Lessons learned from Dutch medical disciplinary law regarding aortic aneurysm and dissection care.

OBJECTIVES: The current study is an explanatory analysis of Dutch disciplinary law regarding aortic aneurysm and aortic dissection care. We aim to give insight in the way disciplinary judges rule on quality of care and to extract the lessons to be learned. METHODS: The online open-access governmental database, which includes all disciplinary rulings since 2010, was searched using search terms related to aortic aneurysm and dissection care. First, abstracts were screened for relevance. Thereafter, the full text of all remaining cases was read. Cases related to the diagnosis, treatment, or the postoperative phase of an aortic aneurysm or aortic dissection were included. Characteristics were registered and analyzed for quantitative assessment. Each case was summarized and coded for qualitative analysis. RESULTS: Forty-eight first-instance cases were included, of which 19 (40%) were founded. Reprimands (n=9) and warnings (n=7) were the prevailing measures. Seven out of 8 appeal cases filed by plaintiffs were unfounded. Six out of 9 appeals filed by defendants were adjudged and led to a less severe measure. Most cases concerned the subject of 'wrong treatment/wrong diagnosis' (75%). Whether not recognizing an aneurysm or dissection led to disciplinary culpability depended on case-specific circumstances, and much importance was attached to adequate documentation. In many complaints, an element of inadequate communication was recognized. CONCLUSIONS: Patient-involvement, clear communication, and implementing changes after a mistake could increase patient satisfaction, avert complaints, and prevent time-consuming trials. Maintaining adequate documentation and having knowledge on the analytical framework of the court is beneficial when confronted with a complaint.

The association between sarcopenia and adverse outcomes after complex endovascular aortic repair.

BACKGROUND: Sarcopenia is identified as a predictive factor for adverse outcomes after complex endovascular aortic repair (complex EVAR). Consensus on preferred parameters for sarcopenia is not yet reached. The current study compares three CT-assessed parameters on their association with adverse outcomes after complex EVAR. METHODS: This was a single-center retrospective cohort study. Psoas Muscle Index (PMI), Skeletal Muscle Index (SMI), and lean psoas muscle area (LPMA) were examined by CT-segmentation. PMI, SMI, and LPMA were analyzed as continuous variables. In addition, cut-off values from previous research were used to diagnose patients as sarcopenic or non-sarcopenic. Outcomes were: all-cause mortality, major adverse events (MAE), length of hospital stay, and non-home discharge. A sub-analysis was made for severe sarcopenia; sarcopenia combined with low physical performance (gait speed, Time Up and Go test, Metabolic Equivalent of Task-score). RESULTS: We included 101 patients. A higher PMI (HR=0.590, CI: 0.374-0.930, P=0.023), SMI (HR=0.453, CI: 0.267-0.768, P=0.003), and LPMA (HR=0.559, CI: 0.333-0.944, P=0.029) were associated with a lower risk of mortality. Sarcopenia based on cut-off values for PMI and LPMA was not significantly associated with survival. Sarcopenia based on SMI did present a higher mortality risk (P=0.017). A sub-analysis showed that severely sarcopenic patients were at even higher risk of mortality (P=0.036). None of the parameters were significantly associated with the other outcomes. CONCLUSIONS: SMI had a slightly stronger association with mortality compared to PMI and LPMA. High-risk patients were selected by adding physical performance scores. Future research could focus on complex EVAR-specific PMI and LPMA cut-off values.

Learning Curve Analysis of Complex Endovascular Aortic Repair.

BACKGROUND: When introducing new techniques, attention must be paid to learning curve. Besides quantitative outcomes, qualitative factors of influence should be taken into consideration. This retrospective cohort study describes the quantitative learning curve of complex endovascular aortic repair (EVAR) in a nonhigh-volume academic center and provides qualitative factors that were perceived as contributors to this learning curve. With these factors, we aim to aid in future implementation of new techniques. METHODS: All patients undergoing complex EVAR in the Leiden University Medical Center (LUMC) between July 2013 and April 2021 were included (n = 90). Quantitative outcomes were as follows: operating time, blood loss, volume of contrast, hospital stay, major adverse events (MAE), 30-day mortality, and complexity. Patients were divided into 3 temporal groups (n = 30) for dichotomous outcomes. Regression plots were used for continuous outcomes. In 2017, the treatment team was interviewed by an external researcher. These interviews were reanalyzed for factors that contributed to successful implementation. RESULTS: Length of hospital stay (P = 0.008) and operating time (P = 0.010) decreased significantly over time. Fewer cardiac complications occurred in the third group (3: 0% vs. 2: 17% vs. 1: 17%, P = 0.042). There was a trend of increasing complexity (P = 0.076) and number of fenestrations (P = 0.060). No significant changes occurred in MAE and 30-day mortality. Qualitative factors that, according to the interviewees, positively influenced the learning curve were as follows: communication, mutual trust, a shared sense of responsibility and collective goals, clear authoritative structures, mutual learning, and team capabilities. CONCLUSIONS: In addition to factors previously identified in the literature, new learning curve factors were found (mutual learning and shared goals in the operating room (OR)) that should be taken into account when implementing new techniques.

Functional Performance After Complex Endovascular Aortic Repair: A Single-Center Retrospective Cohort Study.

PURPOSE: Complex endovascular aortic repair (EVAR) procedures provide a treatment option for patients with aortic aneurysms involving visceral branches. Good technical results and short-term outcomes have been reported. Whether complex EVAR provides acceptable functional outcomes is not clear. The current study aims to describe postoperative functional outcomes in complex EVAR patients-an older and relatively frail patient group. MATERIALS AND METHODS: A single-center retrospective cohort study was performed, using data from a computerized database of consecutive patients who underwent complex EVAR in the Leiden University Medical Center (LUMC, The Netherlands) between July 2013 and September 2020. As of May 2017, patients scheduled for complex EVAR were referred to a geriatric care pathway to determine (Instrumental) Activities of Daily Living ((I)ADL) scores at baseline and, if informed consent was given, after 12 months. For the total patient group, adverse functional performance outcomes were: discharge to a nursing home and 12-month mortality. For the patients included in geriatric follow-up, the additional outcome was the incidence of functional decline (defined by a ≥2 point increase in (I)ADL-score) at 12-month follow-up. RESULTS: Eighty-two patients underwent complex EVAR, of which 68 (82.9%) were male. Mean age was 73.3 years (SD=6.3). Within 30 days postsurgery, 6 patients (7.3%) died. Mortality within 12 months for the total patient group was 14.6% (n=12). After surgery, no patients had to be discharged to a nursing home. Fifteen patients (18.3%) were discharged to a rehabilitation center. Twenty-three patients gave informed consent and were included in geriatric follow-up. Five patients (21.7%) presented functional decline 12 months postsurgery and 4 patients had died (17.4%) by that time. This means that 39.1% of the patients in the care pathway suffered an adverse outcome. CONCLUSION: To our knowledge, this is the only study that examined functional performance after complex EVAR, using a prospectively maintained database. No patients were newly discharged to a nursing home and functional performance results at 12 months are promising. Future multidisciplinary research should focus on determining which patients are most prone to deterioration of function, so that efforts can be directed toward preventing postoperative functional decline.