Prospective Ultrasound Screening of Men With Cerebrovascular Disease for Abdominal Aortic Aneurysms.

BACKGROUND: The prevalence of abdominal aortic aneurysms is higher in population with other vascular comorbidities, especially among men. Utility of screening among patients with cerebrovascular disease is unclear. OBJECTIVE: To determine the prevalence of abdominal aortic aneurysm in male patients with diagnosed cerebrovascular disease manifested by transient ischemic attack or stroke. METHODS: Between May 2013 and May 2014, all consecutive male patients undergoing carotid ultrasound in single tertiary center with a catchment area of 179,000 inhabitants were evaluated for ultrasound screening of abdominal aortic aneurysm. Abdominal aortic aneurysm was defined as maximum diameter of infrarenal aorta 30 mm or more. RESULTS: Of 105 (n = 105) consecutively evaluated male patients, only 69% (n = 72) were eligible for the study and underwent aortic screening. Reason for ineligibility was most often poor general medical condition (n = 29). Mean age of screened patients was 66 years (SD 9.8 years). Half of the screened patients suffered stroke (n = 36). The incidence of abdominal aortic aneurysm was 5.6% (n = 4). All found abdominal aortic aneurysms were small and did not require immediate surgical intervention. During a follow-up period of over 4 years, none of the aneurysms exhibited tendency for growth. CONCLUSIONS: The male population with cerebrovascular disease is comorbid and frail. Only, moderate prevalence of abdominal aortic aneurysms can be found in this subpopulation.

Effect of Endovascular Treatment Rate on Population Level Outcomes and Survival After Intact Abdominal Aortic Aneurysm Repair.

OBJECTIVES: The aim was to study outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in four geographically adjacent populations with identical demographics and variable EVAR rates. METHODS: This was a multicentre cohort study based on local and national registry data from an area of 815 000 inhabitants. The study involved 527 consecutive patients with an intact AAA treated with EVAR (n = 327) or OSR (n = 200) between 2010 and 2016. The catchment area was divided into four health care districts (populations A, B, C, and D) with one central hospital in each district. Each hospital decided independently between OSR and EVAR for patients within their population; OSR was performed in all hospitals while EVAR was centralised in one of them. Patient demographics and treatment outcomes were extracted from local registries. Population demographics, overall AAA incidence, and mortality data were retrieved from a national database. RESULTS: The rate of new intact AAA diagnosis varied between 20 and 29 per 100 000 inhabitants/year with the highest incidence in population D (p < .001). The intact AAA repair rates were 9.8, 8.9, 9.9, and 8.7 per 100 000 inhabitants/year for populations A, B, C, and D, respectively (p = .64). There were no significant differences in mean age (73.6 ± 8.0 years) or mean aortic diameter (62 ± 13 mm) between the treated patient populations. Groups A and B had high EVAR rates (74% and 72%, respectively) whereas the EVAR rates were lower in groups C and D (50% and 38%, respectively) (p < .001). The 30 day mortality rates were 2%, 2%, 4%, and 1% (p = .55), and complication rates were 17%, 12%, 15%, and 11% (p = .39) for A, B, C and D, respectively. There were no significant differences in mortality, complication or re-intervention rates between the groups during the mean follow up of 3.3 ± 2.0 years. CONCLUSIONS: At population level, high EVAR rates had no measurable effect compared with lower EVAR rates on the outcomes in patients with intact AAA.

Drug-Eluting Stent Shows Similar Patency Results as Prosthetic Bypass in Patients with Femoropopliteal Occlusion in a Randomized Trial.

BACKGROUND: Claudication and critical limb threatening ischemia are significant causes of mortality in the elderly. The gold standard of superficial femoral artery (SFA) revascularization is thus far considered to be the femoropopliteal bypass. The aim of this study was to compare mid-term patency between drug-eluting stents (DESs) and prosthetic bypass grafts (BSX). Studies have reported comparable results for both the methods. METHODS: Forty-six patients with claudication or rest pain due to a 5-25 cm SFA occlusion were randomized between DES and BSX groups. The follow-up period was 24 months, and the primary outcome measure was overall patency. Secondary outcome measures were primary and primary assisted patency, change in ankle-brachial index (ABI), and amputation-free survival. RESULTS: Forty-one patients were eventually analyzed. Six-month secondary patency was 91% (DES) versus 83% (BSX) (P = 0.450). The corresponding numbers at 12 months in the DES and BSX groups were 74% and 80% (P = 0.750), respectively. At 24 months, the respective numbers were 56% and 71% (P = 0.830). There were no statistically significant differences in primary or assisted primary patency at 1, 6, or 12 months. CONCLUSION: There were no demonstrable differences in patency rates or clinical outcomes such as ABI or major amputations between DES and BSX. Although underpowered, the results suggest noninferiority of the DES compared with prosthetic bypass surgery. TRIAL REGISTRATION: The trial was preregistered at ClinicalTrials.org (NCT01450722).

New onset postoperative atrial fibrillation and early anticoagulation after cardiac surgery.

OBJECTIVES: New onset postoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased risk for thromboembolic complications. Compliance with anticoagulation treatment is prerequisite for successful outcome after POAF. We hypothesized that a disciplined anticoagulation protocol initiated instantly after POAF secures a long-term outcome. DESIGN: A total of 519 consecutive patients undergoing cardiac surgery were retrospectively analyzed. Patients received anticoagulation using warfarin whenever POAF lasted longer than five min. Postoperative outcome including mortality, myocardial infarction and stroke were compared with patients on sinus rhythm (non-POAF). RESULTS: Mean age of the study cohort was 64.3 ± 9.0 years and median follow-up time was 76 months. There were 177 (34%) POAF and 342 (66%) non-POAF patients. At discharge, 144 (81%) POAF patients complied with warfarin, while 82 (24%) non-POAF patients received warfarin for non-rhythm causes (p < .001). Mortality was higher in POAF as compared with non-POAF patients (p = .03). After adjustment for comorbidities, major adverse clinical events (MACE)- including a combination of late cardiovascular mortality, myocardial infarction, stroke and late atrial fibrillation- was independently associated with POAF (OR 2.73, 95%CI 1.69-4.45, p < .0001). CONCLUSIONS: POAF after cardiac surgery was associated with high risk of MACE. Early anticoagulation may be justified in POAF patients to secure a long-term outcome after cardiac surgery.

Pharmacomechanical Thrombectomy in Paget-Schroetter Syndrome.

PURPOSE: The purpose of the study was to evaluate feasibility of pharmacomechanical thrombectomy (PMT) in the treatment of Paget-Schroetter syndrome (PSS) followed by thoracoscopic or open surgical decompression of the subclavian vein. METHODS: Twenty-two out of 27 consecutive patients with PSS received PMT using the Trellis-8 peripheral infusion system (Covidien) between 2010 and 2014. Subsequent surgery was performed in 18 of those patients, 9 patients were treated with thoracoscopic, 7 patients with subclavicular, and 2 patients with transaxillary first rib resection, 4 patients were treated with PMT and anticoagulation alone. Technical success, complications, and patency were registered. RESULTS: PMT was successful in 21 (95 %) patients; 1 patient with unsatisfactory lysis received further catheter-directed thrombolysis, which, however, did not improve the result. The mean endovascular procedure time was 105 ± 33 min (range 70-200 min), and the required median amount of thrombolytic agent was 500,000 international unit (IU; range 250,000-1,000,000 IU). Adjunctive balloon venoplasty and aspiration were used in 18 (82 %) and 7 (32 %) cases, respectively. One patient had an intimal tear of the subclavian vein that was discovered and repaired during surgery. There were no other complications related to the endovascular procedure. At follow-up, 18 of 21 patients (86 %) with follow-up imaging available had patent subclavian vein, and all except 1 of the 22 patients were asymptomatic. The mean follow-up time was 25 ± 17 months. CONCLUSIONS: In experienced hands, PMT is effective for early thrombus removal in PSS. Surgical decompression must be considered after PMT.

Amplatzer Device in Bronchial Stump Fistula after Extrapleural Pneumonectomy.

Endoscopically superimposed Amplatzer (St. Jude Medical, St. Paul, Minnesota, United States) septal occluder plug was successfully used in the treatment of septic right main bronchus fistula having developed after extrapleural pneumonectomy and heated chemotherapy in two patients with malignant pleural mesothelioma. In the first case the method was curative and in the other Amplatzer served as temporary bridging allowing rehabilitation from empyema and sepsis. After 4.5 and 4.2 years both patients are alive with no sign of relapse of mesothelioma or infection.

Vascular comorbidities and demographics of patients with ruptured abdominal aortic aneurysms.

BACKGROUND: The results of previous studies reporting the epidemiology of ruptured abdominal aortic aneurysm (RAAA) are highly heterogeneous. Furthermore, although RAAA and the preceding abnormal dilation of the abdominal aorta (AAA) are associated with other cardiovascular comorbidities, the demographic profile of all patients with RAAA has not been thoroughly investigated. OBJECTIVE: To document accurately the epidemiology, survival, and demographic data (including vascular comorbidities and previous use of health care services) in RAAA-patients. MATERIAL AND METHODS: We conducted a comprehensive retrospective register study of all RAAA patients (operatively treated RAAA patients as well as in- and out-of-hospital nonsurvivors) in a well-defined geographic area during an 11-year period. RESULTS: We found 488 RAAA cases in a catchment area of 689,000. The annual incidence of RAAA was 6.5/100,000. Of these patients 43.2% were underwent surgery. Overall mortality was 79.5%, and 27.5% of the population died out-of-hospital. Age was the only independent risk factor affecting survival (P < .0001). The mean age at the time of RAAA was 73.6 years for men and 82.3 years for women. Off all unexpected RAAA patients, 40% had a previous history of cardiovascular disease (most often coronary artery disease: 32%), and 38% had visited a physician within the previous year. CONCLUSION: RAAA remains a highly lethal condition with age as the only significant risk factor for mortality. The proportion of women increases strongly with age. A large proportion of patients with unexpected RAAA have history of cardiovascular disease.

Screening Men with Coronary Heart Disease for Abdominal Aortic Aneurysm: A Prospective Cohort Study.

BACKGROUND: The prevalence of abdominal aortic aneurysms (AAA) is higher among patients with coronary heart disease (CHD) compared with control population. OBJECTIVE: To assess and determine the prevalence of non-diagnosed AAA in men with CHD. MATERIALS AND METHODS: A total of 438 active male out-patients with CHD were screened for AAA by abdominal ultrasound (US) examination. The largest infrarenal aortic dimension was registered. The patient was regarded to have AAA when the aortic diameter was greater than 30 mm. RESULTS: We found altogether 25 AAAs. The incidence of AAA was 5.7%. One AAA patient was operated on, and the other AAA patients are under surveillance. Independent predictors for AAA among CHD patients were increased age, family history of AAA, and current or previous smoking. The screening process took on average 5 min per patient, and the cost of screening was 15 ($18.50) per patient or 257 ($325) per found AAA. CONCLUSIONS: The prevalence of previously undiagnosed AAAs among patients with CHD is considerable. Screening of AAA should be considered among active patients with CHD. The most feasible and simplest option would be to perform the screening during any routine or elective cardiac US by a cardiologist, and we recommend to adopt it as a standard practice.

Rewarming a patient with accidental hypothermia and cardiac arrest using thoracic lavage.

The optimal treatment for severe accidental hypothermia is cardiopulmonary bypass because this offers the most rapid rate of rewarming. However, cardiopulmonary bypass therapy is not available in every hospital. In these circumstances, rewarming has to be achieved with other methods. We present a patient who was successfully rewarmed with thoracic lavage after he had been found with a core temperature of 21°C and asystole.

Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. In a prospective study, triclosan-coated sutures were reported to decrease the incidence of surgical site infection after various surgical procedures. The aim of our study was to test the hypothesis that use of triclosan-coated sutures decreases the incidence of SWI after lower limb vascular surgery. METHODS: This prospective, randomized, multicenter, double-blinded trial was conducted between July 2010 and January 2011 in five hospitals in Finland. We randomly allocated 276 patients undergoing lower limb revascularization surgery to a study (n = 139) or a control (n = 137) group. Surgical wounds in the study group were closed with triclosan-coated suture material, and wounds in the control group were closed with noncoated sutures. The main outcome measure was SWI. A surgical wound complication was considered to be an infection if there were bacteria isolated from the wound or if there were areas of localized redness, heat, swelling, and pain around the wound appearing within 30 days after the operative procedure. Logistic regression analysis was used to assess the independent effect of triclosan-coated sutures on the incidence of SWI. RESULTS: Altogether, 61 (22.1 %) patients developed SWI. SWI occurred in 31 (22.3 %) patients in the study group and in 30 (21.9 %) patients in the control group (odds ratio 1.10, 95% confidence interval 0.61-2.01, p = 0.75.) CONCLUSIONS: The use of triclosan-coated sutures does not reduce the incidence of SWI after lower limb vascular surgery.

Supplemental postoperative oxygen in the prevention of surgical wound infection after lower limb vascular surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. Infections increase morbidity and costs of treatment. The aim of the present study was to test the hypothesis that supplemental postoperative oxygen decreases the incidence of SWI after lower limb revascularization. METHODS: This prospective, randomized, multicenter, single-blinded trial was conducted between May 2009 and February 2010 in six secondary referral hospitals in Finland. We randomly allocated 274 patients undergoing surgery for lower limb revascularization to the study group (n=137) or a control group (n=137). The study group received supplemental inspired oxygen for the first 2 days after surgery. The main outcome was SWI. Patients were followed up for 30 days or until the SWI was healed. Logistic regression analysis was used to assess the independent effect of supplemental oxygen on the incidence of SWI. RESULTS: Altogether 63 (23%) patients developed SWI; 47 (75%) of the infections were superficial. There were two vascular graft infections. SWI occurred in 25 patients (18.2%) in the study group and in 38 patients (27.7%) in the control group [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.30-1.04; P=0.07]. In isolated groin incisions, 3 patients of 52 (5.8%) in the study group and 12 patients of 51 (23.5%) in the control group developed SWI; OR=0.20, 95% CI 0.04-0.95; P=0.04. CONCLUSIONS: There was an indication that supplemental inspired oxygen tended to decrease the incidence of SWI after lower limb vascular surgery. In isolated groin incisions, the decrease of SWI incidence in the supplemental oxygen group was significant.