Three-dimensional intravascular ultrasound assessment of abdominal aortic aneurysm necks

PURPOSE

To document the accuracy of an automated analysis system for measuring lumen diameter and neck lengths of abdominal aortic aneurysms (AAAs) from intravascular ultrasound (IVUS) images and to describe additional features associated with 3-dimensional (3D) IVUS imaging.

METHODS

Twenty-two aortic aneurysms were studied with IVUS. Lumen diameters obtained using the automated analysis system were compared with manual measurements from axial IVUS scans, as were neck lengths obtained using automated analysis versus those measured with the aid of a displacement sensing device. Automated analyses were repeated by a second observer. Agreement was expressed as the coefficient of variation (CV).

RESULTS

Twenty proximal aortic, 6 distal aortic, and 3 iliac necks were available for analysis. Comparison between automated analysis and manual measurements for lumen diameter revealed a difference of 0.45 +/- 0.42 mm (mean +/- SD, Pearson's r = 0.99, p < 0.001, CV = 2.1%) and a difference of 0.05 +/- 0.12 cm (r = 0.99, p = 0.04, CV = 4.1%) for neck length. Interobserver difference for lumen diameter was 0.13 +/- 0.66 mm (r = 0.99, p < 0.001, CV = 3.4%) and 0.05 +/- 0.11 cm for length measurements (r = 0.99, p = 0.02, CV = 3.5%). The 3D IVUS imaging facilitated the identification of neck configuration.

CONCLUSIONS

Automated analysis of IVUS images allows accurate measurement of the lumen diameter of proximal and distal AAA necks and gives length measurements comparable to those of manual analysis. Longitudinal display of IVUS images aids in the elucidation of neck anatomy.

A simple technique to improve the accuracy of proximal AAA endograft deployment

PURPOSE

To report a technique for overcoming the positioning errors caused by angulation and rotation of the proximal aortic neck when anteroposterior fluoroscopic imaging is used during endograft deployment.

TECHNIQUE

Aortic neck angulation and rotation were measured preoperatively using spiral computed tomographic angiography in sagittal and axial projections. Before proximal graft deployment, the proximal end of the endograft was centered in the field of view, and the position of the C-arm was adjusted to the aortic neck angulation. Using this technique, optimal positioning of the endograft relative to the true position of the renal arteries can be achieved.

CONCLUSIONS

C-arm angulation and rotation is helpful in facilitating perfect positioning for an optimal seal between the endograft and the infrarenal aortic neck.

Maximal aneurysm diameter follow-up is inadequate after endovascular abdominal aortic aneurysm repair

BACKGROUND

follow-up after endovascular abdominal aortic aneurysm repair (EAR) generally consists of serial diameter measurements. A size change after EAR, however, is the consequence of alterations of the excluded aneurysm sac volume.

OBJECTIVE

to assess the agreement between diameter measurements and volume measurements after endovascular aneurysm repair.

PATIENTS AND METHODS

from 53 consecutive patients scheduled for EAR, follow-up of at least 6 months was available in 35 patients. CTA was performed on all patients at discharge, at 6 months and yearly thereafter. The resulting 113 datasets were processed on a workstation in a blinded and random order. Maximal aneurysm diameter (DMAX) was measured along the central lumen line. Total aneurysm volume was measured by manual segmentation. All measurements of an individual patient were compared with each other, resulting in 149 comparisons. The significance of individual size changes was classified based on the 95% confidence limits of the intra-observer variability, using difference-of-means analysis. DMAX changes were compared to volume changes.

RESULTS

in 37% of the comparisons, discordance was found between DMAX and volume measurements. A decrease in aneurysm size was missed using DMAX in 14% of cases and an increase in 19% of cases.

CONCLUSION

aneurysm size changes after EAR are not noticed using maximal diameter measurements in over one-third of cases.

Mortality and morbidity rates after conventional abdominal aortic aneurysm repair

AIM

To grade and analyse by levels of evidence the mortality and morbidity rates of elective abdominal aortic aneurysm (AAA) surgery as reported over the past 12 years.

METHODS

Articles on elective AAA surgery published between 1985 and 1996 were retrieved and classified into 5 levels of evidence. Level 1 contains prospective studies and is subdivided into population-based (Level 1a) and hospital-based (Level 1b) studies. Level 2 includes retrospective studies, subdivided into population-based (Level 2a), hospital-based (Level 2b), and hospital-based studies concerning a specified group of selected patients (Level 2c). Operative mortality and systemic and local/vascular complication rates and 95% confidence intervals were calculated per level of evidence.

RESULTS

Seventy-two articles describing a total of 37,654 patients could be included: 2 level 1a studies (patient total: 692), 9 Level 1b studies (patient total: 1,677), 13 Level 2a studies (patient total 21,409), 32 Level 2b studies (patient total: 12,019), and 16 Level 2c studies (patient total: 1,857). The mean 30-day mortality rates of the two population-based levels were similar: 8.2% (6.4%-10.6%) for the prospective (1a) and 7.4% (7.0%-7.7%) for the retrospective series (2a). These figures were significantly higher than the remarkably similar hospital-based mortality rates: 3.8% (3.0%-4.8%) for the prospective (1b), 3.8% (3.5%-4.2%) for the retrospective (2b), and 3.5% (2.8%-4.4%) for selected patient group studies (2c). The most frequent complication was of cardiac origin. In the population-based series the cardiac complication rate was 10.6% (8.5%-13.2%) and 11.1% (9.1%-13.6%) for Levels 1a and 2a respectively. This compared well with the 12.0% (10.5%-13.9%) for the prospective, hospital-based series (Level 1b). The cardiac complication rates in the retrospective, hospital-based studies was significantly lower: 8.9% (8.4%-9.5%) and 6.1% (4.9%-7.6%) for Levels 2b and 2c respectively.

CONCLUSION

There is a clear and consistent disagreement in reported mortality rates between hospital-based and population-based studies of elective AAA-surgery. Prospective studies give the best documentation of postoperative morbidity.

Dilatation of the proximal neck of infrarenal aortic aneurysms after endovascular AAA repair

OBJECTIVES

to assess size changes of the proximal aortic neck after endograft placement.

METHODS

since 1994, 54 consecutive patients have undergone abdominal aortic aneurysm (AAA) repair with the Endovascular Technologies (EVT) endograft. The study group comprised the 33 patients who had completed at least six months of the prospective follow-up protocol. The pre-, postoperative and follow-up helical computed tomography (CT) angiograms (CTAs) were processed on a workstation. The proximal neck dimensions were measured perpendicular to the central lumen line of the aortic neck. The cross-sectional area was measured at the proximal attachment system and at 1 cm proximal to the renal arteries.

RESULTS

while the dimensions of suprarenal aorta did not change, a significant dilatation of the proximal neck was found. The median increase was 10.3% at 6 months and 15.5% at 12 months. No correlation could be found between the amount of dilatation and pre- or postoperative neck-size, graft diameter and amount of graft-oversizing.

CONCLUSION

the infrarenal aortic neck demonstrates continued dilatation during follow-up after endograft placement.

The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group

BACKGROUND

Cardiovascular complications are the most important causes of perioperative morbidity and mortality among patients undergoing major vascular surgery.

METHODS

We performed a randomized, multicenter trial to assess the effect of perioperative blockade of beta-adrenergic receptors on the incidence of death from cardiac causes and nonfatal myocardial infarction within 30 days after major vascular surgery in patients at high risk for these events. High-risk patients were identified by the presence of both clinical risk factors and positive results on dobutamine echocardiography. Eligible patients were randomly assigned to receive standard perioperative care or standard care plus perioperative beta-blockade with bisoprolol.

RESULTS

A total of 1351 patients were screened, and 846 were found to have one or more cardiac risk factors. Of these 846 patients, 173 had positive results on dobutamine echocardiography. Fifty-nine patients were randomly assigned to receive bisoprolol, and 53 to receive standard care. Fifty-three patients were excluded from randomization because they were already taking a beta-blocker, and eight were excluded because they had extensive wall-motion abnormalities either at rest or during stress testing. Two patients in the bisoprolol group died of cardiac causes (3.4 percent), as compared with nine patients in the standard-care group (17 percent, P=0.02). Nonfatal myocardial infarction occurred in nine patients given standard care only (17 percent) and in none of those given standard care plus bisoprolol (P<0.001). Thus, the primary study end point of death from cardiac causes or nonfatal myocardial infarction occurred in 2 patients in the bisoprolol group (3.4 percent) and 18 patients in the standard-care group (34 percent, P<0.001).

CONCLUSIONS

Bisoprolol reduces the perioperative incidence of death from cardiac causes and nonfatal myocardial infarction in high-risk patients who are undergoing major vascular surgery.

Preoperative imaging of the aortoiliac anatomy in endovascular aneurysm surgery

Endovascular aneurysm repair (EAR) requires precise measurement of aortoiliac lengths and diameters to select the most suitable endograft. A combination of computed tomography (CT) scanning and contrast arteriography is usually applied for this purpose. We have investigated whether spiral CT angiography with specialized data processing (CTA) may replace these imaging methods as a sole technique for sizing of endografts for EAR and present these data as a background for discussion of preoperative imaging before EAR. Typical measurements for EAR were performed using CTA, conventional CT scanning, and arteriography. The resulting measurements were compared, and their consequences on graft selection were studied. Graft diameters based on arteriography were too small in 62% of the patients, as compared with CTA. The difference in length sizing between CTA and arteriography never exceeded 1 cm. A similar graft diameter was selected by conventional CT scan and CTA in 81% of the patients, whereas minor graft oversizing by conventional CT scan was found in 14% of the patients. Length sizing by conventional CT scanning resulted in underestimation of graft length in 91% of the patients. Neither conventional CT scanning nor arteriography is adequate as a sole preoperative radiological investigation for endograft sizing in EAR. Spiral CTA with special processing combines the specific advantages of both imaging techniques and should be regarded as the method of first choice for this purpose.

Length measurements of the aorta after endovascular abdominal aortic aneurysm repair

BACKGROUND

successful endovascular repair of abdominal aortic aneurysms (AAA) generally leads to a decrease in aneurysm size. Theoretically, this may lead to foreshortening of the excluded segment. If so, vertically rigid endografts may dislocate over time and cover renal or hypogastric arteries.

AIM

to assess length changes of the infrarenal aorta after endovascular AAA exclusion.

PATIENTS AND METHODS

forty-four consecutive patients were scheduled for the EndoVascular Technologies endograft, a vertically non-rigid prosthesis which would potentially accommodate longitudinal changes. Twenty-four patients had completed at least 6 months of follow-up. In 18/24 patients a decrease in size was established by aneurysm volume measurements at 6 months' follow-up. Helical computer tomography (CT) angiograms were processed on a workstation. Aortic lengths were measured along the central lumen line from the lower renal artery orifice to the native aortic bifurcation. The computer tomography angiogram (CTA) reconstruction thickness of 2 mm yields at least a 4-mm error for each length measurement.

RESULTS

in the shrinking aneurysm group, the median length change was 0 mm (range -9 mm to +4 mm) at 6 months' follow-up (n =18) and also 0 mm (range -7 mm to +4 mm) at 12 months' follow-up ( n =10). In 16/18 patients, length changes remained within the measurement error range of 4 mm.

CONCLUSION

in this group of shrinking aneurysms after endovascular AAA repair, foreshortening of the excluded aortic segment appears not to be a clinically significant problem.

Mid-term fixation stability of the EndoVascular Technologies endograft. EVT Investigators

AIM OF THE STUDY

to determine the positional stability of the EndoVascular Technologies (EVT) endograft after endovascular aneurysm repair during morphologic changes of the abdominal aorta during follow-up.

PATIENTS AND METHODS

all patients treated worldwide with an EVT endograft with an adequate postoperative and at least 12 months postoperative CT scan were included (n=125). Endograft migration was investigated by recording the position of the endograft attachment systems relative to the renal arteries and the aortic or iliac bifurcations. The vertical body axis served as a scale to quantify migration. Aortic cross-sectional areas were measured in the suprarenal aorta and in the proximal and distal aneurysm necks. Length changes of the infrarenal aorta during follow-up were measured, comparing the distance between the left renal artery and the aortic bifurcation.

RESULTS

the median follow-up was 24 months (range 12-48 months). Graft migration was identified in 4 out of 125 patients (3%). Significant infrarenal aortic dilation was observed at the proximal and distal aneurysm neck during follow-up. However, aortic neck dilation was not associated with endograft migration. The length of the infrarenal aorta did not change significantly after endovascular repair.

CONCLUSION

fixation by stents containing hooks of the EVT design appear to be effective in preventing migration of endografts with an unsupported trunk for up to four years. A stable position was maintained in spite of changes in cross-sectional areas of the aneurysm neck.

Deformation of self-expanding stent-grafts complicating endovascular peripheral aneurysm repair

PURPOSE

To demonstrate the deformation of self-expandable stents after endovascular repair of peripheral aneurysms.

METHODS AND RESULTS

The Corvita Endoluminal Graft was used to treat a traumatic false aneurysm of the right subclavian artery and a common iliac artery aneurysm in 2 patients. In the subclavian case, the stent-graft showed a "cigar-shaped" deformation with hemodynamically significant stenoses at the proximal and distal ends at 3 months. In the second case, the same type of deformity was noted only 1 day after implantation. Two months later, the stent-graft occluded, necessitating surgical repair.

CONCLUSIONS

Both cases demonstrate the possibility of stent deformation of self-expanding stent-grafts implanted at arterial sites not subject to external compression.

Is organ ischaemia a determinant of the outcome of operations for suprarenal aortic aneurysms?

OBJECTIVE

To find out if morbidity and mortality after thoracoabdominal approaches for suprarenal aortic aneurysms are related to the duration of organ ischaemia.

DESIGN

Retrospective study.

SETTING

University hospital, The Netherlands.

SUBJECTS

72 operations for suprarenal aortic aneurysms.

MAIN OUTCOME MEASURES

Duration of organ ischaemia, morbidity and mortality.

RESULTS

There were 72 patients with 3 group A (Crawford type III), 10 group B (Crawford type IV), 37 group C (supracoeliac), and 22 group D (suprarenal) aneurysms. Median duration of ischaemia was 57 minutes for both the spinal cord and the mesenteric arteries, and 59 and 63 minutes for the right and left renal arteries, respectively. There were 52 major complications in 33 patients. Mesenteric ischaemia of longer than 60 minutes was associated with a significant higher complication rate (21/32, 66% compared with 13/40, 33%, p = 0.01). Spinal cord ischaemia of longer than 60 minutes was not associated with a significantly increased incidence of paraplegia (2/40 compared with 6/32, p = 0.13).

CONCLUSIONS

We conclude that with surgery for suprarenal aneurysms a significant higher complication rate is noted with increased duration of mesenteric ischaemia.

Influence of study design on reported mortality and morbidity rates after abdominal aortic aneurysm repair

BACKGROUND

The mortality and morbidity rates of elective abdominal aortic aneurysm (AAA) surgery, as reported over the past 12 years, were graded and analysed by levels of evidence.

METHODS

Articles on elective AAA surgery published between 1985 and 1996 were retrieved and classified into five levels of evidence. Level 1 contains prospective studies and is subdivided into population-based (level 1a) and hospital-based (level 1b) studies. Level 2 includes retrospective studies, subdivided into population-based studies (level 2a), hospital-based studies (level 2b) and hospital-based studies concerning a specified group of selected patients (level 2c). Operative mortality and systemic and local/vascular complication rates with 95 per cent confidence intervals were calculated for each level of evidence.

RESULTS

Seventy-two articles describing a total of 37 654 patients could be included: two level 1a studies (692 patients), nine level 1b studies (1677 patients), 13 level 2a studies (21 409 patients), 32 level 2b studies (12019 patients) and 16 level 2c studies (1857 patients). The mean 30-day mortality rates of the two population-based levels were similar: 8.2 (95 per cent confidence interval 6.4-10.6) per cent for the prospective (la) and 7.4 (7.0-7.7) per cent for the retrospective (2a) series. These figures were significantly higher than the remarkably similar hospital-based mortality rates: 3.8 (3.0-4.8) per cent for the prospective (1b), 3.8 (3.5-4.2) per cent for the retrospective (2b) and 3.5 (2.8-4.4) per cent for selected patient group (2c) studies. The most frequent complication was of cardiac origin. In the population-based series the cardiac complication rates were 10.6 (8.5-13.2) and 11.1 (9.1-13.6) per cent for levels 1a and 2a respectively. This compared well with 12.0 (10.5-13.9) per cent for the prospective hospital-based series (level 1b). The cardiac complication rates in the retrospective hospital-based studies were significantly lower: 8.9 (8.4-9.5) and 6.1 (4.9-7.6) per cent for levels 2b and 2c respectively.

CONCLUSION

There is a clear and consistent disagreement in reported mortality rates between hospital-based and population-based studies of elective surgery for AAA. Prospective studies give the best documentation of postoperative morbidity.

The Utrecht endovascular technologies (EVT) experience

The aim of this report is to review the single center, clinical experience with the Endovascular Grafting System (EGS/Ancure Endovascular Technologies, Menlo Park, Calif, USA) in the Netherlands. The program was started in January 1994 and at the moment of writing consists of 35 patients on an intention-to-treat basis. From January 1994 through January 1995, 11 patients (Group I) were treated. In January 1995, hook breaks of the attachments system were reported and consequently the EVT program was discontinued from January 1995 through January 1996, pending renewal of FDA approval. From January 1996 through October 1997, another 24 patients were treated with the redesigned EGS-II (group II). Patient and aneurysm characteristics are summarized in the table I. All patients were ASA class I-III and were scheduled for elective repair of asymptomatic infrarenal AAA. No compassionate cases or high-risk patients were included in this study. All patients were entered into a prospective follow-up program, including the following studies postoperatively, at 6 weeks, 6 and 12 months, and yearly thereafter. Duplex, plain X-rays and CT-angiography (CTA) with cine-mode post-processing. In Group I, there were 10 tubes and 1 one bifurcated system. The bifurcated EGS was explanted on the 1st postoperative day due to a significant proximal leak and lower back pain. Of the 10 tube grafts, 3 have been explanted. In one case (day 2) due to a proximal endoleak, in another case (at 12 months) due to persistent aneurysm growth with a distal endoleak and in the third case (at 3 years) due to a recurrent endoleak with aneurysm growth after initial spontaneous closure and shrinkage. These conversions and their postoperative courses were uneventful. In two cases, proximal hook breaks were detected after 6 and 15 months, but in both patients the aneurysm diameter has decreased and follow-up exceeds 3 years. Another 2 patients are alive more than 3 years after the procedure without signs of endoleak, but in one the aneurysm failed to shrink, probably due to complete circular calcification. The other 3 patients have died during follow-up (6, 11, and 20 months) from diseases unrelated to the aneurysm: one pancreatic carcinoma that had been missed on CT angiography, one respiratory failure and one myocardia infarction. Overall, at three years 4 out of 11 Group I patients are alive and well, with an excluded aneurysm. In Group II, there were 17 bifurcated grafts, 5 tubes, and 2 patients in whom a tube graft could not be placed because the introduction sheath could not pass the iliac artery. In one case, this was complicated by a tear in the external iliac artery. At conversion, both patients needed a conventional bifurcated graft, one extending into the groin to bypass the damaged external iliac artery. In a third patient, a tear in the distal aortic neck was detected intraoperatively after tube endograft placement. Conversion was performed in the same session. Of the 21 endografts that left the operating room, 2 have been explanted. In one case (day 5) a tear of the proximal neck was detected. Conversion to conventional repair involved suprarenal clamping which led to multiple organ failure in this 82-y/o patient who ultimately died. In the other the bifurcated endograft showed a distal endoleak on one side, which was locally repaired by an iliac interposition graft. Three months later a proximal and left distal endoleak was diagnosed, his aneurysm had not decreased in size, and his iliac interposition graft had occluded. He was then successfully converted to a conventional bifurcated graft. In 9 of the remaining 15 bifurcated and 4 tube grafts, endoleak was detected on the postoperative CTA. Five appeared to have closed spontaneously at 6 weeks, conversion has been scheduled in one, and 3 small endoleaks are being observed (2 weeks, 6 and 12 months). In all 35 attempts, there were four cases of injury to the common femoral artery at the introduction site, wh

The role of infrarenal aortic side branches in the pathogenesis of endoleaks after endovascular aneurysm repair

AIM

To investigate the relation between the number of preoperative patent side branches and the presence or absence of postoperative endoleaks, and to study the fate of patent branches after operation.

PATIENTS AND METHODS

Thirty consecutive patients were included. Cine mode viewing of axial CT angiography images was applied to detect infrarenal aortic side branches. The position of side branches relative to the renal arteries, branch patency and run-off pathways were studied.

RESULTS

A total of 160 patent side branches were found. All patients had two or more patent side branches. A patent inferior mesenteric artery was found in 22/30 patients (73%). Postoperative CT scans revealed major endoleaks in five patients (16%) and minor endoleaks in eight (27%). There was no significant difference in the number of preoperative patent side branches in patients with a completely thrombosed aneurysm sac (five; range 2-8) compared to patients with postoperative endoleaks (six; range 3-9; p = 0.12). Backbleeding from patent side branches as the sole cause of endoleak was seen in one patient only (3.3%).

CONCLUSION

Postoperative endoleaks are not related to the number of preoperative patent side branches. In patients without endoleaks, contrast enhancement of side branches was repeatedly seen in the vicinity of the aneurysm wall. Although close follow-up of these branches is warranted, they did not affect the outcome of endovascular aneurysm repair.

The EASI project--improving the effectiveness and quality of image-guided surgery

In recent years, advances in computer technology and a significant increase in the accuracy of medical imaging have made it possible to develop systems that can assist the clinician in diagnosis, planning, and treatment. This paper deals with an area that is generally referred to as computer-assisted surgery, image-directed surgery, or image-guided surgery. We report the research, development, and clinical validation performed since January 1996 in the European Applications in Surgical Interventions (EASI) project, which is funded by the European Commission in their "4th Framework Telematics Applications for Health" program. The goal of this project is the improvement of the effectiveness and quality of image-guided neurosurgery of the brain and image-guided vascular surgery of abdominal aortic aneurysms, while at the same time reducing patient risks and overall cost. We have developed advanced prototype systems for preoperative surgical planning and intraoperative surgical navigation, and we have extensively clinically validated these systems. The prototype systems and the clinical validation results are described in this paper.

In vivo experiments with mesothelial cell seeded ePTFE vascular grafts

OBJECTIVES

To investigate the influence of mesothelial cell (MC) seeding on patency and neointimal formation of small diameter ePTFE grafts in a canine model.

MATERIALS AND METHODS

MC were isolated from the omentum, cultured, seeded on fibronectin-coated ePTFE grafts (4 cm, 4 mm ID), and implanted in the carotid artery of five Beagle dogs. Each dog also received a non-seeded control graft. Patency was assessed by palpation immediately after implantation, and non-invasively by magnetic resonance angiography (MRA) after 1 week and just prior to sacrifice (4 weeks). Intimal thickness was quantified on histological sections by use of computer-aided morphometry.

RESULTS

All grafts were patent after implantation. After 1 week, MRA showed the loss of lumen diameter in two seeded grafts. After 4 weeks, two seeded grafts were occluded, one seeded graft was severely stenosed, and all others were without angiographic lumen reduction. Histology and morphometry confirmed that two seeded grafts were occluded, and demonstrated that the other three seeded grafts showed significantly more intima formation (0.22-1.34 mm) than the control grafts (< 0.08 mm; p < 0.01).

CONCLUSIONS

The MC seeding process decreases patency and increases neointimal formation of small diameter ePTFE grafts in dogs and does not seem to be useful for reduction of graft thrombogenicity.

Flow volume changes in the major cerebral arteries before and after carotid endarterectomy: an MR angiography study

OBJECTIVES

To characterise changes in blood flow in the major cerebral arteries before and after carotid endarterectomy (CEA).

DESIGN

Prospective, non-randomised, observational study.

MATERIALS

Twenty-nine patients with symptomatic, unilateral, severe stenosis of the internal carotid artery (ICA) undergoing CEA and 16 control subjects.

METHODS

Quantitative blood flow volume measurement using magnetic resonance angiography (MRA) on both symptomatic and asymptomatic sides in the common carotid artery (CCA), ICA, and middle cerebral artery (MCA) and in the basilar artery, 1 week before and 3 months after CEA.

RESULTS

Before CEA, blood flow was decreased on the symptomatic side in the CCA, ICA, and MCA as compared to the contralateral side and to control subjects (p < 0.001). After CEA, flow on the symptomatic side in the CCA, ICA, and MJCA was increased to normal level (p < 0.005) and flow in the basilar artery was decreased to normal level (p < 0.005).

CONCLUSIONS

These results demonstrate that arterial blood flow to the symptomatic hemisphere is decreased in patients with severe ICA stenosis. CEA restores arterial blood flow, rendering cerebral blood flow less dependent on collateral flow through the basilar artery. MRA flow measurements provide new insight in the complex haemodynamics of the extra- and intracranial circulation.

The efficacy of transfemoral endovascular aneurysm management: a study on size changes of the abdominal aorta during mid-term follow-up

OBJECTIVES

The aim of this study was to assess efficacy of transfemoral endovascular aneurysm management (TEAM) during mid-term follow-up.

DESIGN

Prospective multicentre study.

MATERIALS AND METHODS

In 26 patients treated by a Tube Endograft, the pre- and postoperative contrast enhanced computed tomography (CT) images were reviewed in a blinded fashion. Aortic diameters were measured at the coeliac trunk, the inferior and superior aneurysm neck and the level of the maximal aneurysm size. The changes in diameter were related to the presence or absence of an endoleak.

RESULTS

The median follow-up was 12 months. In 10 patients an endoleak was found. Three endoleaks sealed spontaneously within 30 days after operation. All aneurysms with persistent endoleaks expanded, at a median rate of 0.30 mm per month. Four patients were converted between 9 and 14 months after TEAM. Aneurysms excluded by the endoprosthesis showed a median shrinkage of 0.41 mm per month. The inferior aneurysm neck demonstrated significant growth during follow-up, unrelated to endoleaks.

CONCLUSIONS

This study demonstrated the efficacy of TEAM in discontinuing the process of aneurysm expansion. Complete seal of the aneurysm sac after TEAM leads to shrinkage or arrest of growth of the aneurysm, while persistent endoleak is associated with progressive expansion.

Preoperative sizing of grafts for transfemoral endovascular aneurysm management: a prospective comparative study of spiral CT angiography, arteriography, and conventional CT imaging

PURPOSE

To define the impact of spiral computed tomographic angiography (CTA) with image reconstruction on graft selection for Transfemoral Endovascular Aneurysm Management (TEAM) by comparing it to conventional computed tomography (CT) and contrast arteriography.

METHODS

Twenty-one candidates for TEAM were included. The diameters of the superior and inferior aneurysm necks and lengths between the graft attachment sites were measured using the three imaging techniques. These measurements and their consequences on graft selection were studied.

RESULTS

The difference in length sizing between spiral CTA and arteriography never exceeded 1 cm; however, lengths measured by conventional CT scanning resulted in underestimation of graft length in 91% of patients. Graft diameters were chosen too small in 62% of the patients when based on arteriographic diameter measurements. A graft of similar diameter was selected by spiral CTA and conventional CT scanning in 81% of the patients, while minor oversizing by conventional CT scanning was found in 14%.

CONCLUSIONS

Neither conventional CT scanning nor arteriography is adequate as a sole preoperative radiological investigation for TEAM graft sizing. Spiral CTA with image processing produces all information required for selection of the optimal graft size and should be regarded the method of first choice for this purpose.

Computed tomographic angiographic imaging of abdominal aortic aneurysms: implications for transfemoral endovascular aneurysm management

PURPOSE

To describe anatomic features pertinent to patient selection and graft design for transfemoral endovascular aneurysm management (TEAM) of the infrarenal aorta using computed tomographic (CT) angiography.

METHODS

A prospective noncomparative analysis of 102 spiral CT scans of the abdominal aorta of patients with abdominal aortic aneurysms was performed. From the original CT data set, slices were reconstructed perpendicular to the vessel axis (central lumen line) at a 10 mm interval. In these reconstructed slices, diameter measurements were performed. Vessel length was measured along the central lumen line. In each patient possibilities for TEAM were analyzed.

RESULTS

Because of technical reasons, 36 scans were excluded from the analysis. Of the remaining 66 patients, 18 could potentially be treated with a bifurcated endovascular device. The infrarenal aortic diameter-to-iliac artery diameter ratio was less than 2 in most patients. The vessel segments judged to be adequate for endovascular graft anchoring had a noncylindrical shape in the majority of cases.

CONCLUSION

Only a minority of patients with abdominal aortic aneurysms can at this stage be treated with an endovascular graft. The ideal endovascular graft should be a combination of rigid and flexible components. The proximal and distal attachment systems should have some flexibility with an intrinsic maximum diameter while the midsection of the graft can be relatively rigid.

CT-angiography of abdominal aortic aneurysms after transfemoral endovascular aneurysm management

OBJECTIVE

To evaluate short-term effect of Transfemoral Endovascular Aneurysm Management (TEAM) on aortic diameters and volumes after aneurysm exclusion, using CT-angiography.

DESIGN

Analysis of preoperative, 1 week postoperative and 6 months postoperative CT measurements.

SETTING

University Hospital.

MATERIALS

Nine patients treated with an endovascular tube prosthesis.

CHIEF OUTCOME MEASURES

True cross-sectional diameters of the aorta and the aneurysm, volume of the infrarenal aortic lumen, of the thrombus and of the iliac arteries and length of the aorta and of the endovascular prosthesis.

MAIN RESULTS

CT-angiography detected shrinkage of the aneurysm in seven patients. Aneurysm growth was observed in one patient with persistent flow outside the graft and in one patient with fully thrombosed aneurysm sac. In the two patients with increasing thrombus volume, the volume of the aortic lumen decreased.

CONCLUSIONS

Although successful aneurysm exclusion can be confirmed by maximum aneurysm diameter measurement, changes in aortic lumen volume and thrombus volume may be more appropriate to discriminate successful from failed exclusion.

Continuous pulse amplitude monitoring of infrainguinal bypass grafts in the first 24 postoperative hours

To evaluate continuous pulse amplitude monitoring (CPAM) as a method for early postoperative graft surveillance following infrainguinal bypass surgery, a prospective observational study was carried out in 34 consecutive infrainguinal bypass grafts. CPAM tracings were compared with pre- and postoperative pulse palpation, ankle/brachial index (ABI) measurements, and pulse volume recordings (PVR). The utility of each method was defined by its ability to demonstrate graft patency in the first 24 hours. Pulse palpation was considered a useful monitoring tool if a postoperative pedal pulse was found in the absence of palpable preoperative pulses. The ABI qualified in this respect if a postoperative increase of at least 0.25 could be demonstrated; for PVR tracings an increase of at least one category was required. The utility of CPAM was established by an increase of at least 5 mm compared to the preoperative values. There were no early graft failures. We were therefore unable to calculate the ability of the studies to predict graft failure. The percentages (95% confidence limits) for which pulse palpation, ABI, and PVR were found capable of demonstrating graft patency were 50% (range 34% to 66%), 53% (range 36% to 70%), and 71% (range 54% to 83%), respectively. CPAM appeared to be far superior to these three methods with a utility of 94% (range 81% to 98%; p < 0.05). Patient and operator acceptability of CPAM was high. Skin pressure problems are a potential risk if the CPAM probe is left attached to the skin for more than 24 hours. CPAM was a valuable and reliable means of monitoring infrainguinal vascular reconstructions. Apart from being inexpensive, continuous, objective, and simple, CPAM is noninvasive and painless. It is advisable to remove the probe 24 hours after surgery, when the most crucial period for graft monitoring has passed.

Avoiding infrainguinal bypass wound complications in patients with chronic renal insufficiency: the role of the anatomic plane

OBJECTIVE

To study the factors leading to wound problems in patients with chronic renal insufficiency (CRI) with emphasis on subcutaneous vs. deep placement of grafts.

METHODS

The outcomes of patients undergoing an infrainguinal bypass with preoperative CRI (serum creatinine > or = 2.0 mg/dl) were reviewed. Surgical site infection (SSI) was classified as superficial or deep according to the Centres for Disease Control standards.

RESULTS

Forty-two patients underwent a total of 47 infrainguinal bypasses for ischaemic rest pain or tissue loss. The graft location was partially or predominantly subcutaneous in 21 limbs (Group I) and 26 grafts were positioned in the anatomic or subfascial planes (Group II). In Group I, seven early (< 30 days postoperative), one intermediate (4-6 weeks postoperative), and one late (> 6 weeks postoperative) SSI's were found (9/21, 43%). In three of these patients the graft was exposed and two required removal. In contrast, only two early and one intermediate SSI's (3/26, 12%) were noted in Group II (p = 0.02). A logistic regression analysis, with twelve possible covariables wound healing, confirmed the subcutaneous location to be the only controllable factor significantly predicting SSI (relative risk = 11.6, p = 0.01).

CONCLUSIONS

The infrainguinal bypass in patients with CRI is associated with a high incidence of wound complications. In our retrospective series, the presence of a vascular conduit in the subcutaneous plane was connected with a higher rate of SSI. Despite the growing trend toward the use of the in situ bypass, CRI may represent a circumstance where deeply placed grafts should be used preferentially.

Intraoperative determinants of infrainguinal bypass graft patency: a prospective study

OBJECTIVES

To evaluate a number of currently available methods for intraoperative assessment of infrainguinal bypass grafts (IBG) in terms of detecting technical errors and predicting graft failure.

DESIGN

Prospective open clinical study.

METHODS

Forty-nine patients undergoing 54 consecutive IBG were studied. Intraoperatively, the following measurements were performed: distal pulse palpation (DPP), continuous wave Doppler (CWD), pulse volume recording (PVR), and ultrasonic volume flowmetry (UVF), followed by intraoperative angiography of the entire graft and runoff vessels. The outflow resistance was graded according to the guidelines of the Society for Vascular Surgery and International Society for Cardiovascular Surgery (SVS/ISCVS runoff score). Graft patency was determined noninvasively (PVR, colour Duplex) up to 12 months following surgery. Predictive values and likelihood ratios for the intraoperative tests in detecting a technical problem during the bypass procedure and in predicting early graft failure were calculated.

RESULTS

There were five immediate revisions for problems detected intraoperatively. Angiography did not identify any additional problems but assisted in the correct location of the problems detected by the other tests. DPP and CWD were highly significant indicators of the need for revision with likelihood ratios for a positive test of 14.7 (p < 0.01) and 12.3 (p < 0.01) respectively. PVR did not achieve statistical significance in this respect. None of the intraoperative tests was a statistically significant predictor of early graft failure. The SVS/ISCVS runoff score, on the other hand, predicted early failure with a PPV of 33% (likelihood ratio for a positive test of 4.9, p < 0.05). None of the grafts with a perfect SVS/ISCVS runoff score (n = 39) failed in the first postoperative month.

CONCLUSIONS

Simple CWD insonation of graft and anastomoses is the best intraoperative indicator for technical inadequacies after IBG. Routine intraoperative angiography is not necessary and intraoperative anatomical imaging may be reserved for situations in which noninvasive documentation of technical success is absent. Contrary to the intraoperative haemodynamic test results, the SVS/ISCVS runoff score is a good predictor of early graft failure.

Femorodistal venous bypass evaluated with intravascular ultrasound

OBJECTIVE

To evaluate the feasibility of intravascular ultrasound imaging during femorodistal venous bypass procedures to assess qualitative and quantitative parameters of the greater saphenous vein and to detect potential causes for (re)stenosis and/or occlusion.

METHODS

Intravascular ultrasound data obtained from 15 patients were reviewed and compared with angiographic data.

RESULTS

Intravascular ultrasound enabled differentiation between normal and thickened vein wall. Venous side-branches could be located. Intact valves could be differentiated from valves disrupted by valve cutting. Patent anastomoses could be distinguished from anastomoses with some degree of obstruction. Intravascular ultrasound imaging of the inflow and outflow tracts revealed obstructive lesions, not evidenced angiographically. Quantitative analysis revealed that the median normal vein wall thickness (tunica intima and tunica media) was 0.25 mm (range 0.17-0.40 mm). The distinct vein wall thickening encountered in three patients measured 0.82, 0.95 and 1.06 mm, respectively, and was associated with narrowing in two patients. In five of 15 patients intravascular ultrasound findings altered surgical management.

CONCLUSION

Intravascular ultrasound is able to assess qualitative and quantitative parameters of the venous bypass and has the potential to influence surgical management based on morphologic and quantitative data.

Repeated resection of recurrent pulmonary metastatic soft tissue sarcoma

A series of nine patients who presented with recurrent lung metastases from soft tissue sarcoma after pulmonary surgery were treated with a second or further thoracotomy. There were no postoperative deaths. The median interval between the first and second thoracotomy was 23 months. Four patients underwent three or more operations. Post-thoracotomy survival was 24-209 months after the first thoracotomy. Five patients are alive after repeated thoracotomies more than 10 years after initial treatment of the primary STS. It is concluded that in cases of recurrent lung metastases from STS repeated thoracotomy is the best therapy if all metastases can be removed completely.

Surgical treatment of pulmonary metastases from soft tissue sarcomas: a retrospective study in The Netherlands

Sixty-seven of 87 patients with soft tissue sarcoma underwent complete resection of the metastases in the lung. In this retrospective study, follow-up was for a median of 24 months. The 5-year overall, crude and disease-free survival was 38%, 45%, and 41%, respectively. Twenty-seven (40%) patients developed a recurrence in the lung. Of the six prognostic variables, the only factor significantly related to disease-free survival was grade. It is concluded that surgery for lung metastases of soft tissue sarcoma should be considered as standard therapy when preoperative evaluation predicts a complete resection. By adding chemotherapy to surgery, an improvement of prognosis probably can be achieved.

Carotid endarterectomy for unstable and compelling neurologic conditions: do results justify an aggressive approach?

PURPOSE

In a retrospective study the outcome of 70 carotid endarterectomies (CEA) in 68 patients with neurologically unstable conditions or anatomically compelling findings on carotid angiography was examined to more accurately identify patients who might benefit from CEA in this setting.

METHODS

Out of a total of 1734 CEAs performed from 1978 to 1992, five groups of patients were selected: group A, stroke in evolution with tight stenosis (n = 5); group C, crescendo transient ischemic attacks (CTIA) continuing despite heparin (n = 14); group D, CTIA (above criteria) ceasing with heparin (n = 21); and group E, anatomically compelling situation on carotid angiography (n = 13). Data collected included preoperative and postoperative Neurologic Event Severity Score (NESS), CHAT classification, arteriosclerosis risk factors, demographics, and long-term overall and transient ischemic attack/stroke-free survival rates.

RESULTS

Risk factors and demographics were similar in all groups. By NESS criteria the conditions of 97.3% of patients in the neurologically unstable groups A to C were improved or stabilized after operation, with one deterioration (2.7%). All patients in group B either stabilized or improved. In group D, one patient's NESS deteriorated, resulting in 3.5% overall morbidity rate and no deaths for groups A to D. Follow-up showed an overall survival rate by Kaplan-Meier analysis equivalent to a matched control population, with 85% alive at 5 years. The cumulative TIA/stroke-free survival rate at 5 years was 75%.

CONCLUSIONS

In this retrospective series, CEA performed for compelling or unstable neurologic findings carried low morbidity and mortality rates. Early aggressive surgical therapy of neurologically unstable patients may be warranted because our results improved on the anticipated natural history of the conditions studied. Further clarification of proper patient selection is necessary before this principle can be applied broadly.

The effects of long-term graft preservation on intraoperative hemostatic changes in liver transplantation. A comparison between orthotopic and heterotopic transplantation in the pig

We compared hemostatic changes during OLT and HLT after various periods of graft storage, to investigate whether the host liver in HLT protects the recipient from hemostatic deterioration induced by severe graft storage damage. In particular, the mechanism of fibrinolytic deterioration was investigated. The effect of prostaglandin E1 (PGE1) on these parameters was also studied.

MATERIAL AND METHODS

69 pigs underwent either OLT (N = 32) or HLT (N = 37) with a graft stored for 2 hr (N = 31), 24 hr (N = 16), 48 hr (N = 7), or 72 hr (N = 15). PGE1 was given intravenously to both donor and recipient animals and was added to the preservation and flushing solutions. Fibrinolysis (euglobulin clot lysis time, t-PA activity and alpha 2-antiplasmin) and coagulation parameters (activated partial thromboplasmin time, prothrombin time, fibrinogen and platelet count) were measured at several intervals during transplantation.

STATISTICS

Univariate non-parametric tests were used for analysis of coagulation and fibrinolysis parameters. For the three main variables- i.e., the type of transplantation, the use of PGE1, and the preservation time, multiple regression analysis was performed.

RESULTS

Fibrinolytic activity increased during the anhepatic period of OLT. Graft reperfusion was followed by a rise in t-PA in both OLT and HLT. In HLT, t-PA quickly returned to normal, whereas a continuous increase was found in OLT. The coagulation parameters, in turn, remained unchanged during the anhepatic period and deteriorated in OLT compared to HLT. The duration of graft storage was directly related to the severity of the hemostatic changes, although this effect was more apparent in OLT than in HLT.

CONCLUSIONS

Changes in hemostasis are more pronounced in OLT than in HLT. This suggests that the host liver protects the recipient from the effects of graft storage damage, even after long preservation times. Early postreperfusion fibrinolytic activity was presumably due to t-PA release from the graft both in OLT and HLT. The further rise t-PA in OLT might be caused by the release of cytokines from the graft, that subsequently evoke endothelial t-PA release. In HLT, t-PA and cytokines may be cleared by the native liver. No positive or negative effect of PGE1 on coagulation or fibrinolysis parameters was noticed.

Ultra slow wave pressure variations in the anal canal before and after lateral internal sphincterotomy

Ultra slow waves (USW's) in the anal canal are discrete pressure fluctuations with a low frequency (1-2/minute) and high amplitude (> or = 10% above or below baseline resting pressure). To investigate the nature of these USW's, anorectal manometry was performed in 20 control subjects as well as in 58 patients presenting with anal fissure or symptomatic hemorrhoids, before and 2 weeks after lateral internal sphincterotomy. USW's could be demonstrated in two control subjects and in 29 patients. The median value of maximum anal resting pressure (MARP) in the two control subjects with USW's was significantly higher than the median MARP in the 18 control subjects without USW's (181.5 vs. 92 cm H2O, p < 0.001, two-tailed Mann-Whitney test). The same difference was found between MARP in patients with and without USW's (158 vs. 138 cm H2O, p < 0.05, two-tailed Mann-Whitney test). All patients were treated by means of lateral internal sphincterotomy (LIS). Two weeks after this procedure USW's had disappeared in half of the patients. The MARP in these patients was reduced to a level found in control subjects without USW's. This pressure reduction was significantly greater than in patients with persistent USW's (40% vs. 15%, p < 0.02, two-tailed Mann-Whitney test). Because USW's are associated with high MARP and disappear when such a high anal canal resting pressure is reduced by LIS to a level found in control subjects without USW's, it can be concluded that USW's are the manifestation of increased activity of the internal anal sphincter.

The effects of long-term graft preservation and prostaglandin E1 on intraoperative hemodynamic changes in liver transplantation. A comparison between orthotopic and heterotopic transplantation in the pig

The study aimed to compare the intraoperative hemodynamic changes during orthotopic liver transplantation (OLT) with those during heterotopic liver transplantation (HLT) after different durations of cold storage of the graft. The effect of prostaglandin E1 (PGE1) on these parameters was also studied. Sixty-nine female Yorkshire pigs underwent either OLT (n = 32) or HLT (n = 37) with a graft stored for 2 hr (n = 31), 24 hr (n = 16), 48 hr (n = 7), or 72 hr (n = 15). In 16 transplantations in the various groups, PGE1 was given intravenously to both donor and recipient animals and it was added to the preservation and flushing solutions. Univariate nonparametric tests (Mann-Whitney and Wilcoxon rank-sum) were used for analysis of cardiac output (CO), mean arterial pressure (MAP), left and right ventricular minute work (LVMW, RVMW), pulmonary capillary wedge pressure (PCWP), and systemic and pulmonary vascular resistance (SVR, PVR), at different intervals during the operative procedure. For the three main variables--i.e., the type of transplantation, the use of PGE1, and the preservation time, multiple regression analysis was performed. During HLT, portal vein clamping lowered MAP and CO, while during the anhepatic phase in OLT, SVR increased and CO dropped. After recirculation of the graft, an increase in PVR and a decrease in SVR were found in both OLT and HLT. At different stages of the surgical procedure, longer graft storage time diminished CO and MAP (P less than 0.001), especially in OLT. PGE1 appeared to reduce the cardiovascular reserves needed to compensate the changes after recirculation of the graft. The observed differences in intraoperative hemodynamics between OLT and HLT can partly be attributed to differences in operative techniques. Extension of the graft preservation period resulted in poor cardiac performance, more so in OLT than HLT. The native liver in HLT might be able to metabolize the presumed myocardial depressant factors, released by the graft upon reperfusion. Prostaglandin E1 did not protect against the reperfusion syndrome.

New aspects of heterotopic liver transplantation

In this report the history and clinical results of heterotopic liver transplantation (HLT) are reviewed and some special aspects of current research on HLT are high-lighted. The first laboratory experiments on liver transplantation were performed with auxiliary heterotopic grafts. The initial clinical results of HLT, however, were disappointing and orthotopic liver transplantation (OLT) evolved to be the procedure of choice. Of all the patients who received a heterotopic graft before 1980, only two survived. Since 1980, 50 HLTs are known to have been performed on 48 patients. Results of HLTs after 1986 are clearly better than earlier ones, and survival rates come within the range of those reported for OLT. Intraoperative fibrinolysis is found in the anhepatic phase of OLT, something which is absent in HLT. Tissue-type plasminogen activator (t-PA) is said to be responsible for this phenomenon, as well as for the postreperfusion hyperfibrinolysis. Parallel to the hemostatic changes, the intraoperative hemodynamic stability may be impaired by deleterious substances that arise during liver transplantation. Furthermore, the interaction between the two livers, the effect of HLT on portal pressure and hypersplenism, and the possible role of HLT in inborn errors of hepatic metabolism are described. Special attention is given to the treatment of acute hepatic failure. OLT, in an early phase of the disease, negates the possibility of spontaneous recovery, while delay of the decision to transplant may lead to further deterioration of the patient's clinical condition. As the procedure of HLT is reversible, the decision to transplant can be made more quickly. The clinical experience with HLT for acute liver failure is reported in detail.

A comparative study on changes in hemostasis in orthotopic and auxiliary liver transplantation in pigs

We compared blood loss and hemostasis in pigs which had undergone either orthotopic liver transplantation (OLT) (group A, n = 12) or auxiliary heterotopic partial liver transplantation (APLT) (group B, n = 11). Blood samples were taken at regular intervals during and after the operations. In both groups, nine animals survived longer than 24 h and data from these animals were used for analysis. Median (range) intraoperative blood loss was 825 ml (250-1500 ml) in OLT and 425 ml (300-750) in APLT (P less than 0.01). Routine clotting times, as the activated partial thromboplastin time, prothrombin time and thrombin time, showed no major intraoperative changes in either group. Fibrinogen levels decreased in both groups, but no significant difference was found between the two groups. The only significant difference between group A and B was a more sustained increase in fibrinolytic activity after graft recirculation in group A. Postoperatively, restoration of fibrinogen, antithrombin-III and alpha 2-antiplasmin levels was slightly faster in group B, resulting in significantly higher levels during the first day. We conclude that, in this animal model, APLT is associated with significantly lower blood loss and less severe fibrinolytic activity, than OLT. This difference might result from the lack of an anhepatic period and the reduced surgical trauma in auxiliary heterotopic liver transplantation.

Intraoperative hemodynamics in liver transplantation comparing orthotopic with heterotopic transplantation in the pig

The intraoperative hemodynamic changes and several graft function parameters were studied comparing orthotopic liver transplantation with auxiliary partial liver transplantation (APLT) in the pig. Thirty-one Yorkshire pigs (ca. 25 kg b.w.) were randomly allocated to OLT (n = 16) or APLT (n = 15). During the construction of portal anastomosis the median cardiac output dropped to 67% of the initial value in OLT and to 49% in APLT (P less than 0.02). Median duration of the portal flow interruption was shorter in APLT: 15 min versus 48 min in OLT (P less than 0.002). After unclamping of the aorta, the median systolic blood pressure dropped to 75 mmHg in OLT and to 90 mmHg in APLT (P less than 0.02). APLT is less time-consuming: median duration of transplantation was 128 min versus 165 min in OLT (P less than 0.002). SGOT levels were lower in APLT than in OLT (median SGOT on the first postoperative day 67 was IU/L versus 177 IU/L, P less than 0.002). It is concluded that APLT is a shorter procedure than OLT with a shorter portal flow interruption, being less offensive to the recipient.

Early and late results following choledochoduodenostomy and choledochojejunostomy

OBJECTIVE

To evaluate the results and complications of choledochoduodenostomy and choledochojejunostomy for benign and malignant disease and to review them in the light of the survival of the underlying disorders.

DESIGN

Retrospective analysis of medical records completed by a thorough inquiry for all patients who were lost to follow-up.

SETTING

Referrals for primary and secondary surgery for obstructive biliary disease to a university hospital from 1974-1987.

PATIENTS

After exclusion of patients who underwent a pancreaticoduodenectomy for cancer (Whipple procedure) 113 patients were included in the study (choledochoduodenostomy = CD,N = 64 and choledochojejunostomy = CJ, N = 49). A complete follow-up was achieved in 105 of 113 patients (93%).

INTERVENTIONS

An inquiry was made at the civil registration office if the patients were alive or not. The general practitioners of the patients who had died were contacted about the cause of death and the possible biliary symptoms preceding death and the patients who were still alive received a questionnaire which scrutinized all possible complications and side effects of the operation.

ENDPOINTS

Cholangitis, recurrence of the underlying disease or death of the patient.

MEASUREMENTS AND MAIN RESULTS

Operative mortality was 4.7% following CD and 12.2% following CJ. Procedure-related complications were found in 10.9% and 28.6% respectively. Recurrent cholangitis was not seen after CD and in three patients with a CJ (6.1%). Survival following biliodigestive anastomosis for benign obstruction was comparable for age and sex matched survival.

CONCLUSIONS

Although CD for choledocholithiasis has largely been replaced by endoscopic papillotomy and although the choice between the two procedures in malignant disease is most frequently dictated by the operative findings, we conclude that the choledochoduodenostomy is a relative simple operation with a low risk of cholangitis.

[Partial hepatectomy for benign or malignant liver diseases; experience in 94 patients]

In this retrospective study, we analyse the results of 94 partial liver resections performed between 1972 and January 1989. The resections were performed for malignant (48 patients) and benign (46 patients) liver tumours. Nine patients (9.6%) died of resection-related complications. Mortality was significantly lower in the patients with resections for benign liver tumours (2.2%) compared with patients with resections for malignant liver tumours (16.7%) (p less than 0.05). In the patients who survived the first 30 days, complications occurred in 25.9%. The 5-year survival of patients with a primary malignant liver tumour (57%) is significantly (p = 0.05) better than in patients with a secondary malignant liver tumour (19%). From this study we conclude that partial liver resections for primary or secondary liver tumours can be performed with an acceptable mortality and morbidity, and should be the therapy of choice for selected patients.

Intraoperative ultrasonography and ultrasonic dissection in liver surgery

The results of 79 liver resections performed in the period January 1972 to May 1987 are described with emphasis on the role of intraoperative ultrasonography and ultrasonic liver parenchyma dissection. The aim of this study is to see whether these adjunctive techniques are able to lower mortality and morbidity. Resections were done for benign disease (44 patients) or malignancy (35 patients). In these patients, 24 major and 55 minor liver resections were performed. Six of these patients (7.6%) died within 30 days after the operation. In one-third of the patients, complications occurred. In 25 of the 79 resections, intraoperative ultrasonography and ultrasonic liver dissection were used. Intraoperative ultrasonography changed the planned resection in eight patients. No statistically significant difference in morbidity and mortality could be found in patients operated with ultrasonic dissection, compared to patients with conventional dissection techniques. From this study, we conclude that intraoperative ultrasonography is a useful adjunct in liver surgery.

Adenocarcinoma in Barrett's oesophagus: an overrated risk

Barrett's oesophagus is a risk factor for the development of oesophageal cancer and for this reason annual endoscopic surveillance has been proposed. In this retrospective study of all patients with Barrett's oesophagus diagnosed in a 12 year period carcinoma had developed in only four patients. The incidence of oesophageal cancer in this series was one in 170 patient years, which means a 30-fold increase compared with the general population. The survival of patients with Barrett's oesophagus was not different, however, from an age and sex matched control population. It is concluded that systematic endoscopic surveillance of patients with Barrett's oesophagus is not indicated.

Consequences of failure of femoro-popliteal grafts for claudication

In order to evaluate the repercussions of failure of femoro-popliteal reconstruction undertaken for claudication the records of 219 patients with 251 femoro-popliteal conduits were reviewed. Autogenous Saphenous Vein graft (SV) was used in 109 limbs, Polytetrafluoroethylene graft (PTFE) in 101 and human umbilical vein graft (HUV) in 41. Primary patency rates after 3 years of follow-up of 72% for all grafts, 81% for SV-grafts, 84% for HUV-grafts and 59% for PTFE-grafts were calculated: the difference between SV-grafts and PTFE-grafts is statistically significant (P = 0.0047). Accordingly the authors advise against the use of PTFE-grafts in femoro-popliteal reconstruction. Including reinterventions secondary patency rates after 3 years of follow-up of 88% for all grafts, 86% for SV-grafts, 94% for HUV-grafts and 79% for PTFE-grafts were found: these differences were statistically not significant. Further analysis of the occluded grafts showed that in case of graft failure one or two re-operations are justified. The 12-months patency rate of reinterventions was 58%. Considering the life-expectancy and the natural history for the next five years of a patient with claudication the authors have become conservative towards femoro-popliteal reconstruction for claudication.