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1.
Eur J Vasc Endovasc Surg ; 40(6): 715-21, 2010 Dec.
Article in English | MEDLINE | ID: mdl-20920861

ABSTRACT

OBJECTIVE: To evaluate the outcome of hybrid treatment of the aortic arch with supra-aortic debranching and endovascular stent-graft repair in a selected group of patients with complex disease. DESIGN: Case series study with retrospective analysis of prospectively collected non-randomised data. METHODS: Patients with hybrid repair of complex arch disease at a single centre over a 6-year period were enrolled in the study. Only patients with extensive arch pathologies requiring debranching of at least the left carotid artery were considered. Patients were divided into those who underwent complete and partial supra-aortic revascularisation. The χ2 test was used to evaluate differences in outcomes. Logistic regression analyses were applied to identify predictors of poor outcome. RESULTS: A total of 33 patients were included in the study. Complete and partial arch repair was performed in nine and 24 patients, respectively. The aortic disease extended to the thoracic and abdominal aorta in 39% and 52% of the patients, respectively. One-third of the patients (30%) were treated on an urgent/emergency basis. Elective 30-day mortality and morbidity rates were 13% and 35%, respectively. Early mortality was significantly higher in the complete arch repair group (p=0.046). Pre-existing renal impairment was identified as a poor prognostic factor. All extra-anatomic bypasses remained patent and no aortic disease-related deaths occurred during a mean follow-up period of 23 months (range, 1.5-58 months). Complete arch repair was associated with an increased incidence of late endoleak (p=0.018). CONCLUSIONS: Hybrid treatment of the aortic arch provides a feasible alternative treatment in patients who are high risk for conventional open surgical repair. Careful selection of patients is required to achieve satisfactory results.


Subject(s)
Aorta, Abdominal/surgery , Aorta, Thoracic/surgery , Aortic Diseases/surgery , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Adult , Aged , Aged, 80 and over , Aorta, Abdominal/diagnostic imaging , Aorta, Thoracic/diagnostic imaging , Aortic Diseases/diagnostic imaging , Aortic Diseases/mortality , Aortography/methods , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis Implantation/mortality , Chi-Square Distribution , Endoleak/etiology , Endovascular Procedures/adverse effects , Endovascular Procedures/instrumentation , Endovascular Procedures/mortality , Female , Humans , Logistic Models , London , Male , Middle Aged , Patient Selection , Prosthesis Design , Retrospective Studies , Risk Assessment , Risk Factors , Stents , Time Factors , Tomography, X-Ray Computed , Treatment Outcome
2.
Eur J Vasc Endovasc Surg ; 39(6): 683-90, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20227895

ABSTRACT

BACKGROUND: Aortic arch disease has conventionally been the domain of open surgical repair. Hybrid open and endovascular repair has evolved as an alternative, less invasive, treatment option with promising results. A systematic literature review and analysis of the reported outcomes was undertaken. METHODS: An Internet-based literature search using MEDLINE was performed to identify all studies reporting on hybrid aortic arch repair with supra-aortic branch revascularisation and subsequent stent graft deployment. Debranching should involve at least one carotid artery, so that patients merely requiring a carotid-subclavian bypass were not included. Only reports of five patients or more were included in the analysis. Outcome measures were technical success, perioperative, 30-day and late morbidity and mortality. RESULTS: Eighteen studies fulfilled our search criteria, and data from 195 patients were entered for the analysis. No comparative studies of hybrid aortic arch repair with other conventional or innovative treatment modalities were identified. Complete arch repair was performed in 122 patients (63%). The overall technical success rate was 86% (167/195). The most common reason for technical failure was endoleak (9%, 17/195). Overall perioperative morbidity and mortality rates were 21% (41/195) and 9% (18/195), respectively. The most common perioperative complication was stroke (7%, 14/195). Four aneurysm-related deaths were reported during follow-up (2%). No long-term data on hybrid aortic arch repair were identified. CONCLUSIONS: Hybrid repair of complex aortic arch disease is an alternative treatment option with acceptable short-term results. Stroke remains a frequent complication and mortality rates are significant. Further research with large comparative studies and longer follow-up is required.


Subject(s)
Aorta, Thoracic/surgery , Aortic Arch Syndromes/surgery , Blood Vessel Prosthesis Implantation/methods , Stents , Humans , Treatment Outcome
3.
Br J Surg ; 97(4): 511-6, 2010 Apr.
Article in English | MEDLINE | ID: mdl-20186898

ABSTRACT

BACKGROUND: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. METHODS: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. RESULTS: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0.001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0.001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: r(s) = 0.80, P < 0.001; crisis: r(s) = 0.85, P < 0.001). Inter-rater reliability was high (alpha > or = 0.80 for all scales). CONCLUSION: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.


Subject(s)
Anesthesia, Local/standards , Clinical Competence/standards , Computer Simulation/standards , Education, Medical, Graduate/methods , Endarterectomy, Carotid/standards , General Surgery/education , Competency-Based Education , Consultants , General Surgery/standards , Humans , Medical Staff, Hospital/standards , Observer Variation , Operating Rooms , Patient Simulation , Self-Assessment
5.
Eur J Vasc Endovasc Surg ; 37(6): 654-60, 2009 Jun.
Article in English | MEDLINE | ID: mdl-19359200

ABSTRACT

Paraplegia affects up to 22% of patients undergoing thoarcoabdominal aneurysm surgery, producing long-term morbidity and a significant burden to healthcare. This article discusses the mechanisms that may lead to paraplegia during open and endovascular repair from an anatomical and physiological perspective. There are many adjuncts that must be considered to reduce the risk of spinal cord injury, such as revascularisation of intercostal arteries, maintenance of high mean blood pressure, spinal cord drainage and cooling. These adjuncts are discussed, highlighting the evidence available for each method and the practical ways in which they may be used.


Subject(s)
Aortic Aneurysm, Thoracic/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Paraplegia/prevention & control , Spinal Cord Ischemia/prevention & control , Spinal Cord/blood supply , Vascular Surgical Procedures/adverse effects , Aortic Aneurysm, Thoracic/physiopathology , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/instrumentation , Drainage , Hemodynamics , Humans , Hypothermia, Induced , Monitoring, Intraoperative , Paraplegia/etiology , Paraplegia/physiopathology , Perfusion/methods , Spinal Cord Ischemia/etiology , Spinal Cord Ischemia/physiopathology , Stents , Time Factors , Treatment Outcome , Vascular Surgical Procedures/instrumentation
6.
Eur J Vasc Endovasc Surg ; 37(2): 134-9, 2009 Feb.
Article in English | MEDLINE | ID: mdl-19046646

ABSTRACT

AIM: Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). METHODS: Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEA's (n=11); 2: senior vascular trainees--1-50 CEA's (n=11); 3: consultant vascular surgeons - > 50 CEA's (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. RESULTS: There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001). CONCLUSION: Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.


Subject(s)
Clinical Competence , Education, Medical, Graduate , Endarterectomy, Carotid , Informed Consent , Patient Simulation , Anesthesia, Local , Endarterectomy, Carotid/adverse effects , Endarterectomy, Carotid/education , Female , Humans , Internship and Residency , Male , Observer Variation , Referral and Consultation , Reproducibility of Results , Risk Assessment , Task Performance and Analysis , Time Factors , Video Recording
7.
Eur J Vasc Endovasc Surg ; 37(2): 175-81, 2009 Feb.
Article in English | MEDLINE | ID: mdl-19046650

ABSTRACT

OBJECTIVES: To describe our experience of treating juxtarenal (JRAAA's <4mm neck) and thoracoabdominal aortic aneurysms (TAAA's) using fenestrated and branched stent graft technology. DESIGN: Prospective single centre experience. METHODS: Since 2005, 29 fenestrated/branched procedures have been performed. 15 patients are studied with JRAAAs (n=7; median neck length 0mm (IQR 0-3.8)) or TAAAs (type I (n=2), III (n=2), IV (n=4)). ASA grade III in 12/15. Maximum diameter of aneurysm 64 mm (56-74 mm). Aneurysms were excluded using covered stents or branches from the main body to patent visceral vessels (40 target vessels total). Pre-operative and follow-up CT scans (1, 3, and 12 months) were analysed by a single Vascular Interventional Radiologist. RESULTS: Technical success for cannulation and stenting of target vessels was 98%. In-hospital mortality was 0%. One patient underwent conversion to open repair. Five had major complications including one paraplegia (type III TAAA) with subsequent recovery. Median length of stay was 9 days (IQR 7-18.75). At a median follow-up of 12 months (9-14), CT confirmed 36/37 (97%) target vessels remain patent. Sac size increased >5 mm in one patient only. There were no type I endoleaks, three type II endoleaks (one embolised, two under surveillance) and three type III endoleaks (two successfully treated percutaneously, one aneurysm ruptured 18 months after endografting and died). CONCLUSION: In selected patients, fenestrated and branched stents appear to be a safe and effective alternative to surgery for juxtarenal and thoracoabdominal aneurysms. The complication and mortality rates are low. The long-term durability of this procedure, however, needs to be proven.


Subject(s)
Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Thoracic/surgery , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Stents , Aged , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/mortality , Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/mortality , Aortic Rupture/etiology , Aortic Rupture/surgery , Aortography/methods , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/mortality , Databases as Topic , Female , Humans , Length of Stay , Male , Paraplegia/etiology , Prospective Studies , Prosthesis Design , Prosthesis Failure , Reoperation , Time Factors , Tomography, X-Ray Computed , Treatment Outcome
8.
Int Angiol ; 26(4): 361-6, 2007 Dec.
Article in English | MEDLINE | ID: mdl-18091704

ABSTRACT

AIM: Continuing medical education (CME) can be defined as ''educational activities that serve to maintain, develop, or increase the knowledge, skills and professional performance of a physician to provide services for patients, the public, or the profession''. CME is a major professional responsibility. The European Board of Vascular Surgery of the Union Européenne des Médecins Spécialistes (UEMS) Section of Vascular Surgery has, through its European Vascular CME (EVCME) Committee, accredited 74 congresses during the 5-year period from 2000-2004. METHODS: Official evaluation forms were completed by the congress participants for a personal appraisal of the quality of the activities. The data in this manuscript focused on questions that were the most relevant and of the greatest interest to the participants. A statistical analysis of the results was performed utilizing ANOVA and Robust tests of equality of means as well as a posthoc analysis for further investigation, and non parametric Wilcoxon signed ranks test. RESULTS: The educational needs of participants regarding new diagnostic and therapeutic modes were stated as ''important'' and ''extremely important'' in the responses at over 80% in total. Over 75% of the participants answered ''extremely important'' and ''important'' to the question ''how important is evidence-based practice to your practice''. CONCLUSION: This survey indicates that the EVCME approved congresses had a positive impact for the vascular surgeon by updating overall knowledge on vascular surgery; the majority of comments by the participants also indicates that EVCME is fulfilling its aim to bring as much evidence-based practice as possible into the daily work schedule of the surgeon by turning knowledge acquired by CME into performance of the participants.


Subject(s)
Education, Medical, Continuing/organization & administration , Vascular Surgical Procedures/education , Accreditation/organization & administration , Clinical Competence , Congresses as Topic , Europe , Humans , Needs Assessment , Program Evaluation , Societies, Medical , Time Factors
9.
Br J Surg ; 94(10): 1226-31, 2007 Oct.
Article in English | MEDLINE | ID: mdl-17579347

ABSTRACT

BACKGROUND: Competency-based assessment is being introduced to surgical training. The value of bench-top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants. METHODS: Forty-one surgeons (13 junior trainees, 15 senior trainees and 13 experienced consultants with experience of more than 50 CEAs) performed a three-throw knot-tying exercise on a jig and a CEA on the bench model. A composite score for knot-tying was calculated, incorporating electromagnetic motion analysis. CEA technical skill was assessed using validated rating scales by blinded video analysis. RESULTS: Senior trainees performed better than junior trainees in knot-tying (P = 0.025) as well as generic (P < 0.001) and procedural (P < 0.001) skills on CEA model assessment. There was no difference between senior trainees and consultants on any of these measures. The CEA model interobserver reliability was high for all rating scales (generic alpha = 0.974, procedural alpha = 0.952, end-product alpha = 0.976). CONCLUSION: Senior trainees achieved the same score as consultants, suggesting a similar level of basic technical skill and knowledge required to perform CEA, and were significantly better than junior trainees. Performance on the bench model could provide an early assessment for suitability to proceed to operative training in a competency-based training and assessment programme.


Subject(s)
Clinical Competence/standards , Education, Medical, Graduate , Vascular Surgical Procedures/education , Endarterectomy, Carotid , Humans , Medical Staff, Hospital/education , Models, Biological , Self-Assessment , Suture Techniques , Vascular Surgical Procedures/standards
10.
Ann R Coll Surg Engl ; 89(4): 384-8, 2007 May.
Article in English | MEDLINE | ID: mdl-17535616

ABSTRACT

INTRODUCTION: The publication of interpretable performance data for hospitals is an important service. In November 2002, the medical benchmarking company Dr Foster published a league table based on the results of abdominal aortic aneurysm (AAA) repair. The purpose of our study was to establish the validity of the data used in benchmarking. PATIENTS AND METHODS: Data on elective infra-renal AAA (IRAAA) repair was obtained from three sources. Data used by Dr Foster was based on the hospital PAS system. The databases for both Dr Foster and PAS were analysed and cross-referenced to the vascular unit database maintained by a separately employed audit co-ordinator. RESULTS: Of 395 total aortic aneurysm repairs, 223 (56%) were identified as elective IRAAA repairs on the unit database. Of these, 125 were identified on the PAS database and 115 on the Dr Foster database. The number of deaths was the same in both the unit and Dr Foster databases (n = 11) but the Dr Foster database included deaths in patients who had undergone juxtarenal (n = 1), Type III TAAA (n = 2) and Type IV TAAA (n = 4) repairs and omitted 7 deaths following IRAAA. The sensitivity and specificity for the PAS dataset was 0.51 and 0.93, respectively. For Dr Foster, the results were worse with a sensitivity and specificity of 0.41 and 0.86, respectively. The accuracy of the data was 0.6 and 0.69 for Dr Foster and PAS, respectively. Standardised mortality ratios (SMRs) were used to rank hospitals. Dr Foster's published SMR for elective AAA repair for our unit was 160. The actual SMR was 67. CONCLUSIONS: Robust and accurate published league tables should be supported and commended but currently available data appear to be misleading and may cause unnecessary concern to patients.


Subject(s)
Aortic Aneurysm, Abdominal/surgery , Benchmarking/standards , Vascular Surgical Procedures/standards , Aged , Aortic Aneurysm, Abdominal/mortality , Databases as Topic/standards , Emergencies/epidemiology , Emergency Treatment/standards , Emergency Treatment/statistics & numerical data , Forms and Records Control/standards , Humans , Length of Stay/statistics & numerical data , London/epidemiology , Middle Aged , Sensitivity and Specificity , Vascular Surgical Procedures/statistics & numerical data
11.
Eur J Vasc Endovasc Surg ; 33(5): 518-24, 2007 May.
Article in English | MEDLINE | ID: mdl-17296317

ABSTRACT

BACKGROUND: Carotid interventions are performed to reduce the cumulative risk of stroke. The success of the procedure is dependent upon maintaining low operative risk. This article reviews the current state of training for both carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). METHODS: Medline searches were performed to identify articles with the combination of the following key words: carotid, endarterectomy, stent, training, assessment and simulation. Manual searches of the reference lists and related papers was conducted. RESULTS: Training and assessment for CEA and CAS follows the traditional apprenticeship model. There is no formal training protocol or objective means of assessment for either carotid endarterectomy or stenting. Models and simulators to allow for training and assessment away from the operative theatre have been developed, and exist for both CEA and CAS. CONCLUSION: The technology exists to allow for both training and assessment of competency to take place in a controlled and objective environment for both CEA and CAS. The use of simulation needs to be robustly evaluated and assessed to both complement and augment existing training programs to ensure that the highest standards of care are maintained for treatment of carotid territory disease. Objective competency based training and assessment is no longer unattainable. Simulators augment this process and without them operative exposure is sporadic and crisis management infrequent.


Subject(s)
Angioplasty, Balloon/education , Endarterectomy, Carotid/education , General Surgery/education , Clinical Competence , Humans , Patient Simulation , Stents
12.
Vasc Endovascular Surg ; 40(5): 362-6, 2006.
Article in English | MEDLINE | ID: mdl-17038569

ABSTRACT

The combination of critical limb ischemia and end-stage renal failure (ESRF, ie, dialysis- dependent) represents severe systemic atherosclerosis and is associated with a very poor medium-term survival. Many nephrologists and surgeons advocate primary amputation. We examined the recent experience in this unit to determine whether infrainguinal bypass in these patients can be justified. Retrospective study of all patients with critical limb ischemia and ESRF undergoing surgery in a regional vascular and renal unit between January 1996 and May 2003. Forty-two patients with ESRF (median age 65 years) were referred with critical limb ischemia. Seventeen patients underwent 24 (7 bilateral) infrainguinal bypasses (17 autologous vein, 7 polytetrafluoroethylene [PTFE] conduit; tissue loss in 21/24, 88%), and 25 patients had primary major amputations of 32 limbs. Early occlusion occurred in 5 grafts (21%, all 5/5 PTFE). In-hospital mortality was 13% in the bypass group, 24% in the amputation group. Median in-hospital stay was 59 days in the bypass group, 46 days in the amputation group. Thirty-day, 1- and 2-year survival was 88%, 50%, and 33% in the bypass group; 83%, 39%, and 35% in the amputation group. The limb salvage rate was 66% at 1 year. Seventy-five percent (18/24) of operated on limbs (15/17 of vein grafts) avoided major amputation at follow-up (median 18 months) or death. The combination of critical limb ischemia and end- stage renal failure carries a poor medium-term survival independent of primary amputation or surgical revascularization. Infrainguinal bypass in selected cases with vein conduit can, however, allow the majority of these patients to avoid major limb amputation.


Subject(s)
Blood Vessel Prosthesis Implantation , Ischemia/surgery , Limb Salvage , Lower Extremity/blood supply , Renal Dialysis , Veins/transplantation , Adult , Aged , Amputation, Surgical , Female , Graft Occlusion, Vascular , Humans , Ischemia/complications , Ischemia/mortality , Kidney Failure, Chronic/complications , Kidney Failure, Chronic/mortality , Kidney Failure, Chronic/therapy , Male , Middle Aged , Polytetrafluoroethylene , Prognosis , Retrospective Studies , Survival Analysis , Time Factors , Treatment Outcome
13.
Br J Surg ; 93(9): 1132-8, 2006 Sep.
Article in English | MEDLINE | ID: mdl-16862608

ABSTRACT

BACKGROUND: The European Board of Surgery Qualification in Vascular Surgery is a pan-European examination for vascular surgeons who have attained a national certificate of completion of specialist training. A 2-year study was conducted before the introduction of a technical skills assessment in the examination. METHODS: The study included 30 surgeons: 22 candidates and eight examiners. They were tested on dissection (on a synthetic saphenofemoral junction model), anastomosis (on to anterior tibial artery of a synthetic leg model) and dexterity (a knot-tying simulator with electromagnetic motion analysis). Validated rating scales were used by two independent examiners. Composite knot-tying scores were calculated for the computerized station. The stations were weighted 35, 45 and 20 percent, respectively. RESULTS: Examiners performed better than candidates in the dissection (P<0.001), anastomosis (P=0.002) and dexterity (P=0.005) stations. Participants performed consistently in the examination (dissection versus anastomosis: r=0.79, P<0.001; dexterity versus total operative score: r=-0.73, P<0.001). Interobserver reliability was high (alpha=0.91). No correlation was seen between a candidate's technical skill and oral examination performance or logbook-accredited scores. CONCLUSION: Current surgical examinations do not address technical competence. This model appears to be a valid assessment of technical skills in an examination setting. The standards are set at a level appropriate for a specialist vascular surgeon.


Subject(s)
Clinical Competence/standards , Medical Staff, Hospital/standards , Vascular Surgical Procedures/standards , Competency-Based Education/methods , Competency-Based Education/standards , Educational Measurement/standards , Humans , Medical Staff, Hospital/education , Observer Variation , Pilot Projects , Reproducibility of Results , Vascular Surgical Procedures/education
14.
Eur J Vasc Endovasc Surg ; 32(3): 300-4, 2006 Sep.
Article in English | MEDLINE | ID: mdl-16781877

ABSTRACT

AIM: To investigate the impact of pre and peri-operative renal impairment on outcome, and the need for renal replacement therapy, in a multicenter study of patients undergoing a variety of surgical and radiological arterial procedures. METHODS: A six month prospective multi-centre study of 1,559 consecutive patients undergoing arterial interventions was performed. The primary outcome measures were the development of renal impairment, 30 day mortality and the need for renal replacement therapy. CRI was defined as an admission serum Creatinine>125 micromol/l. ARI was defined as a rise in serum Creatinine of >50% above pre-operative levels, excluding patients in whom the post operative level remained <125 micromol/l. A multivariate logistic regression model was constructed to identify independent risk factors for the development of ARI and mortality. RESULTS: There was a significantly increased 30 day mortality in those patients who developed ARI (29/90 - 32%) or who had CRI (43/269 - 16%) when compared with those whose creatinine remained normal throughout (44/1200 - 4%) (p<0.0001 - Chi-square test). One thousand two hundred and ninety patients had normal pre operative renal function and 269 patients had CRI. Seven percent (90/1290) of the patients with normal pre-operative creatinine developed ARI. Operation type, emergency presentation, and chronic renal impairment were independent predictors of both acute renal impairment (p<0.01) and mortality (p<0.001). Sixteen patients (1%) required temporary haemofiltration (in 9 patients this developed in the context of multiple organ failure) with only 1 requiring long term support. Eleven of these patients died (30 day mortality 69%). CONCLUSIONS: Renal failure following arterial intervention is associated with significant mortality. Renal replacement therapy is necessary mainly in the setting of multiple organ failure on intensive care units with few patients surviving to require long term renal replacement therapy. The identification of the 'at risk' patient is most strongly associated with age, raised preoperative creatinine, emergency procedures and thoraco-abdominal aneurysm.


Subject(s)
Renal Insufficiency, Chronic/epidemiology , Vascular Diseases/epidemiology , Vascular Diseases/surgery , Acute Kidney Injury/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Aortic Aneurysm, Abdominal/epidemiology , Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Thoracic/epidemiology , Aortic Aneurysm, Thoracic/surgery , Creatinine/blood , Female , Hemofiltration , Humans , Logistic Models , Male , Middle Aged , Multiple Organ Failure/therapy , Postoperative Period , Prospective Studies , Renal Dialysis , Risk Factors , Treatment Outcome , Vascular Diseases/mortality
15.
Eur J Vasc Endovasc Surg ; 30(4): 441-7, 2005 Oct.
Article in English | MEDLINE | ID: mdl-16206377

ABSTRACT

AIMS: Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators. METHODS: Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis. RESULTS: The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course. CONCLUSION: Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.


Subject(s)
Anastomosis, Surgical/education , Aortic Aneurysm, Abdominal/surgery , Clinical Competence , Education, Medical , Computer Simulation , Educational Measurement , Europe , Humans , Video Recording
18.
Eur J Vasc Endovasc Surg ; 28(5): 500-7, 2004 Nov.
Article in English | MEDLINE | ID: mdl-15465371

ABSTRACT

BACKGROUND: Patients undergoing carotid endoluminal intervention are at risk of embolic stroke even with the use of distal protection devices. Matrix metalloproteinases (MMPs) have been implicated as a causal factor in plaque instability leading to spontaneous embolisation. We investigated whether plasma MMP levels correlated with the embolisation during carotid endoluminal intervention. METHODS: Thirty circumferentially intact carotid endarterectomy specimens were subjected to a standardised angioplasty procedure in a pulsatile ex vivo model. Emboli collected in a series of distal filters were counted and sized. Plasma samples were collected pre-operatively and analysed for MMP-7 and MMP-8 levels using Western immunoblotting. MMP-1 and MMP-13 levels were determined using ELISA. Emboli number and maximum size were correlated with plasma levels of the MMPs using Spearmans rank. RESULTS: Total MMP-8 levels were related to maximum embolus size (r=0.442, p=0.005) but not emboli number (r=0.342, p=0.052). MMP-1, -7 and -13 were not correlated with either emboli number or with maximum embolus size. CONCLUSION: Pre-operative plasma MMP-8 levels are related to the size of emboli from plaques during carotid endovascular intervention. Further in vivo studies need to be performed to assess the importance of this finding. There is potential for development of plasma markers to identify those patients at greater risk of embolic stroke during carotid endoluminal intervention.


Subject(s)
Angioplasty/adverse effects , Carotid Artery Diseases/therapy , Embolism/blood , Matrix Metalloproteinase 8/blood , Aged , Carotid Artery Diseases/blood , Carotid Artery Diseases/complications , Collagenases/blood , Embolism/etiology , Endarterectomy, Carotid , Female , Humans , Male , Matrix Metalloproteinase 1/blood , Matrix Metalloproteinase 13 , Matrix Metalloproteinase 7/blood , Middle Aged , Models, Cardiovascular
19.
Eur J Vasc Endovasc Surg ; 27(6): 585-9, 2004 Jun.
Article in English | MEDLINE | ID: mdl-15121107

ABSTRACT

BACKGROUND: We have reviewed our management, of both ruptured and non-ruptured, abdominal and thoraco-abdominal mycotic aneurysms in order to determine the safety and efficacy of in situ and extra-anatomical prosthetic repairs. METHODS: Data regarding presenting symptoms, investigations, operative techniques and outcome, were collected on patients treated at a singe centre over 11 years. RESULTS: There were 11 men and four women, with a median age of 70 years (range, 24-79). All but one patient were symptomatic and six had a contained leak on admission. In six patients no organisms were identified in either blood or tissue cultures. Pre-operative CT identified; four infra-renal, four juxta-renal, three (Crawford thoraco-abdominal) type IV, three type III and one type II, aortic aneurysms. Thirteen were repaired with in situ prostheses and two required axillo-femoral prosthetic grafts. There were four early deaths. All surviving patients have been followed-up for a median duration of 38 months (range 1/2-112 months). There were two late deaths at 3 months (juxta-renal) and at 2 years (type III), the latter relating to graft infection. CONCLUSIONS: In the absence of uncontrolled sepsis, repair of mycotic aortic aneurysms using prosthetic grafts can achieve durable results.


Subject(s)
Aneurysm, Infected/surgery , Aortic Aneurysm, Abdominal/surgery , Aortic Aneurysm, Thoracic/surgery , Aged , Aneurysm, Infected/epidemiology , Anti-Bacterial Agents/therapeutic use , Aortic Aneurysm, Abdominal/epidemiology , Aortic Aneurysm, Thoracic/epidemiology , Aortic Rupture/epidemiology , Aortic Rupture/surgery , Blood Vessel Prosthesis Implantation/mortality , Female , Humans , Male , Postoperative Care
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