Rationale of EndoAnchors in abdominal aortic aneurysms with short or angulated necks.

Diseased pararenal aortic anatomy including thrombus, calcification, and progressive dilatation, may impact the long-term durability of endovascular aortic aneurysm repair. EndoAnchors have been shown to mimic the security of a hand sewn aortic anastomosis. Several investigators have evaluated the use of EndoAnchors to repair endograft problems or repair type 1 endoleaks in the abdominal or the thoracic position. The ANCHOR Registry is designed to evaluate up to 2000 patients at multiple sites in North America and Europe who have been treated with the Aptus Heli-FX EndoAnchor System to secure an aortic endograft. The registry collects important clinical characteristics of patients (1000) who are treated at the initial endograft implant (PRIMARY ARM) due to the presence of an endoleak or the concern about late failure due to a hostile aortic neck. An additional 1000 patients, who undergo a secondary procedure for treatment of an endoleak or other proximal graft failure (e.g., migration, aortic dilatation) will also be evaluated and followed (REVISION ARM). Currently, more than 290 patients have been entered and will be followed to evaluate the long-term efficacy of this treatment.

Influence of antiplatelet therapy on cerebral micro-emboli after carotid endarterectomy using postoperative transcranial Doppler monitoring.

AIM: To study the effect of different antiplatelet regimens (APT) on the rate of postoperative TCD registered micro-embolic signals (MES) following carotid endarterectomy (CEA). DESIGN: Prospective, randomised, double-blinded, pilot study. METHODS: The study group of 102 CEA patients (76 men, mean age 66.8 years) was randomised to routine Asasantin (Dipyridamole 200mg/Aspirin 25mg) twice daily (group I; n=39), Asasantin plus 75 mg Clopidogrel once daily (group II; n=33), or Asasantin plus Rheomacrodex (Dextran 40) 100g/L iv; 500 ml (group III; n=30). TCD monitoring of the ipsilateral middle cerebral artery for the occurrence of MES was performed intra-operatively and during the second postoperative hour following CEA. Primary endpoints were the rate of postoperative emboli and the occurrence of cerebrovascular complications. Secondary endpoint was any adverse bleeding. RESULTS: There were no deaths or major strokes. We observed 2 intraoperative TIA's (group II and III) and 1 postoperative minor stroke (group I). In comparison with placebo, Clopidogrel or Rheomacrodex in addition to Asasantin produced no significant reduction in the number of postoperative MES. There was no significant difference between the number of postoperative MES and different antiplatelet regimens. The incidence of bleeding complications was not significantly different between the 3 APT groups. CONCLUSION: In the present study, we could not show a significant influence of different antiplatelet regimens on TCD detected postoperative embolization following CEA.

Long-term results of percutaneous transluminal angioplasty for symptomatic iliac in-stent stenosis.

OBJECTIVE: This study describes the long-term results of endoluminal therapy for iliac in-stent obstructions. DESIGN: This is a retrospective study. MATERIALS AND METHODS: From 1992 to 2005, 68 patients (22 women), with a mean age of 61+/- 13 years and 16 bi-iliac in-stent obstructions, underwent 84 endovascular interventions for focal iliac in-stent stenoses (n = 61) or occlusions (n = 23). Primarily, only uncovered stents were placed. All patients were symptomatic: 70% had disabling intermittent claudication, 23% had resting pain, and 7% had trophic changes. All had in-stent diameter reduction exceeding 50% that was confirmed by duplex scanning and angiography. Procedures were performed under local anesthesia via the femoral route. RESULTS: All interventions were initially technically successful, with a minor complication of pneumonia in one patient (2%). Initial clinical success was achieved in 86% of patients. PTA alone was used to treat 72 (86%) in-stent obstructions, the other 12 (14%) had PTA and renewed stent placement. The 30-day mortality rate was 0%. Mean follow-up was 35 months (range, 3 months to 10 years) and included duplex scanning. Primary clinical patency was 88% at 1 year, 62% at 3 years, and 38% at 5 years follow-up. During follow-up, 28 (33%) of 84 extremities required secondary reinterventions because of symptomatic renewed in-stent stenosis, and 11 were treated successfully with repeated endovascular interventions. Secondary patency at 1 year was 94%, 78% at 3 years, and 63% at 5 years. Surgical intervention was eventually needed in 17 (20%) of the 84 extremities. CONCLUSIONS: Endoluminal therapy for iliac focal in-stent obstructive disease seems to be a safe technique with acceptable long-term outcome and therefore a true alternative to primary surgical reconstruction.

[Carotid endarterectomy indicated in asymptomatic stenosis]. / Carotisendarteriëctomie voor een asymptomatische stenose.

Carotid endarterectomy (CE) is of proven value for patients with a high-grade symptomatic stenosis of the internal carotid artery (ICA). Recently, the Asymptomatic Carotid Atherosclerosis Study group showed that in patients with an asymptomatic ICA stenosis of more than 60%, CE caused an absolute risk reduction of perioperative death or stroke during 5 year follow-up of 5.4% (95% confidence interval: 3.0-7.8). Half of these strokes were disabling. The number needed to treat to save one patient from death within 30 days or stroke within in the following 5 years was 19. Further studies are needed to isolate a group of patients that will substantially benefit from the operation. CE is probably most effective in males under 75 years of age. A low surgical morbidity and mortality is an absolute prerequisite to justify CE for an asymptomatic ICA stenosis.

Carotid endarterectomy in octogenarians with symptomatic high-grade internal carotid artery stenosis: long-term clinical and duplex follow-up.

The objective of this study was to evaluate the clinical and duplex outcome after carotid endarterectomy (CEA) in recently symptomatic patients aged 80 years or older. Information was assembled from a prospective data collection of all CEAs performed from January 1986 to December 1999. Included were all patients with recently symptomatic carotid artery stenosis who were aged 80 years or older at time of operation. Thirty-two patients, with a mean age of 82 years, were included. Outcome events were stroke, death, and restenosis (more than 50% diameter reduction) during routine duplex scan follow-up. Conventional surgical technique was used regarding anesthesia and selective shunting or patching. None of the operated-on patients suffered a stroke at any time during follow-up. One patient (3.1%) died in the early postoperative phase (<30 days). An additional 8 patients died during follow-up. None of these deaths were of cerebrovascular origin. Survival at 3 years was 73% (life table analysis). Routine duplex scan follow-up showed 2 patients with a diameter reduction of more than 50%, both 3 months after CEA. Restenosis rate on duplex scan was 7.4% after 1 year. The authors conclude that there seems to be no reason to deny the very elderly the benefits of CEA. Stroke-free survival and survival rates show that carotid surgery is a safe procedure in patients aged 80 and over who are in apparently good health. These findings are supported by a low incidence of restenosis on duplex scan follow-up, indicating a durable repair.

Stroke from carotid endarterectomy: when and how to reduce perioperative stroke rate?

OBJECTIVES: To analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. PATIENTS AND METHODS: From January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. RESULTS: Perioperative stroke or death occurred in 20 (3.3%) patients. In four operations stroke was apparent immediately after surgery. Mechanisms of these strokes were ipsilateral carotid artery occlusion (1) and embolisation (3). In 16 patients stroke developed after a symptom-free interval (2-72 h, mean 18 h) due to occlusion of the internal carotid artery on the side of surgery (9). Other mechanisms were: contralateral occlusion of the internal carotid artery (1), postoperative hyperperfusion syndrome (1), intracerebral haemorrhage (1), and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. CONCLUSIONS: In our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.

Adrenocortical function in patients with ruptured aneurysm of the abdominal aorta.

OBJECTIVE: To investigate adrenocortical function in patients with ruptured aneurysm of the abdominal aorta. DESIGN: Prospective clinical investigation. SETTING: Surgical intensive care unit in a university teaching hospital and intensive care unit in a general hospital. PATIENTS AND PARTICIPANTS: 54 patients with a documented rupture of the abdominal aorta. INTERVENTIONS: A short adrenocorticotrophic hormone (ACTH) stimulation test was performed. MEASUREMENTS AND RESULTS: Patients were studied within 24 h of admission to the hospital. Blood samples for the measurement of cortisol and ACTH were collected at 0800 h. Subsequently 0.25 mg tetracosactrin (Synacthen) was injected i.v. and after 60 min cortisol measurement was repeated. The criterion for a normal short ACTH test was: stimulated or unstimulated cortisol levels > or = 0.55 mumol/l. For the group as a whole, an unstimulated plasma cortisol level of 0.76 mumol/l was comparable to that in other groups of critically ill patients with similar severity of illness. Between survivors and non survivors, significant differences were found between unstimulated plasma cortisol levels (0.70 vs 1.03 mumol/l), stimulated plasma cortisol levels (1.00 vs 1.30 mumol/l), and plasma ACTH levels (72 vs 133 ng/l). One patient did not meet the criteria for normal adrenocortical function: unstimulated plasma cortisol 0.26 mumol/l, stimulated plasma cortisol 0.47 mumol/l. CONCLUSIONS: In the patients studied with ruptured aneurysm of the abdominal aorta, adrenocortical response was comparable to that in other groups of critically ill patients with similar severity of illness. High cortisol levels were associated with mortality. One patient did not meet the criteria for normal adrenocortical function but survival without steroid treatment.

Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device.

OBJECTIVES: One-year clinical outcome of a new endovascular treatment for long segmental arterial occlusive disease using a ring strip cutter (RSC) to minimise surgical exposure. DESIGN: Prospective, open study. MATERIALS: Thirty-eight consecutive RSC procedures in 36 consecutive patients with lengthy occlusive (34) or multiple stenotic (4) femoropopliteal lesions were performed. Indications for operation were disabling claudication in 25 (66%), rest pain in 3 (8%), and gangrene in 10 (26%) patients. METHODS: A newly developed endovascular ring strip cutter device was used to perform a remote endarterectomy through a single groin incision. Clinical data were analysed based on intention-to-treat. RESULTS: Initial angiographic, clinical and haemodynamic success was achieved in all 38 (100%) limbs. Mean ankle-brachial index increased significantly from 0.62 +/- 0.14 to 1.02 +/- 0.14 postoperatively (p = 0.01). Four failures have occurred during follow-up. After one-year experience the cumulative (assisted) primary and secondary patency rates are 80% and 85% respectively. Duplex surveillance has detected progressive recurrent stenoses in 10 cases. CONCLUSIONS: Remote endarterectomy of long segmental femoropopliteal occlusive disease through a single groin incision with the Ring Strip Cutter device is a safe and effective procedure. The early patency rates are good. Further long-term results are needed to evaluate this technique.

[Arterial injuries in lower leg fractures, a rare but severe complication]. / Arterieel vaatletsel bij onderbeenfracturen, een zeldzame doch ernstige complicatie.

Vascular injuries of the popliteal or crural arteries complicating tibial fractures are rare. They often lead to acute critical limb ischaemia requiring immediate invasive diagnostic procedures and surgical repair. To illuminate the acute situation of this combined injury two case histories are presented. A comprehensive surgical approach is mandatory to salvage the injured limb.

The preperitoneal approach in the repair of recurrent inguinal hernias.

Preperitoneal repair of 98 recurrent inguinal hernias performed at our teaching hospital was studied. In 55 instances, primary closure was performed and in 43 hernias, mesh prosthesis was applied. Rerecurrence was seen after 32 corrections (a follow-up examination period of 45 months). Nine asymptomatic recurrences were found. Unilateral versus bilateral repair showed a 27 and 50 per cent recurrence rate, respectively (p = 0.037). Results after primary closure and after mesh application were similar, and no correlation with the number of recurrences, age or presence of causes of raised abdominal pressure was observed. In 20 reoperations performed after the follow-up date, ten lateral hernias were found, indicating technical failure as a possible cause of rerecurrence. A high rate of recurrence after preperitoneal approach for recurrent inguinal hernia may be explained by technical shortcomings and detection of a high percentage of asymptomatic recurrences at physical examination.

A future role for loop ileostomy in colorectal surgery?

Thirty patients underwent a defunctioning loop ileostomy. Elective ileostomy was performed in 23 patients to protect a potentially vulnerable colorectal anastomosis and in one patient as a permanent faecal diversion for colonic atony. Six emergency loop ileostomies were performed; in four patients after colonic perforations and in two patients as a primary treatment secondary to colonic anastomotic leakage. Peri-operatively, none of the patients with an elective operation died. Four patients with an emergency operation, however, all died of irreversible peritoneal sepsis. Complications were a diversion colitis and an abdominal sepsis after anastomotic leakage in a second patient who required a re-operation. During follow-up (up to four years) one patient suffered from an episode of severe dehydration six months after operation. The ileal continuity was, without mortality, restored in 23 patients. Two patients had a wound infection with, in one of them, a late cicatricial hernia. In our experience, a defunctioning loop ileostomy is a relatively safe procedure and is, in our opinion, preferable to loop colostomy for temporary faecal diversion. The high mortality following emergency loop ileostomy reflects the bad prognosis of these patients and indicates the need for resection of the primary disease.

Thoraco-abdominal aortic approach for the treatment of pararenal aneurysm.

The results of a thoraco-abdominal retroperitoneal approach for the treatment of pararenal aneurysms are discussed. Fifteen patients with juxtarenal (7 pts) and suprarenal (8 pts) aneurysms were operated on by a left side thoracolaparotomy with retrocolic dissection. In 12 patients suprarenal aortic cross clamping was necessary for 10 to 60 minutes. Seven tube and eight bifurcation grafts were implanted using the inlay technique. There were no postoperative deaths; only one patient had a severe complication with total renal failure for which hemodialysis was started. In our experience the thoraco-abdominal aortic approach is a safe method for the treatment of patients with pararenal aneurysm.

The outcome of loop ileostomy closure in 293 cases.

Our experience with closure of loop ileostomies between the years 1975-1986 was reviewed. Ninety-three percent of stoma closures were done by simple transverse suture. The overall complication rate was 17%. Of the early postoperative complications (13%), the major complication was small bowel obstruction especially in patients where the stoma was protecting a pelvic ileal reservoir. Abdominal septic complications (postclosure) were rare (1%). These were generally caused by unrecognized enteric tears during the mobilization of the stoma rather than anastomotic leakage. A careful operative technique is required. The wound infection rate after healing by both secondary intention and primary skin closure was low (3%) and mainly superficial. Only one incisional hernia was observed in the late postoperative period. In three patients a posterior rectus sheath defect at the stoma site was found incidentally at laparotomy, without clinical evidence of an incisional hernia. Closure of a loop ileostomy is a safe operation with a low morbidity. In patients with a previous total colectomy there was a significant risk of small bowel obstruction after ileostomy closure.

Results of prosthetic grafts in femoro-crural bypass operations as compared to autogenous saphenous vein grafts.

Since 1971 175 femoro-crural bypasses were performed. Rest pain and gangrene were present in 90% of the cases; 28% had undergone previous surgery for ischemia of the same limb. The autogenous saphenous vein was the first choice and could be used in 81% of cases. Prosthetic material consisted consecutively of the regular PTFE (N = 12), the Dardik biograft (N = 13) and the thin-walled reinforced PTFE (N = 7). One dacron prosthesis was used. The two-year patency (Life-table) for the prostheses was 18%. Results of the composite grafts were as poor as those of complete prosthetic grafts. Saphenous vein grafts had a two-year patency of 70% and a five-year patency of 59%. Veno-venous anastomoses had no adverse influence on patency. Exploration of both legs for acceptable parts of the saphenous vein is indicated before the use of prosthetic material is justified.

A comparison of conventional and digital intravenous arteriography in the follow-up of femoro-crural bypass operations.

The value of intravenous arteriography, otherwise known as digital vascular imaging (DVI) in the late postoperative control of femoro-crural bypass operations is determined by comparing its results with those of conventional arteriography. Ten patients with 12 grafts were studied by both methods after a mean postoperative follow-up period of 83.5 months. DVI was 100% accurate in the determination of graft patency. In most patients it provided reliable information regarding the status of the distal anastomosis and the patency of the distal runoff. Since DVI has been proven accurate, has a good patient acceptance, and can be performed as an outpatient procedure, it is preferable to conventional arteriography for the objective documentation of long-term graft patency.