Long-term results of above knee femoro-popliteal bypass depend on indication for surgery and graft-material.

UNLABELLED: OBJECTIVE To determine the long-term results of above-knee femoro-popliteal bypass with autologous saphenous vein (SV) or expanded polytetrafluoroethylene (ePTFE) in routine surgical practice. METHODS: Data from the Swedish vascular registry, Swedvasc, was reviewed retrospectively. Patients with bypass surgery in 1996 and 1997 were assessed 5-7 years later. Data were gathered from the case-records and from clinical follow-up. The composite endpoint of graft failure included death within 30 days, occlusion, major amputation, extension of the graft to below-knee position and removal of an infected graft. Kaplan-Meier curves and Cox' proportional hazard ratios were calculated. RESULTS: Four hundred and ninety-nine patients undergoing bypass for critical limb ischemia (CLI) (56%) or claudication (44%), SV (28%) or ePTFE (72%), were included. There were no significant differences in patient characteristics between patients with SV or ePTFE. CLI and ePTFE were risk factors for graft failure. For patients with both claudication and CLI SV grafts yielded better long-term results than ePTFE grafts ( p <0.03) and ( p <0.003), respectively. Symptom aggravation after graft occlusion was almost exclusively restricted to ePTFE grafts. CONCLUSIONS: Femoro-popliteal bypass above-knee with SV gives good long-term results, especially for claudication. ePTFE grafts cannot be recommended in claudicants, since occlusion occurs often and frequently leads to CLI.

[Results of vascular surgery in the very old. Costs are comparable to those of younger patients]. / Resultat av kärlkirurgi hos de allra äldsta. Kostnaderna jämförbara med dem för yngre patienter.

An increasing number of very old patients are treated in hospitals but there are few Swedish studies of the results of the treatment. In this study the results and costs of vascular surgery in octogenarians were compared to those of younger patients. All Swedish patients treated in 1996 (10,185 procedures) were analyzed; one fifth were over 80 years of age. During the past ten years the number of procedures had increased 2.6 times in the old age group. The technical result, measured as patency rate one year after bypass surgery, was comparable in the two groups--73 per cent versus 81 per cent--but the mortality was higher in the older age group both in direct connection with the procedure and a year thereafter. The cost per procedure was not higher in the old age group.

Diabetes mellitus as a risk factor for early outcome after carotid endarterectomy--a population-based study.

BACKGROUND AND PURPOSE: to determine if diabetes mellitus is a risk factor for outcome after carotid endarterectomy (CEA). METHODS: the outcome and complications of all vascular procedures performed in Sweden are registered prospectively in the Swedish Vascular Registry (Swedvasc) and form the basis of this report. During the 10-year period 1987-96 2622 CEAs were analysed for notified complications. RESULTS: of the 2622 CEAs, 341 (13%) were performed on diabetics and 2281 (87%) on non-diabetics. Patients with diabetes presented at a younger age (67.1+/-8.3 years vs. 68.2+/-8.3 years p =0.028), were more likely to have a history of hypertension (61.9% vs. 50% p =0.001) and were less often smokers (34.9% vs. 43.2% p =0.001). Diabetics presented more often with minor stroke (41.3% vs. 30.8% p =0.002) and non-diabetics more often with amaurosis fugax (18.9% vs. 14.4% p =0.04). Diabetics had a higher 30-day mortality (3.2% vs. 1. 4% p =0.02). The 30-day neurologic and cardiac morbidity did not differ. The 1-year mortality was 7.9% in diabetics and 4.4% in non-diabetics (p =0.008). Non-diabetics operated on in 1992-96 compared to those operated on in 1987-91 had a significantly lower combined permanent stroke and death rate (3.7% vs. 5.7% p =0.05), a difference not found in diabetics (6.3% for 1987-92 and 6.8% for 1992-96; N.S). CONCLUSIONS: diabetics had both a higher 30-day and 1-year mortality after CEA compared to non-diabetics, mainly because of cardiac complications. However, postoperative neurologic morbidity did not differ.

Costs of the treatment of leg ulcers: initiating a quality assurance process.

Reports on a study which aimed to initiate a quality assurance process among health care personnel in Sweden. An epidemiological survey concerning treatment of leg ulcers in a defined region in Sweden was conducted and the costs of treating leg ulcers at different levels of care were analysed. The epidemiological survey provided the data necessary to calculate the socio-economic costs for the treatment of leg ulcers. The weekly cost was found to be about 24 times higher for hospital inpatients than it was for patients treated at home. The quality assurance process has continued through an interdisciplinary regional consensus conference and the establishment of a consensus programme in the region, with targets and general suggestions for the care and treatment of leg ulcers. To maintain high quality in leg ulcer treatment in the region, an interdisciplinary reference group has been established with members from different clinics at the hospital and members from the primary health care.

Adjusting outcome measurements for case-mix in a vascular surgical register--is it possible and desirable?

OBJECTIVE: We analysed the variation in the outcome of infrainguinal bypass surgery between departments in a register for clinical audit to see if variation in case-mix influenced the results. MATERIALS AND METHODS: The study was a retrospective analysis of 764 infrainguinal bypass operations performed from 1988 to 1990 at six Swedish surgical departments. Results were assessed at 30 days and at 1 year postoperatively. RESULTS: There was a significant variation (p < 0.01) in mortality and amputation rates both at 30 days and at 1 year and in patency rate at 30 days. There were also differences in case-mix. Differences were found in indication, location of distal anastomosis and graft type. Regression analysis found that mortality was influenced by age, diabetes and heart disease and patency rate by location of the distal anastomosis and graft type. When 'hospital' was added as a variable in the regression analysis it was also found to be a significant indicator. CONCLUSION: Location of the distal anastomosis was the main factor in adjusting patency for case-mix.

Secondary aortoenteric fistulae--changes from 1973 to 1993.

AIM: To investigate a series of patients with secondary aortoenteric fistulas and compare it with a previous series (1985-93 vs. 1973-84). DESIGN: Retrospective study of medical records. SETTING: Sixteen vascular surgical centers in Sweden. PATIENTS: Twenty-seven patients were identified making an overall incidence of 0.5% of all aortoiliac operations. Among aneurysm patients the incidence was significantly lower than in the previous series. One patient record could not be identified. Fourteen primary operations were for aortic aneurysm, 12 for occlusive disease and one was an aortorenal vein bypass. RESULTS: Symptoms of the fistula occurred after a median interval of 90 months which is significantly later than the previous series (32 months; p<0.05). The commonest presentation was bleeding followed by septis. The median diagnostic delay was 10.5 days, which was significantly shorter than in the previous series. Most fistulas involved the duodenum (88%). One patient died before surgery. The postoperative mortality was 28%, significantly lower than in the previous series (58%) (p<0.05). At the end of follow up (median 43 months) significantly more patients were alive than in the previous series (42% vs 18%) (p<0.05). CONCLUSION: Over a 21 year period there seems to have been a decrease in the frequency of secondary aortoenteric fistulas after aneurysm surgery, a longer interval before they occur, a shorter diagnostic delay, and a better survival.

Patients not included in medical audit have a worse outcome than those included.

The aim of the present investigation was to analyse a clinical database in order to see how many patients were not included in medical audit and to see whether the outcome of the non-registered patients differed from that of the registered patients. Two independent surgeons studied the records of all infrainguinal bypass operations performed at six vascular surgical departments over a three-year period. A total of 684 bypass operations was reported to the register, of which 636 could be reviewed. One-hundred and twenty-eight cases that had not been reported were found from other sources. The outcome variables were mortality, amputation rate and patency. Sixteen per cent of eligible cases had not been reported. Mortality and amputation rate were twice as high among the missing cases as among the reported cases. There was no difference in patency. Overall judgement of the performance of an individual department may be impaired by cases not included in the register.

The effect of mannitol on reperfusion after severe induced subtotal ischemia of the leg. A hemodynamic, biochemical and metabolic study in a pig hind limb model.

Revascularization of acutely ischemic muscle tissue is followed by edema, decreased oxygen utilization, increased vascular resistance and massive efflux of intracellular compounds indicating loss of cellular integrity, with resultant irreversible damage. In this pig hindlimb study, 8 pigs were submitted to standardized subtotal ischemia of one leg and mannitol was administered i.v. prior to and during 2.5 hours of reperfusion. Compared to 9 controls, the mannitol treated pigs had increased blood flow to the legs, increased oxygen consumption and decreased release of intracellular compounds (CK). This indicates that mannitol attenuates the ischemia/reperfusion syndrome. Muscle energy metabolic parameters showed a similar response to ischemia for both mannitol-treated pigs and controls and no differences in recovery were detected during 2.5 hours of reperfusion between the groups.

Vascular surgical audit during a 5-year period. Steering committee on behalf of the Swedish Vascular Registry (Swedvasc).

UNLABELLED: The objective was to explore possible time trends in the indications for peripheral vascular surgery in Sweden. DESIGN: Analysis of data from the Swedvasc vascular registry 1987-1991. SETTING: Routine vascular surgery in university, county and district hospitals within the Swedish public hospital system. The registry is independent of local administration, run by the surgeons themselves and financed by national authorities. MATERIALS: 4950 procedures registered in the 17 original centres 1987-91 and 1892 procedures registered in 16 new centres 1991. CHIEF OUTCOME MEASURES: Distribution of indications, mortality within 30 days and clinical outcome at one year. MAIN RESULTS: During the first 5 years of the registry (1987 to 1991) the proportion of procedures performed for acute ischaemia significantly decreased from 20% to 14.3%. Simultaneously procedures for critical leg ischaemia significantly increased from 24.8 to 30.3%. Changes in the proportions treated for aortic aneurysms, carotid artery stenosis, claudication, vascular access or other indications were less striking or nonsignificant. The 30-day mortality decreased in patients operated on for acute ischaemia but did not change in other groups. The proportion of elective/emergency operation for aortic aneurysm changed from 1.2 to 2.0 leading to a minimal decrease in overall aneurysm mortality. The proportion of patients treated for claudication who were alive and improved at one year changed from 77.2% to 72.9% which was not statistically significant, while the proportion of patients treated for critical ischaemia who were alive with an intact leg after one year increased from 65.2% to 80.2% which was a significant improvement. CONCLUSIONS: Decision making among vascular surgeons in Sweden appears to have improved as proportionally fewer patients are operated on for acute ischaemia, more for critical ischaemia with possibly an improved outcome.

Limitations of the use of arteriovenous fistulae in the cubital fossa.

A retrospective analysis of 88 patients operated upon with an arteriovenous fistula in the cubital fossa was made. At operation the intention was to construct a side-to-side fistula between a suitable vein and the brachial artery with an anastomosis length of 7-9 mm. 17 fistulae (19%) failed within three months, mainly due to occlusion. After one and four years, respectively, one-half and one-third of the fistulae at risk were in use. Patients with polycystic kidney disease had a worse prognosis regarding fistula function as well as those operated on with side-to-end technique. A patent cephalic vein in the upper arm was a favourable condition. Diabetic patients had a high risk of developing ischemia of the hand (25%), while this risk was low for patients with other diagnoses. Only one case developed heart decompensation, and 3 needed a flow reducing procedure. The method is thus less likely to function well in diabetics and in patients without a patent cephalic vein at the upper arm.

[Oral contraceptives and blood diseases are the most common causes of Budd-Chiari syndrome]. / P-piller och blodsjukdomar vanligaste orsakerna till Budd-Chiaris syndrom.

Two cases of young patients with the chronic form of Budd-Chiari syndrome are reported. The first concerns a 22-year-old woman with a 6-month history of hepatomegaly, who had used oral contraceptives almost continuously during the five years preceding diagnosis. In a thorough diagnostic work-up, thromboses were detected in all but one of the hepatic veins, and a possible non-occluding thrombosis in the retrohepatic portion of the inferior vena cava. In the blood and bone marrow, findings were compatible with polycythaemia rubra vera, and a high anti-cardiolipin antibody titre was found. The second case concerns a 25-year-old male smoker with normal bone marrow, who had thromboses in at least two of the hepatic veins, though the inferior vena cava was not occluded. In both cases a mesocaval shunt was interposed with synthetic grafts, and postoperatively the patients are doing well--at sixteen and five months, respectively. Both are maintained on anticoagulants, and even without diuretics there has been no recurrence of ascites. The woman takes a small dose of hydroxy-urea to control her hypercoagulability. To our knowledge, hers is the first case to be reported of Budd-Chiari syndrome with hypercoagulability due to the concomitant presence of oral contraceptives, polycythaemia rubra vera and anti-phospholipid antibodies.

PIP: The Budd-Chiari syndrome is a rare condition (0.4-.06 per cent in autopsy material) characterized by ascites, liver function disturbance and abdominal pain caused by thrombosis of the major hepatic veins. $ studies (N = 114) yield the following list of causes with percentages; Oral contraceptives, 18%; polycythemia vera, 13%; other myelo-proliferative disease, 4%; paroxysmal nocturnal hemoglobinuria, 5%; blood vessel malformation, 10%; malignancy, 6%; other simultaneous thrombosis, 3%, vasculitis, 2%; other (trauma, abscess, chronic active hepatitis, pregnancy) 5%; no known cause, 34%. The histories of 2 patients illustrate the difficulty of diagnosis, which is usually verified only by biopsy. One of the patients was a 20-year old woman who had used oral contraceptives for 5 years and presented changes consistent with myeloproliferative syndrome in the peripheral circulation and in the bone marrow, as well as a high cardiolipin antibody titer. Oral contraceptives have been cited as a cause of Budd- Chiari syndrome, but the proportion of oral contraceptives users among patients is no greater than among women in general. One recent French study (N = 33) gives a relative risk factor of 2.4 for women between 15 and 45 years old who have used oral contraceptives during the 12 months before onset of the disease. This risk factor parallels that for stroke, myocardial infarction, and venous thromboembolism. No cases of Budd- Chiari syndrome had been reported to the Swedish side-effects register through December 1988.