Impact of Anxiety in Ambulatory Superficial Venous Surgery : A Prospective Study Using the HADS-A Scale.

BACKGROUND: The aim of the present prospective clinical study is to evaluate the impact of the level of anxiety in patients undergoing ambulatory superficial venous surgery (SVS) and to select a specific group of patients who need more of our attention to reduce the postoperative adverse events. METHODS: Preoperative anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS), especially the HADS-A (Anxiety subscale) in 340 consecutive patients undergoing elective SVS. Venous disease was assessed in all patients according to the established CEAP classification, the Venous Clinical Severity and the Venous Disability scores. RESULTS: According to the HADS-A scores, we could distinguish two groups of patients, with (group A with score ≥ 8; 61 patients) and without potential anxious state (group B with score ≤ 7; 279 patients). Demographic data, varicose veins risk factors and preoperative symptoms were comparable in both groups. The median HADS-A score was 9 (8-17; IQR: 2) in group A and 3 (0-7; IQR: 3) in group B. The rate of complications or adverse events in the recovery room, the mean postoperative pain scores, the apprehension before discharge hospital and the incidence of unexpected hospitalisation rate were significantly higher in group A when compared with group B. CONCLUSIONS: We observed that the presence of preoperative anxiety, even although infrequent, was associated with high incidence of complications or adverse events in the recovery room and a greater postoperative pain level. In this context, this group of patients needs more of our attention, particularly to limit potential anxiety and improve their satisfaction score.

Impact of Anxiety in Ambulatory Superficial Venous Surgery: A Prospective Study Using the HADS-A Scale.

BACKGROUND: The aim of the present prospective clinical study is to evaluate the impact of the level of anxiety in patients undergoing ambulatory superficial venous surgery (SVS) and to select a specific group of patients who need more of our attention to reduce the postoperative adverse events. SUBJECTS AND METHODS: Preoperative anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS), especially the HADS-A (Anxiety subscale) in 340 consecutive patients undergoing elective SVS. Venous disease was assessed in all patients according to the established CEAP classification, the Venous Clinical Severity and the Venous Disability scores. RESULTS: According to the HADS-A scores, we could distinguish two groups of patients, with (group A with score > 8; 61 patients) and without potential anxious state (group B with score < 7; 279 patients). Demographic data, varicose veins risk factors and preoperative symptoms were comparable in both groups. The median HADS-A score was 9 (8-17; IQR: 2) in group A and 3 (0-7; IQR: 3) in group B. The rate of complications or adverse events in the recovery room, the mean postoperative pain scores, the apprehension before discharge hospital and the incidence of unexpected hospitalisation rate were significantly higher in group A when compared with group B. CONCLUSIONS: We observed that the presence of preoperative anxiety, even although infrequent, was associated with high incidence of complications or adverse events in the recovery room and a greater postoperative pain level. In this context, this group of patients needs more of our attention, particularly to limit potential anxiety and improve their satisfaction score.

Bilateral Pretibial Varices with Intraosseous Venous Drainage Anomaly: A Case Report.

We report the case of a 35-year-old male patient who complained of right anteromedial leg pain, after an intensive sport exercise. At physical examination, internal pretibial soft tissue swelling containing prominent painful varices was found. Color Doppler ultrasound, radiographic examinations, followed by CT and MR complementary investigation, were performed.

Influence of respiratory cycle on proximal renal artery motion: an angiographic study in patients undergoing endovascular aneurysm repair.

BACKGROUND: The purpose of our study was to evaluate the influence of respiratory cycle on proximal renal artery (RA) motion in twenty consecutive patients with abdominal aneurysm and the potential impact on endograft deployment during endovascular aneurysm repair (EVAR). METHODS: Prior to the device introduction, a preoperative angiography to define the location of the RAs was performed by a calibrated pigtail catheter. A measuring tape on the table served as the reference point for all measurements. Images of RA levels were acquired during expiration (E) and inspiration (I) cycles. In order to have homogenous comparative values for each patient during inhalation, the anaesthesiologist maintained a controlled inspiration with a uniform pressure of 30 cm of water. Motion of the RAs was defined as the changes in distance between E and I measures, adjusted to the calibrated pigtail. RESULTS: The median right proximal RA motion was 3.0 mm (IQR 2.4 mm; range: 0 to 5.6 mm). The median left proximal RA motion was 3.1 mm (IQR 2.2 mm; range: 0.54 to 5.6 mm). The current results demonstrate the proximal RAs motion during breath with a median magnitude of 3 mm, without significant differences between both RA (P = .83). CONCLUSION: Our data confirm the RAs motion during respiratory cycle. More than the predictive absolute value of the RA motion between inspiratory and expiratory phases, it is the motion itself which is important. This unrecognized condition, even if it interests only a minority of patients, could potentially have clinical disastrous consequences : potential stenosis or covering of RAs.

Mycotic aneurysm of the right iliac artery: imaging diagnosis and correlation with pathological findings.

We report the case of a 55-year-old woman who presented at the emergency department with hypogastric pain, fever, clinical signs of sepsis and a critical inflammation syndrome in her blood test values. CT-scan of the abdomen demonstrated an infected aneurysm of the right iliac artery. The patient underwent surgery with a favorable outcome. Histological examination of resected artery was performed and compared to the CT features. The authors review the literature and stress the importance of early diagnosis and treatement.

Femoral bifurcation infected pseudoaneurysm: a simple and quick arterial reconstruction with reversed bifurcated saphenous vein graft.

Septic endarteritis complicating arterial cannulation is an exceptional condition. The authors report a quick and feasible surgical procedure to reconstruct a femoral bifurcation with reversed bifurcated saphenous vein graft.

Report on initial experience with local anaesthesia for carotid artery endarterectomy.

PURPOSE OF THE STUDY: This prospective study reports our preliminary results with local anaesthesia (LA) for carotid endarterectomy (CEA). MATERIAL AND METHODS: Twenty CEA in nineteen patients were performed using a three-stage local infiltration technique. CEA were performed through a short Duplex-assisted skin incision (median length: 55 mm) using a retro-jugular approach and polyurethane patch closure (median length: 35 mm). RESULTS: There were 13 men and 6 women with a mean age of 71.2 years. The indications of CEA were asymptomatic lesions in 11 cases, stroke in 7 cases and transient ischaemic attack in 2 cases. The median degree of internal carotid artery stenosis was 90%. One patient (5%) required an intraluminal shunt. There were no peri-operative deaths, stroke or conversion to general anaesthesia (GA). The median length of stay was 3 days. CONCLUSIONS: LA is a good alternative to GA. It can be used after a feasibility study and a short teaching procedure. In our centre, it is a safe and effective procedure associated with low morbidity, high acceptance by patients and a short hospital stay.

Varicose veins in ambulatory surgery : patients' perception.

INTRODUCTION: It is mandatory to perform venous surgery in ambulatory surgery units. The aim of this study is to analyse the patient's perception concerning the period before hospital discharge. STUDY DESIGN: This was a prospective observational study of 100 patients who underwent primary varicose vein surgery. Venous disease was assessed according to the CEAP classification and VCSS system. The perception of anxiety or psychological apprehension was documented by simple questions. Additionally, we recorded the daily postoperative pain, the return to normal activity and the patient's satisfaction score. RESULTS: Four patients required unplanned admission from the ambulatory surgery floor to the hospital unit: two for medical reasons (urinary retention and haematomas) and two ladies who stayed overnight because of a severe anxious state. When questioned about the potential anxiety before hospital discharge, the majority of patients (87%) declared no psychological apprehension. Eleven patients decided to leave the hospital despite potential distress. Patients with distress were more frequently male (p = .75) with superficial phlebitis (p = .49), pre-operative painful varicose veins (p = .13) and a higher number of surgical incisions (p = .35). The only significant difference existing between patients with or without anxiety was regarding the complication rate in the recovery room (p = .04). CONCLUSION: Despite careful patient selection, psychological distress could not be prevented or predicted. There is no doubt however that taking these emotional factors into consideration in outpatient surgical practice is essential.

Carotid endarterectomy with internal carotid artery segmental resection, temporary shunt and vein patch angioplasty: early and mid-term results.

AIM: The authors report an alternative procedure to carotid endarterectomy with internal carotid artery (ICA) segmental resection and end-to-end anastomosis associated with temporary shunt and venous patch angioplasty. DESIGN: prospective cohort study. METHODS: Between May 1995 and December 2004, 192 patients underwent 200 primary CEAs for significant ICA stenosis. There were 131 men and 61 women with a mean age of 72.4+/-8.4 years. The indications for CEA were asymptomatic lesions in 51.5%, transient ischemic attack in 27.5% and stroke in 21%. RESULTS: The combined early morbidity and mortality rate was 2%. Two patients died, one due to fatal intracerebral hemorrhage and the second patient died of acute mesenteric ischemia. Neurological complications occurred in 2 patients, including 1 TIA and 1 nondisabling cerebrovascular accident. Non-neurological complications occurred in 26 patients (13.5%). Seventeen patients (8.8%) developed hypertension, 3 neck hematomas (1.5%) required surgical evacuation, 1 patient had reversible supraventricular arrhythmia (0.5%) and 1 patient had pneumonia (0.5%). Furthermore, 1 asymptomatic carotid occlusion was identified (0.5%) and 3 patients suffered permanent cranial nerve injury (1.5%). Mean follow-up was 45.7 months and there were 41 late deaths (21.8%). Survival rates at 1 and 5 years were 96.7+/-1.2% and 73.58+/-4.2%, respectively. CONCLUSIONS: CEA with ICA shortening and reanastomosis is a safe and reliable procedure without any increase in morbidity or mortality.

Does retrojugular route for carotid endarterectomy increase the risk of internal jugular vein thrombosis?

Two different approaches are available to perform carotid endarterectomy: the traditional antejugular or the retrojugular route. With retrojugular route, direct access to the carotid arteries necessitates median retraction and often collapse of the internal jugular vein (IJV). Therefore, we have prospectively evaluated the potential incidence of IJV thrombosis.

Transilluminated powered phlebectomy. Mid-term clinical experience.

AIM: Transilluminated powered phlebectomy (TIPP) was first described in 1996 by Sptiz et al. and was designed to allow minimally invasive surgical treatment of varicose veins (VV). We report our updated experience with TIPP technique. METHODS: Between January 2001 and February 2004, 84 patients underwent treatment by TIPP technique for primary symptomatic VV. Saphenofemoral junction with complete stripping of the great saphenous vein was performed in all patients. Incompetent perforating veins was ligated and prominent VV were ablated with TIPP technique. RESULTS: Mean age of patients was 50.6 years (range 29-79 years) and most of patients were women (73%). The major varicose vein risk factors were standing position and parity. Heaviness (62%), pain (57%) and unsightly veins (30%) were the most common indications for surgery. The mean number of surgical incisions was 6 (range 3-10), the average operative time was 59 min (range 30-100 min) and the mean cosmetic score (out of 10) at 6 weeks was 8 (range 2-10). The mean pain score (out of 10) was at 2 days, 7 days and 6 weeks was 5, 3 and 0, respectively. All the complications were documented. CONCLUSIONS: The TIPP technique is safe without any adverse events, presents advantages and inconvenient which are discussed in this paper.

Maggot therapy: many hands make light work.

We report the case of a diabetic patient with severe ischaemic infected ulcer of the right foot, successfully treated with maggot therapy.

Hook phlebectomy versus transilluminated powered phlebectomy for varicose vein surgery: early results.

OBJECTIVES: to compare Transilluminated Powered Phlebectomy (TIPP) (TriVex System) with Muller's hook phlebectomy. MATERIALS AND METHODS: between January and April 2001, 40 patients (group 1) undergoing TIPP were non-randomly compared to 40 patients undergoing Muller's hook phlebectomy (group 2) in the course of conventional vein stripping and perforator ligation. All patients had at least C2 CEAP disease. RESULTS: hospital stay averaged 2 days (range 1-3 days; median 2 days) and was similar for the two groups. TIPP took significantly longer (56+/-12 vs 45+/-10 min, p<0.001) but was associated with significantly fewer incisions (6 [2-8] vs 8 [4-21], p<0.001). The mean pain score (out of 10) at 2 and 7 days and 6 weeks was 5, 2 and zero after TIPP and 4, 2 and zero after hook phlebectomy. The incidence of postoperative haematoma formation was significantly higher after TIPP (45 vs 25%, p=0.06), especially in the calf region (25 vs 2.5%,p =0.003). CONCLUSION: TIPP was slower (although speed increased with practice) associated with more haematoma (although this reduced with practice) and fewer incisions. In other respects (pain, cosmetic satisfaction, other complications, residual varices) it was not significantly different from hook phlebectomy. Greater clinical experience with the technique and randomized studies are required to determine whether TIPP is a valuable addition to our armamentarium.

Unusual haemorrhage complication after carotid endarterectomy.

An unusual case of haemorrhage complication after carotid endarterectomy caused by vein patch perforation is presented.

Beating heart surgery using the Octopus tissue stabilizers: initial experience including triple vessel disease and high-risk patients.

OBJECTIVE: The aim of this study was to evaluate initial results in beating heart coronary artery bypass grafting performed on patients with multivessel disease, using suction-based tissue stabilizers. METHODS: Forty patients (mean age 65.5 years, range 39-83) underwent beating heart coronary bypass by median sternotomy, with the use of the Octopus 1 (n = 27) and Octopus 2 (n = 13) devices. Twenty patients had unstable angina, four had pulmonary oedema, and four required preoperative intra-aortic balloon counterpulsation. Five interventions were repeat procedures. Mean ejection fraction was 54.4%(range 20-82%). Eighteen patients had triple-vessel disease, 18 patients had double-vessel disease and > 50% left main stem stenosis was present in six patients (isolated or in association). The average number of distal anastomoses was 2.5 (range 1-5, total 101). A mean of 1.5 (range 1-3) anastomoses was achieved with arterial grafts (45 mammary and 12 gastroepiploic arteries). RESULTS: Immediate graft patency was evaluated by Doppler flowmeter and five anastomoses were successfully corrected, based on an occlusion pattern. The perioperative myocardial infarction rate was zero. Transient episodes of supraventricular arrhythmias were detected in 19 patients. The administration of dobutamine at an inotropic concentration > 5 gamma-1 kg-1 min-1 was required in one patient. There were two in-hospital deaths (one non-cardiac-related). Overall survival and cardiac event-free rate at 20 months were 92.4% +/- 4.2% and 81.8% +/- 11.6%, respectively. CONCLUSIONS: Satisfactory results can be achieved in multivessel disease high-risk patients with beating heart coronary bypass surgery.

Six hundred consecutive carotid endarterectomies with temporary shunt and vein patch angioplasty: early and long-term results.

PURPOSE: This retrospective study evaluates the long-term clinical outcome and the survival of 600 consecutive carotid endarterectomies performed with a temporary shunt. All arteriotomies were closed by vein patch angioplasty. MATERIALS AND METHODS: Between November 1989 and November 1998, 600 isolated carotid endarterectomies (CEA) were performed in 540 patients by a uniform surgical technique at the University Clinic of Mont-Godinne. An intraluminal shunt and patch closure were systematically used. The mean age was 68 yr (ranging from 41 to 91 yr), 400 patients were men. The risk factors included hypertension in 73%, smoking history in 60%, coronary artery disease in 51% and hyperlipidemia in 35%. The indications were asymptomatic stenosis in 47%, transient ischemic attack in 40%, vertebrobasilar symptoms in 7% and stroke in 6%. EARLY RESULTS: The combined 30-day stroke and death rate was 0.9%. There were four deaths. The stroke and TIAs rates were 0.2% and 1.5% respectively. The incidence of early carotid occlusion was 0.5%. Cranial or cervical nerve dysfunction was identified in 6.3%. LATE RESULTS: The median follow-up was 49 months with a range of 2-124 months. Cumulative survival rates at 5 and 10 yr were 92+/-1% and 89+/-2% respectively. Thirty-two patients died during long-term follow-up; the death was stroke-related in only three patients. CONCLUSION: Carotid endarterectomy using an intraluminal shunt and vein patch closure is a safe and effective procedure associated with low morbidity and mortality rates at short and long-term follow-up.

Pseudoaneurysm of the internal carotid artery: treatment with a covered stent.

Dissection of the cervical segment of the internal carotid artery may occur spontaneously or after trauma. We report the management of a 53-year-old right-handed man with progressive dizziness and neck pain 6 weeks after a motor vehicle collision. The clinical and neurologic examinations were normal. The CT scan led to the diagnosis of a pseudoaneurysm of the right internal carotid artery near the skull base. We successfully treated this post-traumatic lesion with a covered stent. The patient underwent the endovascular procedure under general anesthesia and transcranial Doppler monitoring. No neurologic event was observed. Obliteration of the pseudoaneurysm with preservation of the carotid artery was achieved. The patient was discharged from the hospital 72 hr later with no complications. Clinical and imaging follow-up at 6 months was unremarkable.

Transilluminated powered mini-phlebectomy: early clinical experience.

We report our preliminary experience with a new surgical endoscopic technique, the Transilluminated Powered Phlebectomy (TriVex System, Smith + Nephew) to remove varicose veins. TriVex System combined an irrigated illuminator device and a powered vein resector. There were 15 patients with a mean age of 50 years, nine were women and six were men. We evaluated prospectively the safety, efficacy and clinical benefits of this new surgical device.