Shared Decision Making in Vascular Surgery: An Exploratory Study.

OBJECTIVES: Shared decision making (SDM) is a process in which patients and their doctors collaborate in choosing a suitable treatment option by incorporating patient values and preferences, as well as the best available evidence. Particularly in vascular surgery, several conditions seem suitable for SDM because there are multiple treatment options. The objective of this study was to assess the degree of SDM behaviour in vascular surgery. METHODS: Vascular surgeons of four Dutch hospitals selected consultations with patients who were facing a treatment decision. Immediately after the consultation, patients and surgeons completed the (subjective) SDM Q-9 and SDM Q-doc questionnaires respectively, to appreciate the perceived level of SDM behaviour. Two evaluators independently and objectively rated SDM behaviour in the audiotaped consultations, using the Observing Patient Involvement (OPTION-12) scale. RESULTS: Nine vascular surgeons and three vascular surgeons in training conducted 54 consultations. The patients' median SDM Q-9 score was high, 93% (IQR 79-100%), and 16/54 (29.6%) of them gave the maximum score. The surgeons' median score was also high, 84% (IQR 73-92%), while 4/54 (7.4%) gave the maximum score. In contrast, mean OPTION score was 31% (SD 11%). Surgeons hardly ever asked the patients for their preferred approach to receive information, whether they had understood the provided information, and how they would like to be involved in SDM. CONCLUSIONS: Currently, objective SDM behaviour among vascular surgeons is limited, even though the presented disorders allow for SDM. Hence, SDM in vascular surgical consultations could be improved by increasing the patients' and surgeons' awareness and knowledge about the concept of SDM.

The role of branch vessels in aortic type B dissection: an in vitro study.

OBJECTIVES: In acute type B aortic dissection (ABAD) a patent false lumen portends a poor outcome. Patent branch vessels originating from the false lumen in a type B aortic dissection are assumed to contribute to persistent blood flow and patent false lumen. Therefore, the morphologic changes of the false lumen generated by different outflow rates in an in vitro model were investigated. METHODS: An artificial dissection was created in two ex vivo porcine aortas. A thin cannula was placed in the false lumen, simulating a branch vessel originating from it. The aorta was positioned in a validated in vitro circulatory system with physiological pulsatile flow (1,500-2,700 mL/minute) and pressure characteristics (130/70 mm Hg). The cannula was attached to a small silicone tube with an adjustable valve mechanism. Three different valve settings were used for creating outflow from the false lumen (fully closed, opened at 50%, and fully opened at 100%). Measurements of lumen areas and flow rates were assessed with time-resolved magnetic resonance imaging. In order to study reproducibility, the experiment was performed twice in two different porcine aortas with a similar morphology. RESULTS: Increasing antegrade outflow through the branch vessel of the false lumen resulted in a significant (p < .01) increase of the mean false lumen area at the proximal and distal location in both models. The distal false lumen expanded up to 107% in the case of high outflow via the false lumen through the branch vessel. CONCLUSIONS: Increasing antegrade outflow through a branch vessel originating from the false lumen when no distal re-entry tear is present results in an expansion of the cross sectional false lumen area.

Infection of endovascular abdominal aortic aneurysm stent graft after urosepsis: case report and review of the literature.

Infection of endovascular abdominal aneurysm stent grafts is an uncommon but known complication. Inoculation with bacteria of the endovascular abdominal aneurysm stent graft during the actual implantation, in the periprocedural hospitalization or later due to an aortoenteric fistula, has been described in the literature. We report a case of endovascular abdominal aortic aneurysm stent graft infection occurring 40 months after implantation in a patient doing well up to an episode of urosepsis. In conclusion, we postulate that poor intraluminal healing of stent grafts, as observed in several explant studies, may result in a higher susceptibility to episodes of bacteremia than prosthetic vascular grafts inserted during open repair. We therefore consider the administration of prophylactic antibiotics in patients with endovascular stent grafts during periods with a likelihood of bacteremia.

Contrast enhanced magnetic resonance angiography versus intra-arterial digital subtraction angiography for treatment planning in patients with peripheral arterial disease: a randomised controlled diagnostic trial.

OBJECTIVES: To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg. DESIGN: Randomised controlled diagnostic trial. MATERIALS AND METHODS: Patients were randomly allocated to MRA (n=97) or DSA (n=100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs. RESULTS: A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p=0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p=0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were euro4768,- in the MRA group compared to euro4697,- in the DSA group (95% CI of difference -1331;1472). CONCLUSIONS: In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable.

[Endovascular prostheses and extra-anatomical bypasses to mesenteric and renal vessels in a patient with a thoraco-abdominal aortic aneurysm: a possible alternative to the standard operation]. / Endovasculaire vaatprothesen en extra-anatomische bypasses naar mesenteriale en renale vaten bij een patiënt met een thoracoabdominaal aneurysma van de aorta als alternatiefvoor de standaardoperatie.

A 57-year-old male had a thoraco-abdominal aortic aneurysm that was increasing in diameter, accompanied by pain in the right lower abdomen and groin. Ten years earlier he had had a dissecting thoraco-abdominal aneurysm that extended from the left subclavian artery to the aortic bifurcation. A CT-scan revealed further growth of the aneurysm. He was treated by an open and an endovascular operation. The distal aorta was replaced by a bifurcation prosthesis via a laparotomy, with 2 other bifurcation prostheses to 2 mesenteric and 2 renal arteries. In a second session, a carotid-subclavian bypass was constructed and the aorta was reinforced by an endograft from the left subclavian artery to the bifurcation prosthesis. Postoperatively he suffered a transient ischaemic attack, hypertension, pneumonia, and vocal cord paresis. At follow-up 1.5 years later, the patient was free of symptoms, with the exception of slight hoarseness during forced speech, and the aneurysm was totally under control. This procedure may be an alternative to the classical thoracophrenicolaparotomy.

Aneurysm sac pressure monitoring: effect of technique on interpretation of measurements.

OBJECTIVES: The purpose of this study is to determine the accuracy of measuring pressure with a fluid filled pressure device (needle) and a non-fluid filled pressure device (catheter) inside a thrombosed aneurysmal sac after exclusion from circulation by endovascular grafting. METHODS: In a static environment, consisting of a syringe to which a pressure monitoring kit was connected, experiments were performed to study the influence of the type of device (either needle or catheter) and the effect of the characteristics of the medium on the accuracy and reproducibility of pressure measurements. The pressures obtained with the needle in the different kinds of media were compared with those obtained in blood. Similar experiments were performed using a pressure catheter. Subsequently, pressure measurements were performed in a dynamic and physiological environment. This environment consisted of an artificial circulation in which an aneurysm, constructed of porcine aorta and filled with human aortic thrombus, was mounted. The pressures were compared and analyzed by Bland-Altman plots. RESULTS: Under static conditions, the pressure levels obtained by a needle in blood, starch solution and thrombus were similar. Under identical conditions, pressures obtained by a catheter in starch solution were significant lower than the pressures measured in blood (P<0.05). Under dynamic pressure conditions the reproducibility of pressures obtained with the needle inserted in the human thrombus was very poor. CONCLUSION: A needle pressure measuring device, inserted into media like human fibrin thrombus, does not yield accurate and reproducible results. A catheter with a tip-sensor rather than a needle is superior to study the pressure in the aneurysm sac after EVAR.