Perceived barriers to endovascular repair of ruptured abdominal aortic aneurysm among Australasian vascular surgeons.

OBJECTIVE: Although endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is widely accepted for elective surgery, the uptake of emergency EVAR for ruptured AAA (REVAR) has trailed behind. This study was intended to identify the barriers to widespread application of REVAR in Australia and New Zealand. METHODS: A cross-sectional survey of members of the Australia and New Zealand Society of Vascular Surgeons was performed in late 2013. Primary themes explored were (1) perceived barriers to performing REVAR and (2) advantages of REVAR compared with open repair. Secondary data measures were the volume of AAA surgery, standard protocol use, and staff accreditation among vascular units. RESULTS: A total of 85 surgeons responded to an anonymous online questionnaire (41% response rate); of these, 23 surgeons (27%) had no experience with REVAR, and 65% currently perform more EVAR than open repair for elective procedures, compared with 18% for ruptured AAA. Of the perceived barriers explored, respondents agreed that poor availability of endovascular facilities (73% agreed or strongly agreed) and ancillary staff (56%) were barriers to REVAR. Most surgeons agreed that the advantages of REVAR include reduced intraoperative blood loss, length of stay, and postoperative complications. Four of 11 vascular units performing REVAR had standard protocols in use, and four had mandatory staff accreditation. CONCLUSIONS: The most common barrier to REVAR identified by surgeons was the poor availability of endovascular facilities, many of which are not ideally suited for this type of procedure. Australian and New Zealand vascular units have low rates of standard protocol use and staff accreditation for REVAR, which may have implications for patient care.

Predictors of outcome following endoscopic thoracic sympathectomy.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) provides definitive management for primary focal hyperhidrosis and facial blushing. These conditions are debilitating and not uncommon, but many clinicians avoid ETS due to the risk of complications, particularly compensatory sweating (CS). This retrospective cohort study aimed to evaluate the degree of symptom resolution, patient satisfaction and adverse reactions after ETS and to identify subgroups of patients more likely to achieve a satisfactory outcome. METHODS: From 2004 to 2010, 210 patients underwent ETS performed by a single surgeon. These patients responded to a questionnaire regarding levels of satisfaction, symptom resolution and complications encountered, particularly CS. RESULTS: Palmar hyperhidrosis (97%) and scalp/facial hyperhidrosis (93%) demonstrated greater degrees of symptom resolution than axillary hyperhidrosis (71%) and facial blushing (71%) (P < 0.001). Rates of severe CS were lowest in patients with palmar hyperhidrosis (8%) and highest in patients with axillary (26%) and scalp/facial (44.5%) hyperhidrosis (P = 0.0003). The probability of experiencing no CS was highest at young ages and decreased with age (P = 0.0006). Satisfaction rates also fell as age increased (P = 0.004). Satisfaction rates were highest in patients with palmar (90%) and lowest in patients with scalp/facial (52%) hyperhidrosis (P < 0.02). DISCUSSION: Patient satisfaction following ETS is highest among younger patients and those undergoing the procedure for palmar hyperhidrosis. Dissatisfaction arises from failure to achieve the desired aim as well as the development of severe CS, which is more common in older patients and those undergoing ETS for axillary and scalp/facial hyperhidrosis.