Spiral vein reconstruction of the infected abdominal aorta using the greater saphenous vein: preliminary results of the Tilburg experience.

OBJECTIVES: The aim of this study was to evaluate patients, who underwent spiral vein reconstruction of the abdominal aorta to repair infected aneurysms or replace infected aortic grafts. METHODS: All spiral vein reconstructions between March 2005 and May 2010 because of vascular infections of the abdominal aorta were retrospectively included. Diagnosis was determined by clinical examination, laboratory results, computed tomography (CT) and positron emission tomography (PET) scan, and microbiological tests. Spiral vein reconstruction consisted of harvesting the greater saphenous vein (GSV) and construction into a spiral graft, aortic reconstruction and a transmesenteric omentumplasty. Primary outcomes were survival and limb salvage. Secondary outcomes included technical, clinical and ongoing success, re-infection, ongoing infection and patency. RESULTS: All five patients survived surgery, and there were no in-hospital deaths. Survival and limb salvage were 100% after median follow-up of 13 months (6-67 months). Further, technical, clinical and continuing success was 100%. There were no re-infections or ongoing infections. CONCLUSIONS: Spiral vein reconstruction using the GSV showed good short-term survival and limb salvage. It, therefore, might be considered as an attractive treatment method for vascular infections of the abdominal aorta. Still, more follow-up is needed to evaluate long-term results.

Functional status as a prognostic factor for primary revascularization for critical limb ischemia.

BACKGROUND: Lower extremity arterial revascularization (LEAR) is the gold-standard for critical lower limb ischemia (CLI). The goal of this study was twofold. First, we evaluated the long-term functional status of patients undergoing primary LEAR for CLI. Second, prognostic factors of long-term functional status and survival after primary LEAR for CLI were assessed. METHODS: All primary LEAR procedures were analyzed. Patients were stratified by preoperative functional status: ambulatory (group I) vs nonambulatory (group II). Patients were followed-up after 3 and 6 years. Adverse events (AEs) were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. Associated patient demographic/clinical data were analyzed using univariate and multivariate methods. RESULTS: There were 106 LEAR patients (group I: n = 42, 40% vs group II: n = 64, 60%). Group II patients were significantly older (75 vs 62 years; P = .00), were classified ASA 3-4 more frequently (78% vs 52%; P < .02), had more cardiac disease (n = 42, 66% vs n = 10, 24%; P = .00), renal disease (n = 26, 41% vs n = 7, 17%; P = .00), diabetes (n = 36, 56% vs n = 8, 19%; P = .00), hypertension (n = 47, 73% vs n = 13, 31%; P = .00) and severe CLI (n = 42, 66% vs n = 18, 38%; P < .01). Group II patients had a higher incidence of death (65.6% vs 14.3%; P = .00), minor AEs (n = 38, 26% vs n = 10, 22%; P = .00), surgical AEs (n = 48, 33% vs n = 12, 26%; P < .02) and systemic AEs (n = 24, 86% vs n = 4, 9%; P < .02). Also more unplanned reinterventions occurred in group II (n = 148, 76% vs n = 47, 24%; P = .00). Nonambulatory status was a multivariate independent predictor of nonambulatory status after LEAR during 6 years follow-up (odds ration [OR[: 21.47; 95% confidence interval [CI]: 2.76-166.77; P = .00). Pulmonary disease (OR: 7.49; 95% CI: 2.17-25.80; P = .00), not prescribing beta-blockers (OR: 4.67; 95% CI: 1.28-17.03; P < .02), nonambulatory status (OR: 22.99; 95% CI: 6.27-84.24; P = .00), and systemic AEs (OR: 9.66; 95% CI: 1.84-50.57; P < .01) were independent predictors of death. Functional status was not improved in group II after long-term follow-up. CONCLUSION: Nonambulatory patients suffer from extensive comorbid conditions. They are accompanied with an increased occurrence of AEs, unplanned reinterventions, and poor long-term survival rates. Successful LEAR did not improve their functional status after 6 years. This emphasizes that attempts for limb salvage must be carefully considered in these patients.

Morbidity and mortality caused by cardiac adverse events after revascularization for critical limb ischemia.

BACKGROUND: We assessed cardiac adverse events (AEs) after primary lower extremity arterial revascularization (LEAR) for critical lower limb ischemia (CLI) in order to evaluate the impact of cardiac AEs on the clinical outcome. We created an optimized care protocol concerning CLI patients' preoperative work-up as well as intra- and postoperative surveillance according to recent important literature and guidelines. METHODS: We conducted a prospective analysis of clinical outcome after LEAR using patient-related risk factors, comorbidity, surgical therapy, and AEs. This cohort was divided into patients with and without AEs. AEs were categorized according to predefined standards: minor, surgical, failed revascularization, and systemic. The consequences of AEs were reoperation, additional medication, irreversible physical damage, and early death. RESULTS: There were 106 patients (Fontaine III n=49, 46%, and Fontaine IV n=57, 56%) who underwent primary revascularization by bypass graft procedure (n=67, 63%) or balloon angioplasty (n=39, 37%). No difference in comorbidity was registered between the two groups. Eighty-four AEs were registered in 34 patients (32%). Patients experiencing AEs had significantly less antiplatelet agents (without AEs n=63, 88%, vs. with AEs n=18, 53%; p=0.000) and/or beta-blockers (without AEs n=66, 92%, vs. with AEs n=16, 47%; p=0.000) compared to patients without AEs. The two most harmful consequences of AEs were irreversible physical damage (n=3) and early death (n=8). Sixty percent (n=9) of systemic AEs were heart-related. The postprocedural mortality rate was 7.5%, with a 75% (n=6) heart-related cause of death. CONCLUSION: AEs occur in >30% of CLI patients after LEAR. The most harmful AEs on the clinical outcome of CLI patients were heart-related, causing increased morbidity and death. Significant correlations between prescription of beta-blockers and antiplatelet agents and prevention of AEs were observed. A persistent focus on the prevention of systemic AEs in order to ameliorate the outcome after LEAR for limb salvage remains of utmost importance. Therefore, we advise the implementation of an optimized care protocol by discussing patients in a strict manner according to a predetermined protocol, to optimize and standardize the preoperative work-up as well as intra- and postoperative patient surveillance.

Saphenous vein spiral graft: successful emergency repair of a mycotic aneurysm with aortoduodenal fistula.

Mycotic aneurysms leading to aortoduodenal fistula (ADF) are associated with high morbidity and mortality. We report a patient with a mycotic aneurysm and ADF who required emergency laparotomy. After excision of the aneurysm, vascular reconstruction was performed using an autologous graft. The left long saphenous vein was harvested and constructed into a spiral graft. The graft was inserted using a standard inlay technique. After 12 months the patient is in good health. No inflammation or dilation of the saphenous vein spiral graft has been noted. We suggest that in the emergency treatment of mycotic abdominal aneurysm, aortic reconstruction with saphenous vein spiral graft is a valuable option.

[Retroperitoneal haematoma seen on CT scan in 2 patients with abdominal symptoms, aneurysm of the abdominal aorta and normal haemodynamics]. / Retroperitoneaal hematoom op CT bij 2 patiënten met buikklachten, een aneurysma van de aorta abdominalis en normale hemodynamiek.

In 2 patients, men aged 73 and 66 undergoing physical and ultrasound examinations for complaints of abdominal pain, an aneurysm of the abdominal aorta (AAA) with a diameter of 7-8 cm was discovered. Both their blood pressure and heart rate were normal. The older man then underwent a CT scan as did the younger man after being observed overnight. They both proved to have a ruptured AAA. They were operated on and recovered well. It can be problematic to diagnose a ruptured AAA quickly in patients with abdominal and back pain, AAA on ultrasound and normal haemodynamic parameters. In this situation an emergency CT scan will visualize any retroperitoneal haematoma and the patient can undergo an emergency operation. If the CT scan does not show any rupture there is time for preoperative preparations before performing a semi-elective procedure.

Assessment of disease impact in patients with intermittent claudication: discrepancy between health status and quality of life.

OBJECTIVE: To describe similarities and differences between health status and quality of life in patients with intermittent claudication. METHODS: This was an observational study in the vascular outpatient department of a teaching hospital; it concerned 200 consecutive patients with intermittent claudication. Health status was assessed with the RAND-36, and quality of life was assessed with a reduced version of the World Health Organization Quality of Life assessment instrument-100. Scores were compared with those of sex- and age-matched healthy controls. Mann-Whitney U tests were used to detect statistically significant differences ( P < .01) between patients and healthy controls. Pearson correlations were calculated between health status and quality-of-life scores. Differences between correlations were examined by using Fisher z statistics. The upper and lower 10% of quality-of-life scores were compared with the response quartiles of the health status scores. RESULTS: Health status was significantly impaired in all domains. Quality of life was significantly worse with respect to aspects of physical health and level of independence and one global evaluative facets overall quality of life and general health. Quality-of-life assessment with the World Health Organization Quality of Life instrument disclosed patient-reported problems that had not been identified in health status. Conversely, patients did not regard all objective functional impairments as a problem. Pearson correlations ranged from 0.20 to 0.74. There were patients with excellent and very poor quality-of-life scores in nearly all the quartiles of the corresponding health status domains. CONCLUSIONS: Health status and quality of life represent different outcomes in patients with intermittent claudication. In addition to functional restrictions as measured in health status, quality of life also permits a personal evaluation of these restrictions. Objective functioning and subjective appraisal of functioning are complementary and not identical. Combining these measures should direct treatment in a way that meets patients' needs.

The impact of walking impairment, cardiovascular risk factors, and comorbidity on quality of life in patients with intermittent claudication.

OBJECTIVE: The objective of this study was to assess the impact of walking impairment, cardiovascular risk factors, and comorbidity on quality of life (QOL) in patients with intermittent claudication (IC). MATERIAL AND METHODS: The prospective observational study was conducted in the setting of a vascular outpatient department of a teaching hospital. QOL was assessed in 200 consecutive patients with IC, with a reduced version of the World Health Organization Quality of Life Assessment Instrument-100. The reduced instrument assesses 17 facets of QOL within five domains (Physical and Psychological Health, Level of Independence, Social Relationships, and Environment). Age, gender, degree of IC, risk factors, comorbidity, as recommended by the Society for Vascular Surgery/North American Chapter of the International Society for Cardiovascular Surgery (SVS/ISCVS), and the presence of back, hip, or knee symptoms were analyzed as possible predictors of QOL. Multiple regression analyses were run with each of the QOL facets and domains as dependent variable. A probability value of less than.05 was considered to be statistically significant. RESULTS: Male gender was found to be a predictor of better scores for Energy and Fatigue and for Sleep and Rest. Women had more Negative Feelings. The presence of back, hip, or knee symptoms was a significant predictive value for many aspects of QOL. With more concomitant diseases, patients had lower scores on the facets of Overall QOL and General Health and of Energy and Fatigue and showed more dependence on medication and treatments. The degree of IC, as expressed in the SVS/ISCVS classification, was a statistically significant predictor of QOL on the domain Level of Independence and its facets Mobility, Activities of Daily Living, and Working Capacity and the facets Pain and Discomfort, Sexual Activity, and Transport. Hypertension was the second most important single predictor of QOL in patients with IC. CONCLUSION: QOL in patients with IC is only partially determined by the severity of walking limitation as expressed in the SVS/ISCVS classification. The significant impact of cardiovascular risk factors and comorbidity and the presence of back, hip, or knee symptoms on QOL should be recognized and taken into account in the treatment policy.

The additional value of angiography after colour-coded duplex on decision making in patients with critical limb ischaemia. A prospective study.

OBJECTIVE: to investigate prospectively the additional value of intra arterial digital subtraction arteriography (IADSA) for decision making in patients with critical limb ischemia (CLI). Treatment plans based on colour-duplex imaging (CDI) were compared with treatment plans based on IADSA. METHODS: ninety-eight consecutive patients with 112 legs with CLI were investigated by CDI and IADSA. Treatment plans based on CDI and IADSA were made separately during a multidisciplinary meeting. Both plans were retrospectively analysed with the outcome of the operation or the endovascular procedure as a reference. RESULTS: eighty-eight patients with 101 legs could be analysed. In 91 out of the 101 legs (90%) CDI offered the same strategy as the IADSA. In 10 legs IADSA provided additional information. Most of the additional information concerned the crural vessels. CONCLUSION: the preoperative planning of treatment in patients with chronic critical ischaemia of the lower limbs can be based on CDI alone in most patients. For planning crural revascularisation additional information may be needed. If severe calcification prevents adequate visualisation of the crural vessels or no patent anterior or posterior tibial artery with outflow across the ankle is present, IADSA should be performed.

Quality of life in patients with intermittent claudication using the World Health Organisation (WHO) questionnaire.

OBJECTIVE: to assess quality of life (QOL) in patients with intermittent claudication. DESIGN: a prospective, open study. MATERIAL AND METHOD: one hundred and fifty-one consecutive claudicants (100 men, 51 women), and 161 healthy controls (70 men and 91 women) completed an adapted version of the World Health Organisation Quality of Life Assessment Instrument-100. RESULTS: patients scored significantly worse on the domains Physical health and Level of independence, as well as on the facets Pain and discomfort, Energy and fatigue, Mobility, Activities of daily living, Dependence on medication and treatments, Working capacity, Negative feelings, Recreation and leisure and Overall QOL and general health. Increasing disease to incapacitating claudication affected only the facet Mobility and the domain Level of independence. CONCLUSION: QOL in patients with intermittent claudication is reduced in many aspects. Where co-morbidity seems to affect QOL strongly, the effect of walking distance on QOL might be small. These findings may justify a reserved attitude towards invasive, even minimally invasive treatment of these patients.

BCG immunotherapy: be cautious of granulomas. Disseminated BCG infection and mycotic aneurysm as late complications of intravesical BCG instillations.

We describe a 65-year-old man with a granulomatous hepatitis and a progressive mycotic aneurysm of the abdominal aorta. One year before he received intravesical bacillus Calmette--Guérin (BCG) for carcinoma of the bladder without any complaints. Only post-mortem investigations could confirm that he suffered from a systemic BCG infection. Literature is reviewed for this rare complication.

Acquired ventricular septal defect and mitral insufficiency without pericardial effusion after stab wound to the chest.

Echocardiography has a role in the management of acute complications of penetrating cardiac trauma. We report the case of a 30-year-old man who sustained a stab wound to the chest. In this case a traumatic perforation of the ventricular septum and the anterior leaflet of the mitral valve caused by a knife occurred without pericardial effusion. The diagnosis was made by transthoracic echocardiography. The ability of transesophageal echocardiography to delineate the intracardiac injuries more precisely helped to guide the surgical procedure.

Chronic obstructive pulmonary disease and abdominal aortic aneurysms.

In a prospective study during the period January-May 1992, 362 consecutive out-patients above 65 years of age, attending the pulmonary department for chronic obstructive airways disease (COPD), were ultrasonographically screened for an aneurysm of the abdominal aorta (AAA). Data from pulmonary function tests together with history of cardiac disease, diabetes mellitus, hypertension, hypercholesterolaemia, peripheral arterial obstructive disease, smoking and corticosteroid medication were collected. 30/282 men and 6/80 women with COPD had an AAA > or = 30 mm in diameter, which equals a prevalence of 9.9% (95% confidence limits: 6.8-13.0%). COPD patients with severe emphysema, having a decreased forced expiratory volume/vital capacity ratio (FEV/VC) of < 55%, have a significantly higher prevalence of aortic dilatation or AAA compared to COPD patients with mild or moderate decreased FEV/VC (chi-squared test: p < 0.05, alpha = 0.05). In the group of patients with AAA, significantly more smokers were seen compared to the group with normal and dilated aortas (chi-squared test: p < 0.05).

Esophageal perforation during surgery on the cervical spine.

Esophageal perforation during surgery for cervical disc herniation is a rare complication. Differences in the time of diagnosis of this complication in three patients--no delay and delays of 6 hours and 4 days, respectively--resulted in different symptoms and outcomes. Early detection of the perforation allows prompt treatment. In the early stage, primary suture and, if necessary, interposition of vital tissue are sufficient to complete healing. In later stages, only drainage procedures, sometimes with a diversion of the salivary leakage, are indicated. In the reported patients, the outcome was favorable. On the other hand as an ongoing infection may cause mediastinitis, awareness of this complication and urgent surgical treatment may be lifesaving.

Aorto-caval fistula after lumbo-sacral disk surgery.

A patient with an aorta-caval fistula after intervertebral disk surgery is presented. Deterioration of the condition of the patient, mainly due to a progressive congestive heart failure, was caused by a large aorto-caval fistula; emergency repair of the lesion led to complete recovery. Because of delay in diagnosis, this insidious complication generally causes serious cardiopulmonary disturbances with a high morbidity and a significant mortality. The surgical treatment consists of the reconstruction of the greater veins and arteries involved.

The femoro-femoral cross-over bypass.

From 1984 to 1990 64 patients (56 men and 8 women) with a mean age of 67.1 years (36-88 yrs.) were treated with a femoro-femoral cross-over bypass (45 primary and 19 secondary procedures). All patients had an occlusion of one iliac artery. In 26 patients there were factors that made a central reconstruction unattractive. These disorders were congestive heart failure, COPD, CVA, an age over 80 years, etc. In 19 patients an occlusion of one leg of a former aortobifemoral bypass determined the choice for cross-over bypass. Three patients died (5 per cent), two patients of the so-called redo-group (septicaemia, one patient and arteriojejunal fistula one patient), the third patient died after a primary femoro-femoral bypass (myocardial infarction). The overall patency rate after three years was 78 per cent. Especially primary cross-over bypasses showed a good outcome with a primary patency of 80 per cent and a secondary patency of 85 per cent after three years. Considering that 23 of the 45 (51 per cent) primary procedures were for treatment of critical ischaemia (stage III and IV of Fontaine), a favourable limb-salvage of 21 out of 23 (91 per cent) was obtained. The cross-over bypass can be recommended as first choice therapy for patients with a unilateral iliac artery occlusion.

[Splenectomy as therapy for esophageal varices in a myeloproliferative syndrome]. / Splenectomie als therapie voor oesophagusvarices bij een myeloproliferatief syndroom.

We describe the history of a man aged 73 with a myeloproliferative syndrome and massive splenomegaly, who was admitted with bleeding oesophageal varices. After sclerotherapy and other conservative measures had failed to stop the bleeding, splenectomy was performed. Liver biopsy obtained at the time of splenectomy showed extramedullary haematopoiesis and no signs of cirrhosis. Six weeks after the operation no varices were present any more. Studies of the pathogenesis of portal hypertension in splenomegaly of different causes show the importance of the increased splenic blood flow as one of the main contributory causes to this specific type of portal hypertension. Therefore this type of portal hypertension can probably be cured by splenectomy, as we saw in our patient and as has been described in several case reports.

[Aneurysms of intestinal arteries]. / Aneurysmen der Intestinalarterien.

Aneurysms of the intestinal arteries are, with an incidence less than 0.1%, rare vascular disorders. The aneurysm of the splenic a. is seen in 60% of the cases. Next are the hepatic and superior mesenteric a. aneurysm with 20 and 6%. The causes are among others mediadegeneration, arteriosclerosis, and infection. The most intestinal aa aneurysms are asymptomatic and accidentally discovered by angiography. Their importance is given by the risk of rupture, which varies between less than 2% and more than 50%. The treatment consists of exclusion with or without reconstruction, aneurysmorrhaphy or embolisation. Only the elective treatment can prevent a rupture with its high mortality.

[Restoration of the circulation in the foot arteries for preservation of the lower leg]. / Herstel van de circulatie in de voetarteriën ter behoud van het onderbeen.

During a period of five years 61 lower extremities in 58 patients were treated by anastomosing venous bypasses to arteries of the last 10 cm of the distal lower leg (27) or to the arteries of the foot (34). In all cases the patients suffered from rest pain or gangrene. The mean age was 68.1 years; 74% of the patients suffered from diabetes mellitus. As the occlusions were principally localised in arteries of the lower leg, the only alternative would have been a major amputation. In an attempt to decrease the outflow resistance a small side to side arteriovenous fistula to the concomitant vein was added to the distal anastomosis. After a follow-up of 24.8 months the patency rate was 54%. In the end 46/61 (75%) of the feet and the legs could be saved from amputation. During the follow-up 16 patients died, a follow-up mortality of 25%. The hospital mortality was 3%. In conclusion it is our opinion, that the negative assessment of the chance of saving patients' feet in the above mentioned situation is not justified.