Long-term outcomes and factors influencing late survival following elective abdominal aortic aneurysm repair: A 24-year experience.

BACKGROUND: Abdominal aortic aneurysms can be either treated by an open abdominal aortic aneurysm repair or an endovascular repair. Comparing clinical predictors of outcomes and those which influence survival rates in the long term is important in determining the choice of treatment offered and the decision-making process with patients. AIMS: To determine the influence of pre-existing clinical predictors and perioperative determinants on late survival of elective open abdominal aortic aneurysm repair and endovascular repair at a tertiary hospital. METHODS: Consecutive patients undergoing elective abdominal aortic aneurysm repair from 1990 to 2013 were included. Data were collected from a prospectively acquired database and death data were gathered from the Queensland state death registry. Pre-existing risks and perioperative factors were assessed independently. Kaplan-Meier and Cox regression modeling were performed. RESULTS: During the study period, 1340 abdominal aortic aneurysms were repaired electively, of which 982 were open abdominal aortic aneurysm repair. The average age was 72.4 years old and 81.7% were males. The cumulative percentage survival rates for open abdominal aortic aneurysms repair at 5, 10, 15 and 20 years were 79, 49, 31 and 22, respectively. The corresponding 5-, 10- and 15-year survival rates for endovascular repair were not significantly different at 75, 49 and 33%, respectively (P = 0.75). Predictors of reduced survival were advanced age, American Society of Anaesthesiology scores, chronic obstructive pulmonary disease, renal impairment, bifurcated grafts, peripheral vascular disease and congestive heart failure. CONCLUSIONS: Open repair offers a good long-term treatment option for patients with an abdominal aortic aneurysm and in our experience there is no significant difference in late survival between open abdominal aortic aneurysms repair and endovascular repair. Consideration of the factors identified in this study that predict reduced long-term survival for open abdominal aortic aneurysms repair and endovascular repair should be considered when deciding repair of abdominal aortic aneurysm.

Important observations made managing carotid body tumors during a 25-year experience.

OBJECTIVES: Our objective was to assess the short- and long-term outcome for patients after carotid body tumor (CBT) resection and discuss the potential pitfalls of the treatment. METHODS: An analysis was undertaken of all patients who underwent CBT resection at Royal Brisbane and Women's Hospital and Greenslopes Private Hospital between 1982 and 2007. Primary tumor characteristics, surgical technique, and outcomes were recorded and analyzed. RESULTS: A total of 49 consecutive CBT resections (2 recurrent tumors) were carried out in 39 patients (26 women [56%]) who were a mean age of 49 years (range, 17-75 years). A nontender neck mass was the presenting complaint in 85%, followed by screening in familial or contralateral tumors in 26%. Familial cases occurred in 11 patients (28%). There were no operative deaths. Complications occurred in 13 of the 49 operations (27%), predominantly temporary nerve palsies and were more likely to occur in tumors of large volume or in cases of removal of coexisting vagal tumors. Malignant disease was present in seven cases (15%). All patients have been followed-up postoperatively for a mean of 11 years (range, 2-26 years). Metachronous paragangliomas have been discovered in six patients, all with familial disease. CONCLUSIONS: Early resection of carotid body tumors should be undertaken while still small to minimize the risk of neural injury, which increases with tumor size. In cases of bilateral CBT, we recommend that the smaller tumor be resected first, before the staged resection of the larger contralateral tumor. In familial or bilateral tumor cases, other synchronous and metachronous paragangliomas should be excluded. Mandatory lifelong follow-up is essential.

Open surgery for atherosclerotic chronic mesenteric ischemia.

BACKGROUND: This study was undertaken to document the results of our current practice of open mesenteric revascularization to enable comparison with the recent trend of percutaneous endovascular therapy for the treatment of chronic mesenteric ischemia. METHODS: Patients were identified via operation code data as well ongoing audit data from 1992 until 2006. Only patients with a history of chronic mesenteric ischemia secondary to atherosclerosis for 3 months or longer were included in the study. Follow-up data have been collected prospectively and include clinical examination and history, as well as graft surveillance consisting of mesenteric duplex ultrasonography, computed tomography, and/or angiography every 6 months for 3 years and then yearly thereafter. RESULTS: Thirty-nine consecutive patients underwent 41 open revascularization procedures for chronic mesenteric ischemia, comprising 67 bypass grafts. The mean patient age was 65 years (range, 45-85 years), and 44% (n = 17) were male. Symptoms were present on average for 11 months (range, 4-48 months) before treatment. The average weight loss was 11.4 kg, and three patients (7.6%) also had evidence of ischemic enteritis. There was one perioperative death, thus giving a perioperative mortality rate of 2.5%. Perioperative morbidity occurred in five patients (12.2%). Primary graft patency was 92% at 5 years. Seven patients died during follow-up, which ranged from 4 to 161 months (mean, 39 months)-one (2.5%) from mesenteric ischemia. Two (5%) other patients have had recurrent mesenteric ischemic symptoms. CONCLUSIONS: Open surgical mesenteric revascularization by bypass grafting for atherosclerotic-induced chronic mesenteric ischemia can be performed with low mortality and morbidity and provides excellent long-term primary patency rates and symptom-free outcomes. Pending more data on the acute and long-term results of endovascular techniques, open mesenteric revascularization remains the gold standard for most patients with chronic mesenteric ischemia.

Endoluminal repair of a thoracic arch aneurysm using a scallop-edged stent-graft.

PURPOSE: To report a new technique of endoluminal thoracic aortic arch aneurysm repair using a scalloped stent-graft. CASE REPORT: A 79-year-old man presented with a 7.5-cm thoracic aneurysm involving the inner curve of the aortic arch. Endoluminal repair was performed with a scalloped stent-graft that allowed perfusion of the brachiocephalic (innominate) artery. Preliminary extra-anatomical left common carotid and subclavian artery bypass grafting had been performed to allow coverage of the origins of these vessels. CONCLUSIONS: The use of fenestrated endoluminal grafts in the aortic arch can be achieved safely and may increase the treatment options for the high-risk patient.

Management practices of Australian surgeons in the treatment of venous ulcers.

INTRODUCTION: Venous ulcers will affect 2% of the general population during the course of their lives causing significant morbidity. The aim of the present paper was to review assessment and treatment regimes used by surgeons throughout Australia and compare these with published guidelines. METHODS: A structured questionnaire was sent to all general and vascular surgeons in Australia. Questions detailing practice demographics, initial treatment, investigation and surgical intervention were asked. Responses were analysed using Fisher's exact test. RESULTS: A response rate of 36% was obtained from 1390 surgeons. This included 30% of the general surgeons and 67% of the vascular surgeons surveyed. Three hundred and seventy-one of these surgeons managed patients with venous ulcers. Vascular surgeons recorded ankle-brachial pressures (88%vs 55%; P < 0.0001) more frequently and used compression therapy more often than general surgeons (99%vs 61%; P < 0.0001). Superficial vein ablation was performed by 95% in the presence of superficial vein reflux and a normal deep system, 46% also performed this procedure in the setting of an incompetent deep system. Antibiotics were prescribed by 15% of surgeons with no evidence of infection. CONCLUSIONS: Initially venous ulcers are well managed in Australia; however, antibiotics are overprescribed in their treatment. The current rate of compression therapy use is low for some groups of surgeons and should be improved. The failure to use compression in all cases of venous ulcers and the overprescription of antibiotics in the absence of cellulitis suggests that significant improvements can be made in the management of venous ulcers in Australia.