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.

Handlebar hernia: a case report and literature review on traumatic abdominal wall hernia in children

A rare case of abdominal trauma, a handlebar hernia, is described, as well as a review of the pertinent literature. A 7-year-old boy presented to our emergency room after sustaining blunt force to the abdomen; he fell on the handlebar of his bicycle. Immediately after the accident, a bulge was noticeable at the point of impact. Handlebar hernia is a diagnosis that is easily missed, which can lead to strangulation and incarceration of the bowel. With this case report, we hope to augment the knowledge on traumatic abdominal wall hernia, hopefully leading to early diagnosis and treatment.

[Diagnostic image (305). A boy with a painful and swollen scrotum]

Left double testis was diagnosed in a 12-year-old boy with a painful and swollen scrotum.

MR angiography of the lower extremities with a moving-bed infusion-tracking technique

PURPOSE

To assess the value of MR angiography (MRA) with automatic table movement in a consecutive series of patients with peripheral arterial disease.

METHODS

Seventy-two patients underwent both conventional angiography (CA) and MRA for peripheral arterial occlusive disease. Both techniques were scored in a masked way. Consensus scoring for CA was compared with MRA scoring per observer. If there was a discrepancy in scoring of a segment on MRA and CA, the images were reviewed and a consensus arrived at.

RESULTS

Observer A found 7.4% and observer B found 6.5% of the segments could not be analyzed on MRA. Observer A scored 11.4% dissimilar on MRA and CA, observer B 15.2%. In the aortoiliac arteries, this was mainly caused by stents and overestimation of stenoses; in the crural arteries it resulted from underestimation of the stenoses on MRA. Overall sensitivity and specificity for the aortoiliac, femoropopliteal and crural vessels were respectively 90% and 91%, 90% and 96%, 59% and 96% for observer A, and 85% and 91%, 84% and 89%, 68% and 85% for observer B.

CONCLUSION

Although MRA of the lower extremities is a promising technique, improvements still need to be made. In particular, MRA below the knee is suboptimal for clinical use.

The effects of long-term graft preservation and prostaglandin E1 on intraoperative hemodynamic changes in liver transplantation. A comparison between orthotopic and heterotopic transplantation in the pig

The study aimed to compare the intraoperative hemodynamic changes during orthotopic liver transplantation (OLT) with those during heterotopic liver transplantation (HLT) after different durations of cold storage of the graft. The effect of prostaglandin E1 (PGE1) on these parameters was also studied. Sixty-nine female Yorkshire pigs underwent either OLT (n = 32) or HLT (n = 37) with a graft stored for 2 hr (n = 31), 24 hr (n = 16), 48 hr (n = 7), or 72 hr (n = 15). In 16 transplantations in the various groups, PGE1 was given intravenously to both donor and recipient animals and it was added to the preservation and flushing solutions. Univariate nonparametric tests (Mann-Whitney and Wilcoxon rank-sum) were used for analysis of cardiac output (CO), mean arterial pressure (MAP), left and right ventricular minute work (LVMW, RVMW), pulmonary capillary wedge pressure (PCWP), and systemic and pulmonary vascular resistance (SVR, PVR), at different intervals during the operative procedure. For the three main variables--i.e., the type of transplantation, the use of PGE1, and the preservation time, multiple regression analysis was performed. During HLT, portal vein clamping lowered MAP and CO, while during the anhepatic phase in OLT, SVR increased and CO dropped. After recirculation of the graft, an increase in PVR and a decrease in SVR were found in both OLT and HLT. At different stages of the surgical procedure, longer graft storage time diminished CO and MAP (P less than 0.001), especially in OLT. PGE1 appeared to reduce the cardiovascular reserves needed to compensate the changes after recirculation of the graft. The observed differences in intraoperative hemodynamics between OLT and HLT can partly be attributed to differences in operative techniques. Extension of the graft preservation period resulted in poor cardiac performance, more so in OLT than HLT. The native liver in HLT might be able to metabolize the presumed myocardial depressant factors, released by the graft upon reperfusion. Prostaglandin E1 did not protect against the reperfusion syndrome.