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.

Left ventricular endocardial pacing in cardiac resynchronisation therapy: Moving from bench to bedside

In cardiac resynchronisation therapy, failure to implant a left ventricular lead in a coronary sinus branch has been reported in up to 10% of cases. Although surgical insertion of epicardial leads is considered the standard alternative, this is not without morbidity and technical limitations. Endocardial left ventricular pacing can be an alternative as it has been associated with a favourable acute haemodynamic response compared with epicardial pacing in both animal and human studies. In this paper, we discuss left ventricular endocardial pacing and compare it with epicardial surgical implantation. Ease of application and procedural complications and morbidity compare favourably with epicardial surgical techniques. However, with limited experience, the most important concern is the still unknown long-term risk of thromboembolic complications. Therefore, for now endovascular implants should remain reserved for severely symptomatic heart failure patients and patients at high surgical risk of failed coronary sinus implantation.

When is supervised exercise therapy considered useful in peripheral arterial occlusive disease? A nationwide survey among vascular surgeons

OBJECTIVES

Although international guidelines state that supervised exercise therapy (SET) should be offered to all patients with intermittent claudication (IC), SET appears to be underutilised in clinical practice. The aim of this study was to document current opinions of Dutch vascular surgeons on SET as treatment option for peripheral arterial occlusive disease (PAOD).

MATERIALS AND METHODS

Vascular surgeons and fellows in vascular surgery were asked to complete a 24-question survey either at the 2011 Annual Meeting of the Dutch Society for Vascular Surgery or online.

RESULTS

Ninety-one participants, including 83 vascular surgeons (51% of all Dutch vascular surgeons), completed the survey. The respondents would refer 75.4% of newly diagnosed patients with IC for SET. SET was considered less useful in patients with IC and major (cardiopulmonary) co-morbidity or a significant iliac artery stenosis. In critical limb ischaemia, the combination of SET and angioplasty was considered useful in 71.9%. Respondents regarded patient satisfaction (63.3%) and improvement in pain-free or maximal walking ability (26.6%) as clinically most relevant goals of SET. Most (84.4%) agreed that SET should also include lifestyle management.

CONCLUSION

Although the vast majority of Dutch vascular surgeons consider SET as an important treatment option for PAOD, SET should receive more emphasis in clinical practice since arguments not to refer for SET are outdated. Furthermore, vascular surgeons agree that lifestyle management should be integrated in SET.

From the Cochrane library: Ginkgo biloba for intermittent claudication

BACKGROUND

Patients with intermittent claudication suffer from pain in the muscles of the legs during exercise that is relieved by a short rest. Ginkgo biloba extract is a vasoactive agent used for symptomatic relief in intermittent claudication. In this article a meta-analysis is discussed that assessed the effect of Ginkgo biloba on walking capacity in patients with intermittent claudication.

PATIENTS AND METHODS

The Cochrane Peripheral Vascular Diseases Group searched their Trials Register and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Furthermore MEDLINE/PUBMED (until May 2008) and EMBASE (until May 2008) were searched and manufacturers of Ginkgo biloba extract were contacted. Randomized controlled trials of Ginkgo biloba extract versus placebo in people with intermittent claudication were included. Two authors independently assessed trials for selection, assessed study quality and extracted data. To standardize walking distance or time, caloric expenditures were used to correct for the different treadmill protocols.

RESULTS

Eleven trials involving 477 participants compared Ginkgo biloba with placebo and assessed the absolute claudication distance (maximal walking distance). At the end of the study the absolute claudication distance increased with an overall effect size of 3.57 kilocalories ( p = 0.06), for treatment with Ginkgo biloba, compared to placebo. This translates to an increase of 64.5 meters (confidence interval -1.8 to 130.7) on a flat treadmill with an average speed of 3.2 km/h.

CONCLUSIONS

There is no evidence that Ginkgo biloba has a clinically significant benefit for patients with intermittent claudication.

Three year single centre experience with the AneuRx aortic stent graft

OBJECTIVES

To report the mid-term single-centre experience with the AneuRx self-expandable nitinol stentgraft for endovascular aneurysm repair.

PATIENTS AND METHODS

Between December 1996 and January 2000 a total of 128 patients were treated with an AneuRx bifurcated stentgraft. Of these, 77 patients had a minimum follow-up of 12 months. Patient operative and follow-up data were prospectively gathered.

RESULTS

Two (3%) conversions were necessary. Median hospital stay was 3 days. One superficial wound infection occurred. Periprocedural (30 days) mortality was 5% (four patients). Three graft occlusions were noted of which two required treatment. Fifteen patients developed 18 endoleaks (six type 1, eight type 2 and four type 3). Type 1 and type 3 endoleaks were treated by extension cuffs. Four type 2 endoleaks were treated with embolisation or direct lumbar puncture. Two-year freedom from endoleak was 76%. Graft migration occurred in six cases, resulting in a 2-year freedom from migration of 90%, kinking only once.

CONCLUSIONS

endovascular AAA treatment is feasible and so far mid-term results are without major problems. Extensive follow-up is essential as secondary problems may occur later. Long-term results are to be awaited.

A minimally invasive technique in occlusive disease of the superficial femoral artery: remote endarterectomy using the MollRing Cutter

Remote endarterectomy is a minimally invasive technique for revascularization that shortens hospital length of stay and reduces patient morbidity and mortality. With the use of the MollRing Cutter (Vascular Architects, Inc., San Jose, CA), a modification of the single ring stripper, the surgeon is able to cut the endoluminal atheroma core remotely from the site of entrance to the vessel. The surgical exposure for remote endarterectomy of the superficial femoral artery can thus be limited to a small, single groin incision.

Use of a balloon-expandable, radially reinforced ePTFE endograft after remote SFA endarterectomy: a single-center experience

PURPOSE

To report our experience with endovascular femoropopliteal bypass grafting using a distensible, radially reinforced polytetrafluoroethylene endograft combined with remote endarterectomy.

METHODS

Forty-one patients (33 men; mean age 70 years, range 45-79) with symptomatic femoropopliteal occlusive disease underwent remote endarterectomy of the superficial femoral artery (SFA) followed by implantation of a balloon-expandable Enduring endovascular graft. All patients entered an extensive surveillance program, including angiography and duplex scanning at regular intervals.

RESULTS

Endarterectomy and endograft implantation were ultimately successful in all patients; 5 (12%) technical difficulties occurred intraoperatively and were treated with additional endovascular techniques. Control angiography at 1 week postoperatively demonstrated a patent endograft in 39 (95%) patients. Mean ankle-brachial index increased significantly from 0.57 to 0.91 (p < 0.001). Including the 2 early failures, 18 occlusions were documented over a median 15-month follow-up (range 3-24), due mainly to significant stenosis at the proximal and distal anastomoses. In 8 of 10 successfully reopened and revised endografts, reocclusion occurred after a median interval of only 1.8 months. Life-table analysis revealed cumulative primary and secondary patency rates of 42% and 56%, respectively, at 18 months. In the last 12 cases, the proximal end of the graft was sutured end-to-end to the transected SFA, which improved the short-term secondary patency rate to 83%.

CONCLUSIONS

Insertion of the Enduring endovascular graft following remote endarterectomy effectively results in a less invasive treatment for femoropopliteal occlusive disease. Additional technical refinements of the procedure may be required to avoid early procedure- and graft-related failures.

[The body-packer syndrome]

In four patients, a woman of 35 and men of 27, 38, and 22 years old, body-packer syndrome was diagnosed. Body-packer syndrome is seen in people concealing drugs in special containers within the body; this may lead to rupture with acute intoxication or to ileus. The clinical presentation can be very deceptive. An abdominal X-ray often reveals the packages. If there are no symptoms treatment is with mild laxatives, acute intoxication requires immediate laparotomy. One of the four patients died, the others recovered. Legally (Dutch law), the physician best delivers the drug to the police as a lost object, without revealing the patient's identity.

Scoring multitrauma patients: which scoring system?

Two methods of estimating the severity of injury and evaluating outcome, the Injury Severity Score (ISS) and the Polytrauma-Schlussel (PTS), were evaluated. The records of 37 victims of multiple injuries were assessed retrospectively by nine trauma surgeons using both methods of scoring. The agreement among the users was calculated by standard deviation. The standard deviation (SD) among users was smaller for the PTS (4.1) than for the ISS (6.2). Each method of scoring comprises six components contributing to the total score. The three highest scoring components of the ISS were first squared and then summated, the sum being the total ISS score. All the PTS categories were summated. Comparison of the SD for each of the components was not possible. However, the category or categories which mostly influenced the standard deviation could be indicated. For the ISS these were the circulation and central nervous system and for PTS, the limbs. We prefer the Polytrauma-Schlussel method because this takes account of age, needs revision of only one category and gives more consistent results among users.