The clinical applicability of an automated plethysmographic determination of the ankle-brachial index after vascular surgery.

An automated ankle-brachial index device could lead to potential time savings and more accuracy in ankle-brachial index-determination after vascular surgery. This prospective cross-sectional study compared postprocedural ankle-brachial indices measured by a manual method with ankle-brachial indices of an automated plethysmographic method. Forty-two patients were included. No significant difference in time performing a measurement was observed (1.1 min, 95% CI: -0.2 to +2.4; P = 0.095). Mean ankle-brachial index with the automated method was 0.105 higher (95% CI: 0.017 to 0.193; P = 0.020) than with the manual method, with limits of agreement of -0.376 and +0.587. Total variance amounted to 0.0759 and the correlation between both methods was 0.60. Reliability expressed as maximum absolute difference (95% level) between duplicate ankle-brachial index-measurements under identical conditions was 0.350 (manual) and 0.152 (automated), although not significant (p = 0.053). Finally, the automated method had 34% points higher failure rate than the manual method. In conclusion based on this study, the automated ankle-brachial index-method seems not to be clinically applicable for measuring ankle-brachial index postoperatively in patients with vascular disease.

Treatment of surgical site infections (SSI) IN patients with peripheral arterial disease: an observational study.

INTRODUCTION: The management of surgical site infections (SSI's) in vascular surgery has been challenging over the years. To assess the outcomes associated with the various strategies, we performed a review of all SSI's after elective vascular procedures in patients with moderate to severe peripheral arterial disease in a single centre hospital. METHODS: All patients with a SSI after peripheral vascular surgery were retrieved from a database on Surgical site infections (SSI)-surveillance after vascular surgery between March 2009 and January 2012. At admission, all patients were approached by microbiological wound sampling and empirical start of antibiotics. Further wound management was based on personal experience and preference of the attending vascular surgeon. Endpoints were treatment success (complete wound healing while staying alive and without major amputation), survival and major amputation during one year follow up. RESULTS: A total of 40 patients with a SSI were identified (60% superficial SSI and 40% deep SSI). In 92% of the patients with a superficial SSI's were successfully treated with adjusted antibiotics and incisional drainages. In the contrast, 25% of the patients with deep-SSI's were successfully treated. No particular treatment was more successful than the others. CONCLUSION: Adjusted antibiotic use and adequate wound drainage are sufficient strategies for superficial SSI management. The management of deep-SSI's is a challenging undertaking and future research on indications and timing of these wide arrays of treatment options is suggested.

Adverse events after treatment of patients with acute limb ischemia.

BACKGROUND: To assess the outcome and the occurrence and consequences of adverse events (AEs) after treatment of acute limb ischemia (ALI). METHODS: Retrospective analysis on intra-arterial thrombolysis (group I) and thromboembolectomy (group II). Outcome measures were primary patency and limb salvage rates. AEs and consequences were registered during admission and 30 days after discharge. RESULTS: A total of 238 procedures were included (group I, 173 vs. group II, 65). The primary patency (P = 0.144) and limb salvage rates (P = 0.166) were not significantly different between both groups. A total of 195 AEs were registered. Most AEs were procedure related and resulted in surgical reintervention (77% vs. 76%). Some AEs resulted in irreversible physical damage (15% vs. 25%) and death (6% vs. 12%). CONCLUSIONS: Both, intra-arterial thrombolysis and thromboembolectomies are adequate therapies; however, they result in a wide variety of AEs resulting in serious morbidity and even death.

Surgical site infection after multiple groin incisions in peripheral vascular surgery.

BACKGROUND: Patients with peripheral arterial disease (PAD) are at risk for revision surgery in the groin and therefore at potential risk for surgical site infections (SSIs). In an observational study, a cohort of patients with peripheral arterial disease was followed to examine the effect of different incision intervals on SSI-free survival. METHODS: Patients, needing peripheral vascular surgery because of PAD, were retrieved from a prospectively collected database on SSIs after vascular surgery between March 2009 and January 2012, the group consisting of 720 patients. Of these, 255 patients were selected (age 71.9±10.4 y). Cox proportional hazards models were used for event-history analyses. The effect of incision interval was estimated with adjustment for a number of potential confounders. Effects were quantified by means of hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: No significant effect on the incision interval on SSI-free survival was observed. After separating incisional SSIs into superficial- and deep-seated, a significant linear trend effect of the groin incision interval on deep-incisional SSI development was observed: the shorter the interval, the higher the event rate (HR 1.5 per category, 95% CI 1.1-2.1, p=0.22). Besides the incision interval, the Rutherford classification was a significant risk factor for SSI development (HR 3.0; 95% CI 2.1-4.2; p<0.0005). CONCLUSION: Revision surgery in the groin puts patients at risk for deep-incisional SSI. No effect on superficial incisional SSI development was observed. Besides the incision interval, the Rutherford classification was a significant risk factor for both superficial- and deep-incisional SSI. Quality improvement and better risk stratification schemes are suggested.

The current position of precuffed expanded polytetrafluoroethylene bypass grafts in peripheral vascular surgery.

OBJECTIVE: Long-term results of precuffed expanded polytetrafluoroethylene (ePTFE) grafts used for peripheral bypass surgery are lacking. The aim of this study was to obtain the long-term outcomes of precuffed ePTFE grafts compared with autologous saphenous vein (ASV) grafts used in patients with peripheral arterial disease (PAD). METHODS: A single-institution retrospective study of precuffed ePTFE and ASV graft performances in patients with PAD was undertaken between January 2004 and December 2012. Five-year primary patency, secondary patency, and limb salvage rates were determined by Kaplan-Meier analyses. RESULTS: A total of 467 bypass grafts were included in this study (169 precuffed ePTFE grafts and 298 ASV grafts). Secondary patency rates of ePTFE vs ASV at 1 and 5 years, respectively, were as follows: for 134 supragenicular femoropopliteal bypasses, 60% and 27% vs 89% and 85% (P < .05); for 190 infragenicular femoropopliteal bypasses, 40% and 25% vs 86% and 79% (P < .05); and for 84 femorocrural bypasses, 30% and 14% vs 50% and 50% (P < .05). Five-year limb salvage rates of ePTFE vs ASV for supragenicular femoropopliteal bypasses were 82% vs 94% (P = .16); for infragenicular femoropopliteal bypasses, 41% vs 92% (P < .05); and for femorocrural bypasses, 43% vs 64% (P = .06). CONCLUSIONS: ASV bypasses are still the first-choice conduit in peripheral bypass surgery performed in patients with PAD. Precuffed ePTFE bypasses are acceptable alternatives in the absence of adequate autologous vein.

Implementation of a bundle of care to reduce surgical site infections in patients undergoing vascular surgery.

BACKGROUND: Surgical site infections (SSI's) are associated with severe morbidity, mortality and increased health care costs in vascular surgery. OBJECTIVE: To implement a bundle of care in vascular surgery and measure the effects on the overall and deep-SSI's rates. DESIGN: Prospective, quasi-experimental, cohort study. METHODS: A prospective surveillance for SSI's after vascular surgery was performed in the Amphia hospital in Breda, from 2009 through 2011. A bundle developed by the Dutch hospital patient safety program (DHPSP) was introduced in 2009. The elements of the bundle were (1) perioperative normothermia, (2) hair removal before surgery, (3) the use of perioperative antibiotic prophylaxis and (4) discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures and this was used for feedback. RESULTS: Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. In total, 720 vascular procedures were performed during the study period and 75 (10.4%) SSI were observed. Deep SSI occurred in 25 (3.5%) patients. Patients with SSI's (28,5±29.3 vs 10.8±11.3, p<0.001) and deep-SSI's (48.3±39.4 vs 11.4±11.8, p<0.001) had a significantly longer length of hospital stay after surgery than patients without an infection. A significantly higher mortality was observed in patients who developed a deep SSI (Adjusted OR: 2.96, 95% confidence interval 1.32-6.63). Multivariate analysis showed a significant and independent decrease of the SSI-rate over time that paralleled the introduction of the bundle. The SSI-rate was 51% lower in 2011 compared to 2009. CONCLUSION: The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI's in patients undergoing vascular surgery.