bronchoscopy, and microscopy at the time of autopsy. The longest survival time was 22 weeks. All the rabbits died of infection at the prosthetic site or of progressive stenosis at the anastomoses. The prosthesis was incorporated by surrounding tissues, but no overgrowth of ciliated epithelium on the luminal surface of the prosthesis was observed. Although a hydroxyapatite tracheal prosthesis is tolerated in rabbits, covering of the luminal surface of the prosthesis with a non-porous layer to prevent infection and to permit mucosal overgrowth is necessary to achieve better long-term results.

Service station attendants' exposure to benzene and gasoline vapors

Service station attendants' exposure to benzene, based on 85 TWA results at 7 stations, were well below 1 ppm except one exposure of 2.08 ppm. Short term exposures were 1.21 ppm or less over 15 minutes. Attendants' TWA exposures to total gasoline vapor were 114 ppm or less, with measured 15 minute exposures no higher than 100 ppm during actual filling operations. One station had vapor recovery nozzles; exposures here were below the detectable level (0.01 ppm benzene) on 10% more days than the next lowest station. Still, the magnitude of overall exposures and the degree of reduction indicate that vapor recovery is not needed to control exposures. Some attendants had consistently higher exposures than others. This is felt to be due to work practices, such as standing close to the fill opening, plus local wind conditions around the car as it is filled with gasoline.