Preoperative White Blood Cell Count in Patients with Abdominal Aortic Aneurysms and Its Relation to Survival following Surgery.

BACKGROUND: The aim of the present study was to explore whether preoperative white blood cell (WBC) count may predict 30-day mortality and long-term survival following surgery for abdominal aortic aneurysm (AAA). Secondarily, we wanted to assess the potential sex differences in WBC in these patients. METHODS: The study was carried out as a retrospective cohort study. Patients undergoing surgery for intact and ruptured AAA (rAAA) at our institution consecutively in the time period 1994-2007 were included. Patients were either treated with open aneurysm repair or with endovascular aneurysm repair. Data were collected from the patients' medical records, including laboratory reports for WBC count prior to surgery. Mortality and long-term survival were extracted from The Patient Administrative System. RESULTS: A total of 988 patients were included, 712 (72%) patients were treated for intact AAA and 276 (28%) underwent surgery for rAAA. Patients with WBC ≥11 ×109/L had a 8.7-fold higher risk of 30-day mortality undergoing surgery for intact AAA compared to patients with WBC <11 ×109/L (95% confidence interval [CI]: 3.2-23.3, P < 0.001). Patients with a high WBC tended to have inferior long-term survival. However, when excluding 30-day mortality, no statistically significant difference was found (hazard ratio, 1.4; 95% CI: 0.9-2.0, P = 0.121). No association between WBC count and 30-day mortality or long-term survival was observed among patients treated for rAAA. We could not identify any sex differences in WBC, neither in intact AAA nor in rAAA. We were not able identify any association between WBC and specific causes of death. CONCLUSIONS: This study suggests that patients with WBC count ≥11 ×109/L prior to surgery for intact AAA have a higher 30-day mortality compared to patients with WBC <11 ×109/L. We could not identify any substantial difference in long-term survival when excluding 30-day mortality. We did not observe any association between preoperative WBC count and case fatality or long-term survival in patients undergoing surgery for rAAA. No sex differences in WBC were found.

Causes of cancellations on the day of surgery at two major university hospitals.

Cancellations of elective cases on the day of surgery waste valuable operating-room time. The authors studied cancellations at an American hospital and a Norwegian university hospital to test (a) whether the quality of hospital administrative data on cancellations is sufficient for meaningful comparative analysis and (b) whether causes of cancellations at these 2 major academic hospitals are comparable. Large retrospective cause-of-cancellation data sets were obtained from each hospital. The authors then prospectively established root causes of cancellations by on-site investigation and interviews of the hospital personnel involved. The surgical department at the Norwegian hospital cancelled 14.58% of cases in 2003 and 16.07% in 2004. The American hospital cancelled 16.52% of all cases between May 1, 2003, and April 30, 2004. Administrative data may give a rough picture of causes of cancellations. However, most findings at either of the hospitals do not translate easily to the other.

The association between diabetes mellitus and the prevalence of intermittent claudication: the HUNT study.

The objective of this study was to investigate the association between diabetes mellitus (DM) and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway were mailed an invitation to participate in a health survey (HUNT 2). A total of 19,712 participants aged 40-69 years old completed and returned the questionnaire included with the invitation. They also attended an examination where brachial blood pressure was measured and non-fasting venous blood was collected. The venous blood sample was subsequently analysed for concentrations of blood lipids. Responses to 12 questions on IC were previously tested against ankle blood pressure measurements (ABPI < 0.9) and the algorithm with the best test properties was used to identify individuals with IC. Participants reported a history of DM by simple questions in the questionnaire. Logistic regression analysis was then used to compute age-adjusted prevalence odds ratios for the association between exposure variables and the prevalence of IC. Potential confounding by smoking, blood lipids and brachial blood pressure was investigated in multivariate analyses. For both sexes IC was more common in individuals with DM (OR(women) = 3.8, CI, 1.9-7.6; OR(men) = 2.8, CI, 1.4-5.8) compared to participants without DM. Adjustment for smoking, blood lipids and brachial blood pressure did not substantially change these results. In conclusion, the prevalence of IC was more than three times higher in patients with DM compared to non-diabetic participants.

Improved long-term survival following infrarenal abdominal aortic aneurysm repair.

BACKGROUND: The aim was to investigate early and long-term results following AAA repair during a 20-year period. METHOD: One thousand and forty one patients with AAA were treated with open surgery (905) or EVAR (136) during the period 1983-2002. Comorbidity and factors influencing early and long-term results were investigated. Data were collected retrospectively from the patients' medical records. A complete follow-up was obtained. RESULTS: Women had a significantly higher 30-day mortality following repair of ruptured AAA than men. The degree of emergency, advancing age and renal failure were significantly associated with 30-day mortality. We observed an improvement in long-term survival during the study period. Time interval of surgery, cerebrovascular disease, diabetes, COPD and renal failure influenced long-term survival negatively. CONCLUSION: Women with ruptured AAA have a higher early mortality than men, which needs to be investigated further. Long-term survival has improved during the study period. Age, diabetes, chronic obstructive pulmonary disease, renal failure and cerebrovascular insufficiency influenced the long-term survival negatively. EVAR is used to an increasing extent and the results are improving.

Infrarenal abdominal aortic aneurysm repair: time-trends during a 20-year period.

BACKGROUND: The goal of the present study was to investigate the number of operations for abdominal aortic aneurysm (AAA) including time-trends in treatment during a 20-year period. Operating time and anesthesia time were also studied. METHOD: During the period 1983-2002, a total of 1,041 patients with AAA were treated with open surgery (905) or EVAR (136). Number of operations, type of graft, anesthesia time, and operating time were the variables investigated. Data were collected retrospectively from the patients' medical records. RESULTS: There was an increase in the number of operations both for ruptured and non-ruptured AAA in men during the study period. Among women, an increase was observed only for ruptured aneurysm. Operating time and anesthesia time increased significantly during the 20-year period. The number of patients treated by EVAR increased significantly, beginning in 1995. CONCLUSIONS: In conclusion, there has been an increase in the number of AAA operations, and the proportion of patients treated with EVAR is increasing. Furthermore, we found an increase in both anesthesia time and operating time. These trends may be important for allocation of resources needed for the treatment of patients with AAA.

Amplification of TOP2A and HER-2 genes in breast cancers occurring in patients harbouring BRCA1 germline mutations.

BRCA1 associated tumours are found to express an oestrogen receptor negative "basal epithelial-like" phenotype. In contrast to ER negative tumours in general, such tumours rarely harbour amplification of the HER-2 gene. However, little is known about TOP2A gene amplification status in BRCA1-associated tumours. Such information may be of importance to therapy, as amplification of TOP2A has been associated with dose-dependent sensitivity to anthracycline therapy in breast cancer. We examined 40 breast carcinomas from BRCA1 mutation carriers and 40 sporadic breast carcinomas matched for age, tumour diameter and histological grade for HER-2 and TOP2A amplification status using fluorescence in situ hybridisation (FISH). Co-amplification of TOP2A and HER-2 was found in four of the mutation carriers and in three of the controls. While six tumours in the control group harboured HER-2 amplifications with normal TOP2A, this occurred in three of the BRCA1 associated tumours only. In contrast, three of the BRCA1-associated tumours but none of the controls harboured TOP2A amplification despite normal HER-2 status. Our findings have potential therapeutic implications. HER-2 assessment is routinely used to select breast cancer patients for trastuzumab but also dose-intensive anthracycline therapy. Our data suggest that BRCA1-associated breast cancers also need to be tested for TOP2A amplification.

Health-related quality of life in long term-survivors of thoracoabdominal aortic aneurysm repair.

The purpose was to assess health-related quality of life (HRQOL) in long-term survivors of thoracoabdominal aneurysm repair. Between 1983 and 2001, 43 patients underwent thoracoabdominal aneurysm repair. Long-term survivors (13) were investigated. Two were lost to follow-up. The mean follow-up period was 6.2 years. HRQOL was measured by Short Form (SF)-36, constructed of 36 items grouped into eight scales measuring physical functioning, role limitations caused by physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations caused by emotional problems, and mental health. Additional questions specific for vascular disease were ascribed. The patients' relatives received corresponding questions, responding on behalf of the patients. Patient data scores were compared with a selection of individuals from the general population. The patients' SF-36 scores were generally poorer than that of the healthy population in both physical and mental dimensions. Patients who had a complicated postoperative course generally scored lowest in physical dimensions. Comparing patients' scores with relatives scoring on behalf of the patients showed no statistical differences. According to disease-specific questions, impotence and pain were reported as major long-term postoperative problems. Patients with uncomplicated postoperative courses all reported improved health status (six) compared with the preoperative status, whereas five patients with complicated postoperative courses reported poorer health status. Nine of 11 patients experienced the same or improved HRQOL, and two patients reported reduced HRQOL after surgery. Ten of 11 patients evaluated the operation as successful. Although the sample size in this study is small, those who had postoperative complications or reported a decreased physical function in the years after surgery generally had low scores in almost all dimensions of the SF-36. When disease-specific questions were related to thoracoabdominal aneurysm surgery, most patients reported an acceptable HRQOL.

[Teleradiologic follow up of patients treated with aortic stent grafting]. / Teleradiologisk oppfølging av pasienter behandlet med stentgraft i aorta.

BACKGROUND: A study has confirmed the possibility of follow up in the local hospital of patients who have undergone endovascular repair. We present a cost analysis of such a regimen compared to follow up at a university hospital. MATERIAL AND METHODS: By using discharge data from the Norwegian Patient Register we identified a group of patients which could have been followed up at their local hospital for their stent-grafted abdominal aortic aneurysm and estimated the cost effects of performing follow ups locally. RESULTS: The cost analysis showed a potential for cost savings from local follow ups, especially from moving from inpatient care at the university hospital to outpatient care locally. The result of this cost analysis differs from other Norwegian studies of teleradiology by identifying a possibility for more cost-effective treatment. INTERPRETATION: Using teleradiology to follow up these patients will free up capacity in the university hospital. Most probably, other groups of patients can also be followed up by teleradiology. The university hospitals can use this freed-up capacity for new patients. Teleradiology could lead to more efficient use of health care facilities, which should be in the interest of the health authorities.

Three-dimensional teleradiology for surveillance following endovascular aortic aneurysm repair: a feasibility study.

PURPOSE: To study the feasibility of 3-dimensional (3D) teleradiology in surveillance of patients treated with stent-grafts for abdominal aortic aneurysm (AAA). METHODS: Between April 2002 and November 2003, 8 AAA patients (7 men; median age 73 years, range 62-84) with stent-grafts had follow-up computed tomograms (CT) performed at their local hospital and transmitted without loss across a broadband connection to the university hospital. On both monitors, the radiologists were presented with the complete CT axial dataset, sagittal and coronal reformatted slices, and a 3D volume-rendered reconstruction. The two radiologists were then able to simultaneously perform measurements and real-time manipulations of the axial and 3D pictures, which were discussed over the telephone or using a videoconferencing unit. Patient satisfaction, the radiologists' evaluation of the method, and the potential cost savings were explored. RESULTS: Twelve follow-up CT scans were performed on the 8 patients. The time for transmission over the teleradiological network averaged 5 minutes, and the evaluation required 15 minutes at the university hospital. The overall technical quality of the images was rated as good by the university radiologist. In 11 studies, the stent-grafts were satisfactory, but a type III endoleak was detected in one 5.5-year-old stent-graft. Neither radiologist had a problem identifying the endoleak. Patients had confidence that the examination at the local hospital was of good quality; they all felt that they received good care and were pleased with avoiding travel to the university hospital. From the economic analysis, an annual savings of 40,000 Euros (USD 52,304) was projected, mostly due to avoiding hospital stays and outpatient consultations at the university hospital. CONCLUSIONS: The experiences from this study are encouraging, but a larger series will be necessary for a thorough evaluation of 3D teleradiology as a surveillance method for aortic stent-graft patients.

The association between smoking and the prevalence of intermittent claudication.

The objective of this study was to investigate the association between smoking and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway, were invited to take part in the Nord-Trøndelag Health Study (Helseundersøkelsen i Nord-Trøndelag: HUNT 2). A total of 19748 participants aged 40-69 years attended. Responses to 12 questions on IC (including a Norwegian translation of the Edinburgh Claudication Questionnaire) had been previously tested against the ankle-brachial pressure index (ABPI < 0.9), and an algorithm of the best test properties was used to identify people with IC. Using logistic regression analysis we computed age-adjusted prevalence odds ratios (OR) for the association between smoking and IC. Both current (ORmen = 3.8, confidence interval (CI) 2.1-6.7, ORwomen = 2.2, CI 1.4-3.4) and former smokers (ORmen = 1.7, CI 0.9-3.2, ORwomen = 1.7, CI 1.1-2.7) had a higher prevalence of IC compared with those who had never smoked, and individuals who had stopped smoking more than 20 years previously had a substantially lower prevalence of IC (ORmen = 0.2, CI 0.1-0.5, ORwomen = 0.4, CI 0.2-0.8) than current smokers. We found no association between passive smoking and IC in either men or women. Current and previous smoking habits were positively associated with the prevalence of IC, and smoking cessation was negatively associated in men and women. Passive smoking was not associated with IC in this study.

Combined open and endovascular treatment of complex aortic disease.

The purpose of this article is to report whether combined open and endovascular treatment could be applied in patients with complex aortic disease. A retrospective study including four patients with complex aortic disease was undertaken. In all patients, extra-anatomic bypass to the visceral arteries was made through a laparotomy while the aortic lesion was repaired by stent grafting. One patient died on the first postoperative day and another died 3 months after treatment from a myocardial infarction. The other two patients were alive 13 and 34 months after treatment, respectively. However, a patient treated for a ruptured thoracoabdominal type 2 aneurysm on the basis of a dissection suffers from postoperative paraplegia. The combination of open surgery with extra-anatomic bypass to visceral arteries and stent grafting could be an option for the treatment of patients with complex aortic disease, especially in high-risk cases in which more extensive open surgery is contraindicated.

Type III endoleak from a thoracic aortic stent-graft.

PURPOSE: To present an as yet unreported late complication of an Excluder thoracic endograft. CASE REPORT: A 78-year-old man underwent surgery for a ruptured type V thoracoabdominal aortic aneurysm in 1996. Four years later, an aneurysm was detected in the proximal thoracic aorta and repaired with 2 Excluder endoprostheses. At 12 months, computed tomography showed an increase in the aneurysm sac diameter and a type III endoleak, which was traced to a hole in the stent-graft fabric on arteriography. No fracture of the metal components was detected in the stent-grafts. Another Excluder device was implanted within the distal endograft. Satisfactory exclusion of the leak has been maintained for 6 months. CONCLUSIONS: The risk of type III leaks must be minimized before stent-grafting can be regarded as a routine procedure in the treatment of thoracic aortic aneurysms.