Femoral incision morbidity following endovascular aortic aneurysm repair

The Safety and Effectiveness of the Prostar XL Closure Device Compared to Open Groin Cutdown for Endovascular Aneurysm Repair

OBJECTIVE

The aim of this study is to compare the outcomes of percutaneous femoral closure with the Prostar XL for endovascular aneurysm repair (EVAR) to those of open femoral cutdown, and to evaluate factors which may predict the failure of percutaneous closure.

METHODS

Patients undergoing endovascular aneurysm repair for an infrarenal abdominal aortic aneurysm between 2005 and 2013 were included. Patient characteristics, anatomic femoral artery measurements, and postoperative complications were recorded retrospectively. Operator experience was defined with a cut-off point of >30 Prostar XL closures performed. Comparisons were made per access site.

RESULTS

A total of 443 access sites were included, with percutaneous closure used in 257 cases (58.0%) and open cutdown in 186 cases (42.0%). The complication rate was 2.7% for the percutaneous and 4.3% for the open cutdown group (P = .482). No significant differences between groups were found with respect to 30-day mortality, wound infections, thrombosis, seromas, or bleeding complications. Fourteen failures (5.4%) of percutaneous closure occurred. The success rates were similar for experienced and unexperienced operators (94.2% vs 95.5%, P = .768). Renal insufficiency was more common in the failed than in the successful percutaneous closure group (64.3% vs 24.7%, P = .003). Common femoral artery calcification or diameter, BMI, sheath size, or operator experience did not predict failure. No further complications were seen in follow-up CT at 1-3 years postoperatively.

CONCLUSION

The use of the Prostar XL is safe compared to open cutdown. The success rate is 94.6%. Operator experience, sheath size, obesity, or femoral artery diameter or calcification do not appear to predict a failure of percutaneous closure. Complications seem to occur perioperatively, and late complications are rare.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. Therefore, it is critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This Cochrane Review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. However, the technique may be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the previous Cochrane Review published in 2017.

OBJECTIVES

To evaluate the benefits and harms of totally percutaneous access compared to cut-down femoral artery access in people undergoing elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

We used standard, extensive Cochrane search methods The latest search was 8 April 2022.

SELECTION CRITERIA

We included randomised controlled trials in people diagnosed with an AAA comparing totally percutaneous versus surgical cut-down access endovascular repair. We considered all device types. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for ruptured AAAs and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. short-term mortality, 2. failure of aneurysm exclusion and 3. wound infection. Secondary outcomes were 4. major complications (30-day or in-hospital); 5. medium- to long-term (6 and 12 months) complications and mortality; 6. bleeding complications and haematoma; and 7. operating time, duration of intensive treatment unit (ITU) stay and hospital stay. We used GRADE to assess the certainty of evidence for the seven most clinically relevant primary and secondary outcomes.

MAIN RESULTS

Three studies with 318 participants met the inclusion criteria, 189 undergoing the percutaneous technique and 129 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report the method of randomisation, allocation concealment or preselected outcomes. The other two larger studies had few sources of bias and good methodology; although one study had a high risk of bias in selective reporting. We observed no clear difference in short-term mortality between groups, with only one death occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.06 to 36.18; 2 studies, 181 participants; low-certainty evidence). One study reported failure of aneurysm exclusion. There was one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 1 study, 151 participants; moderate-certainty evidence). For wound infection, there was no clear difference between groups (RR 0.18, 95% CI 0.01 to 3.59; 3 studies, 318 participants; moderate-certainty evidence). There was no clear difference between percutaneous and cut-down femoral artery access groups in major complications (RR 1.21, 95% CI 0.61 to 2.41; 3 studies, 318 participants; moderate-certainty evidence), bleeding complications (RR 1.02, 95% CI 0.29 to 3.64; 2 studies, 181 participants; moderate-certainty evidence) or haematoma (RR 0.88, 95% CI 0.13 to 6.05; 2 studies, 288 participants). One study reported medium- to long-term complications at six months, with no clear differences between the percutaneous and cut-down femoral artery access groups (RR 0.82, 95% CI 0.25 to 2.65; 1 study, 135 participants; moderate-certainty evidence). We detected differences in operating time, with the percutaneous approach being faster than cut-down femoral artery access (mean difference (MD) -21.13 minutes, 95% CI -41.74 to -0.53 minutes; 3 studies, 318 participants; low-certainty evidence). One study reported the duration of ITU stay and hospital stay, with no clear difference between groups.

AUTHORS' CONCLUSIONS

Skin puncture may make little to no difference to short-term mortality. There is probably little or no difference in failure of aneurysm exclusion (failure to seal the aneurysms), wound infection, major complications within 30 days or while in hospital, medium- to long-term (six months) complications and bleeding complications between the two groups. Compared with exposing the femoral artery, skin puncture may reduce the operating time slightly. We downgraded the certainty of the evidence to moderate and low as a result of imprecision due to the small number of participants, low event rates and wide CIs, and inconsistency due to clinical heterogeneity. As the number of included studies was limited, further research into this technique would be beneficial.

Totally percutaneous endovascular repair for ruptured abdominal aortic aneurysms

Purpose

The PEVAR Trial demonstrated that compared to open femoral exposure, elective percutaneous endovascular AAA repair (ePEVAR) is associated with decreased perioperative morbidity and access site complications. We hypothesized that PEVAR for ruptured AAA (rPEVAR) may also improve perioperative morbidity compared to open femoral exposure (rEVAR). There are currently no reports that evaluate the utility and outcomes of rPEVAR.

Materials and methods

From 2015 to 2021, all patients who underwent an endovascular repair of a ruptured AAA at a single institution were included in the study and grouped into rPEVAR and rEVAR. Demographics, procedural details (successful preclose technique, conversion to femoral cutdown), postoperative variables (blood transfusion, ICU and hospital length of stay) and short-term outcomes (30-day major adverse events (30-day MAE) and 30-day femoral access-site complications (30-day FAAC)) were collected and compared with 50 historical ePEVAR patients from the PEVAR Trial. Statistical significance was determined using χ 2 or Fisher's exact test for categorical variables, and Mann-Whitney U-test for continuous variables.

Results

35 patients were identified (21 rPEVAR; 14 rEVAR), 86% were male with a mean age of 72 ± 9 years. All patients underwent emergent endovascular aortic repair with 100% technical success. Seventeen patients (49%) presented with evidence of hemorrhagic shock and 22 patients (63%) had blood transfusion. 30-day MAE occurred in 12 patients (34%) (7 rPEVAR; 5 rEVAR). There was no difference in demographic, perioperative outcomes and 30-day MAE rate between rPEVAR and rEVAR patients. Compared to ePEVAR patient (from PEVAR trial), rPEVAR patients had higher rate of 30-day MAE (34% vs. 6%; p < 0.006) but no difference in 30-day FAAC (19% vs. 12%; p = 0.54). The success rate of the preclose technique was higher in ePEVAR compared to rPEVAR (96% vs. 76%; p = 0.02), but the rate of conversion to femoral cutdown was similar between the two groups (10% vs. 4%; p = 0.57).

Conclusion

Emergent rPEVAR appears to have similar outcomes when compared to rEVAR. Although patients undergoing rPEVAR have higher 30-day major adverse events rate compared to ePEVAR, the method of percutaneous femoral cannulation does not appear to increase the overall procedural or 30-day femoral artery access-site complications.

Large arteriotomies closure using a combination of vascular closure devices during TEVAR/EVAR: A single centre experience

In this case series, we share our experience of total percutaneous closure of large arteriotomies using combination of vascular closure devices (VCD). A total of six patients with seven sites for endovascular repair were taken for total percutaneous endovascular aortic repair. Ten femoral arteriotomies (26 French (F) = 2, 24 F = 1, 22 F = 3, 20 F = 1, 18 F = 1 &16 F = 2) were successfully closed with 26 Perclose™ and 07 Angio-seal™ devices. There were no local site complications or VCD failure in any of our patients.

Assisting Vascular Surgery with Smartphone Augmented Reality

Background Augmented reality is a technology that expands on image-guided surgery to allow intraoperative guidance and navigation. Augmented reality-assisted surgery (ARAS) has not been implemented in the vascular field yet. The wealth of sensors found on modern smartphones make them a promising platform for implementing vascular ARAS. However, current smartphone augmented reality platforms suffer from tracking instability, making them unsuitable for precise surgery. Novel algorithms need to be developed to tackle the stability and performance limitations of mobile phone augmented reality. Aim The primary aim was to develop an ARAS system utilizing low-cost smartphone hardware for vascular surgery. The second aim was to assess its performance by evaluating the stability of its tracking algorithms. Methods We designed an ARAS system utilizing standard optical tracking (SOT) and developed a novel tracking algorithm: hybrid gyroscopic and optical tracking (HGOT) for improved tracking stability. We evaluated the stability of both tracking algorithms using a phantom model and calculated tracking errors using root mean square error (RMSE).  Results The novel augmented reality system displayed a three-dimensional (3D) guidance model fused with the patient's anatomy on a smartphone in real-time. The rotational tracking RMSE was 3.12 degrees for SOT and 0.091 degrees for HGOT. Positional tracking RMSE was 3.3 mm for SOT compared to 0.03 mm for HGOT. Comparing the stability of both tracking techniques showed HGOT to be significantly superior to SOT (p = 0.004). Conclusion We have developed a novel augmented reality system for vascular procedures. The development of HGOT has significantly increased the stability of a low-cost handheld augmented reality solution.

Large-bore Vascular Closure: New Devices and Techniques

Endovascular aneurysm repair, transcatheter aortic valve implantation and percutaneous mechanical circulatory support systems have become valuable alternatives to conventional surgery and even preferred strategies for a wide array of clinical entities. Their adoption in everyday practice is growing. These procedures require large-bore access into the femoral artery. Their use is thus associated with clinically significant vascular bleeding complications. Meticulous access site management is crucial for safe implementation of large-bore technologies and includes accurate puncture technique and reliable percutaneous closure devices. This article reviews different strategies for obtaining femoral access and contemporary percutaneous closure technologies.

Fascia Suture Technique and Suture-mediated Closure Devices: Systematic Review

Background  The aim of the present study is to review the available data on suture-mediated closure devices (SMCDs) and fascia suture technique (FST), which are alternatives for minimizing the invasiveness of percutaneous endovascular aortic aneurysm repair (p-EVAR) and reduce the complications related to groin dissections. Methods  The Medline, ClinicalTrials.gov, and Cochrane library - Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for publications regarding SMCD and FST between January 1999 and December 2016. Results  We review 37 original articles, 30 referring to SMCDs (Prostar XL and Proglide), which included 3,992 patients, and 6 articles referring to FST, which include 426 patients. The two techniques are compared only in one article (100 patients). The two types of SMCDs were Prostar and Proglide. In most studies on SMCDs, the reported technical success rates were between 89 and 100%, but the complication rates varied greatly between 0 and 25%. Concerning FST, the technical success rates were also high, ranging between 87 and 99%. However, intraoperative complication rates ranged between 1.2 and 13%, whereas postoperative complication rates varied from 0.9 to 6.2% for the short-term and from 1.9 to 13.6% for the long-term. Conclusions  SMCDs and FST seem to be effective and simple methods for closing common femoral artery (CFA) punctures after p-EVAR. FST can reduce the access closure time and the procedural costs with a quite short learning curve, whereas it can work as a bailout procedure for failed SMCDs suture. The few failures of the SMCDs and FST that may occur due to bleeding or occlusion can easily be managed.

Totally percutaneous versus surgical cut-down femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. Endovascular abdominal aortic aneurysm repairs (EVARs) are now a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in people with, for example, groin scarring or arterial calcification. This is an update of the review first published in 2014.

OBJECTIVES

This review aims to compare the clinical outcomes of percutaneous access with surgical cut-down femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist (CIS) searched their Specialised Register (last searched October 2016) and CENTRAL (2016, Issue 9). We also searched clinical trials registries and checked the reference lists of relevant retrieved articles.

SELECTION CRITERIA

We considered only randomised controlled trials. The primary intervention was a totally percutaneous endovascular repair. We considered all device types. We compared this against surgical cut-down femoral artery access endovascular repair. We only considered studies investigating elective repairs. We excluded studies reporting emergency surgery for a ruptured abdominal aortic aneurysm and those reporting aorto-uni-iliac repairs.

DATA COLLECTION AND ANALYSIS

Two review authors independently collected all data. Owing to the small number of trials identified we did not conduct any formal sensitivity analysis. Heterogeneity was not significant for any outcome.

MAIN RESULTS

Two studies with a total of 181 participants met the inclusion criteria, 116 undergoing the percutaneous technique and 65 treated by cut-down femoral artery access. One study had a small sample size and did not adequately report method of randomisation, allocation concealment or pre-selected outcomes. The second study was a larger study with few sources of bias and good methodology.We observed no significant difference in mortality between groups, with only one mortality occurring overall, in the totally percutaneous group (risk ratio (RR) 1.50; 95% confidence interval (CI) 0.06 to 36.18; 181 participants; moderate-quality evidence). Only one study reported aneurysm exclusion. In this study we observed only one failure of aneurysm exclusion in the surgical cut-down femoral artery access group (RR 0.17, 95% CI 0.01 to 4.02; 151 participants; moderate-quality evidence). No wound infections occurred in the cut-down femoral artery access group or the percutaneous group across either study (moderate-quality evidence).There was no difference in major complication rate between cut-down femoral artery access and percutaneous groups (RR 0.91, 95% CI 0.20 to 1.68; 181 participants; moderate-quality evidence); or in bleeding complications and haematoma (RR 0.94, 95% CI 0.31 to 2.82; 181 participants; high-quality evidence).Only one study reported long-term complication rates at six months, with no differences between the percutaneous and cut-down femoral artery access group (RR 1.03, 95% CI 0.34 to 3.15; 134 participants; moderate-quality evidence).We detected differences in surgery time, with percutaneous approach being significantly faster than cut-down femoral artery access (mean difference (MD) -31.46 minutes; 95% CI -47.51 minutes to -15.42 minutes; 181 participants; moderate-quality evidence). Only one study reported duration of ITU (intensive treatment unit) and hospital stay, with no difference found between groups.

AUTHORS' CONCLUSIONS

This review shows moderate-quality evidence of no difference between the percutaneous approach compared with cut-down femoral artery access group for short-term mortality, aneurysm exclusion, major complications, wound infection and long-term (six month) complications, and high-quality evidence for no difference in bleeding complications and haematoma. There was a difference in operating time, with moderate-quality evidence showing that the percutaneous approach was faster than the cut-down femoral artery access technique. We downgraded the quality of the evidence to moderate as a result of the limited number of studies, low event numbers and imprecision. As the number of included studies were limited, further research into this technique would be beneficial. The search identified one ongoing study, which may provide an improved evidence base in the future.

Total Percutaneous Endovascular Repair of Abdominal Aortic Aneurysms Using Perclose ProGlide Closure Devices

Purpose:

To describe a technique for access site closure in percutaneous abdominal aortic aneurysm (AAA) repair using double Perclose ProGlide devices to overcome the problems associated with the bulky delivery system and braided suture of the antecedent (Prostar) device.

Technique:

After obtaining guidewire access, 2 Perclose ProGlide sutures are deployed at 90° to each other. The appropriate sheaths are placed over the stiff guidewires. After the stent-graft procedure is completed, an assistant holds pressure while the knots are tightened with the stiff guidewire still in the artery. Once the second knot is tightened with the knot pusher and after confirming adequate hemostasis, the wire is removed, pressure is applied, and heparin reversed. This method has been used in 17 consecutive patients (age range 65–85 years) undergoing endovascular AAA repair. One patient needed patch angioplasty and 2 required small incisions for additional suture placements (81% primary success rate for total percutaneous repair, 90% success rate for all sites).

Conclusion:

We have found the double Perclose ProGlide technique to be easy to use, safe, and feasible for total percutaneous AAA repair. More experience with longer follow-up is needed to assess its potential to replace the Perclose Prostar closure device for total percutaneous AAA repairs.

Negative Pressure Incision Management System in the Prevention of Groin Wound Infection in Vascular Surgery Patients

Objectives. Groin wounds following vascular surgery are highly susceptible to healing disturbances, with reported site infections reaching 30%. Negative pressure incision management systems (NPIMS) are believed to positively influence the prevention of surgical wound-healing disturbances (WHD) and surgical site infections (SSI). NPIMS placed directly after closure of the surgical wound is thought to result in fewer infections; we analysed its effect on postoperative wound infections in patients after vascular surgery via the groin. Methods. From May 2012 to March 2013 we included 90 surgical patients; 40 received a NPIMS. All patients with WHDs were labelled and subanalysed for surgical site infection in case of positive microbiological culture. These infections were graded according to Szilagyi. Number of WHDs and SSIs were compared across cohorts. Results. Patient and perioperative characteristics were equal, except for a significantly higher number of emergency procedures among non-NPIMS patients. We found no significant differences in number of WHDs, SSIs, or Szilagyi grades between the two cohorts. Conclusion. The equal number of SSIs across cohorts showed that NPIMS could not reduce the number of surgical site infections after vascular groin surgery.

Better Clinical Practice Could Overcome Patient-Related Risk Factors of Vascular Surgical Site Infections

Purpose: To clarify the current status of surgical site infection (SSI) during endovascular aortic repair and to define risk factors for SSI among the patients who underwent thoracic or abdominal stent-graft repair through a groin incision. Methods: Between 2006 and 2013, data were collected from 1604 patients (mean age 75.2±9.5 years; 1282 men) with 2799 groin incisions for transfemoral access during aortic stent-graft procedures. SSIs were classified as superficial or deep (both occurring within 30 days) or organ/space infections (occurring within 1 year after surgery) according to the Centers for Disease Control and Prevention guidelines. Strategies in place for minimizing SSIs were (1) employing oblique groin incisions, (2) covering the incision with saline-soaked gauze, (3) irrigating the incision thoroughly with saline per layer, and (4) using absorbable sutures. Results: Overall incidence of SSI was 0.4% (6 patients). The majority of SSIs were late-onset prosthetic graft infections (5, 0.3%). Five of the 6 were successfully treated with conservative therapy; one patient died of sepsis. Univariate analysis showed additional therapy (eg, coil embolization) with a stent-graft procedure was a risk factor for SSI. Conclusion: Appropriate antibiotic administration, oblique groin incision, meticulous operative technique, protection against airborne infection during the operation, and closed dressings may avert vascular wound SSIs.

New surgical modification of fascial closure following endovascular aortic pathology repair

Introduction

There are clear benefits of percutaneous versus open femoral access for endovascular aortic pathology repair. All closing devices commercially available are expensive. Surgical closure of the femoral artery risks potential prolonged wound healing and as a consequence longer hospital stay. Fascial closure is a technique that remains an interesting option.

Aim

To evaluate the efficacy of the surgical modification of hemostasis control after endovascular repair of aortic pathology.

Material and methods

One hundred sixteen common femoral arteries in a group of 58 patients underwent a minimally invasive procedure. Patients suffering from abdominal, thoracic aorta aneurysms, acute thoracic aorta type B dissections and traumatic aortic injury were treated.

Results

A 1-year period of experience in fascial closure of 116 common femoral arteries was presented in the group of 58 patients undergoing endovascular interventions. Five intraoperative complications were observed and one late. Three primary failures were due to hemorrhage in three arteries, one required open repair and two additional compression after the procedure. Two cases of limb ischemia required surgical correction of artery closure. One limb ischemia was detected 4 weeks later, and was treated conservatively. At 1 year, 92 fascial closures (80%) were in the follow-up and 24 (20%) were lost to follow-up.

Conclusions

This new modification of fascial closure is a safe and cheap method of arterial closure following endovascular repair of selected aortic pathologies. The usage of two suture lines makes this procedure easy and quick. Fascial closure technique is comparable to other techniques in terms of success and complication rates.

Totally percutaneous versus standard femoral artery access for elective bifurcated abdominal endovascular aneurysm repair

BACKGROUND

Abdominal aortic aneurysms (AAAs) are a vascular condition with significant risk attached, particularly if they rupture. It is, therefore, critical to identify and repair these as an elective procedure before they rupture and require emergency surgery. Repair has traditionally been an open surgical technique that required a large incision across the abdomen. More recently endovascular aneurysm repairs (EVARs) have become a common alternative. In this procedure, the common femoral artery is exposed via a cut-down approach and a graft is introduced to the aneurysm in this way. This review examines a totally percutaneous approach to EVAR. This technique gives a minimally invasive approach to femoral artery access that may reduce groin wound complication rates and improve recovery time. The technique may, however, be less applicable in patients with, for example, groin scarring or arterial calcification.

OBJECTIVES

This review aims to compare the clinical outcomes of percutaneous access with standard femoral artery access in elective bifurcated abdominal endovascular aneurysm repair (EVAR).

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched July 2013), CENTRAL (2013, Issue 6) and clinical trials databases. Reference lists of retrieved articles were checked.

SELECTION CRITERIA

Only randomised controlled trials were considered. The primary intervention was a totally percutaneous endovascular repair. All device types were considered. This was compared against standard femoral artery endovascular repair. Only studies investigating elective repairs were considered. Studies reporting emergency surgery for a ruptured abdominal aortic aneurysm (rAAA) and those reporting aorto-uni-iliac repairs were excluded.

DATA COLLECTION AND ANALYSIS

All data were collected independently by two review authors. Owing to the small number of trials identified, no formal assessment of heterogeneity or sensitivity analysis was conducted.

MAIN RESULTS

Only one trial met the inclusion criteria, involving a total of 30 participants, 15 undergoing the percutaneous technique and 15 treated by the standard femoral cut-down approach. There were no significant differences between the two groups at baseline.No mortality or failure of aneurysm exclusion was observed in either group. Three wound infections occurred in the standard femoral cut-down group, whereas none were observed in the percutaneous group. This was not statistically significant. Only one major complication was observed in the study, a conversion to the cut-down technique in the percutaneous access group. No long-term outcomes were reported. One episode of a bleeding complication was reported in the percutaneous group. Significant differences were detected in surgery time (percutaneous 86.7 ± 27 minutes versus conventional 107.8 ± 38.5 minutes; P < 0.05).The included study had a small sample size and failed to report adequately the method of randomisation, allocation concealment and the pre-selected outcomes.

AUTHORS' CONCLUSIONS

Only one small study was identified, which did not provide adequate evidence to determine the efficacy and safety of the percutaneous approach compared with endovascular aneurysm repairs. This review has identified a clear need for further research into this potentially beneficial technique. One ongoing study was identified in the search, which may provide an improved evidence base in the future.

Negative pressure wound therapy for inguinal lymphatic complications in critically ill patients

Purpose

In this study, we investigated the therapeutic potential of regulated negative pressure vacuum-assisted wound therapy for inguinal lymphatic complications in critically ill, liver transplant recipients.

Methods

The great saphenous vein was harvested for hepatic vein reconstruction during liver transplantation in 599 living-donor liver transplant recipients. Fourteen of the recipients (2.3%) developed postoperative inguinal lymphatic complications and were treated with negative pressure wound therapy, and they were included in this study.

Results

The average total duration of negative pressure wound therapy was 23 days (range, 11 to 42 days). Complete resolution of the lymphatic complications and wound healing were achieved in all 14 patients, 5 of whom were treated in hospital and 9 as outpatients. There was no clinically detectable infection, bleeding or recurrence after an average follow-up of 27 months (range, 7 to 36 months).

Conclusion

Negative pressure wound therapy is an effective, readily-available treatment option that is less invasive than exploration and ligation of leaking lymphatics and provides good control of drainage and rapid wound closure in critically ill patients.

Differences in readmissions after open repair versus endovascular aneurysm repair

OBJECTIVE

Reintervention rates after repair of abdominal aortic aneurysm (AAA) are higher for endovascular repair (EVAR) than for open repair, mostly due to treatment for endoleaks, whereas open surgical operations for bowel obstruction and abdominal hernias are higher after open repair. However, readmission rates after EVAR or open repair for nonoperative conditions and complications that do not require an intervention are not well documented. We sought to determine reasons for all-cause readmissions within the first year after open repair and EVAR.

METHODS

Patients who underwent elective AAA repair in California during a 6-year period were identified from the Health Care and Utilization Project State Inpatient Database. All patients who had a readmission in California ≤1 year of their index procedure were included for evaluation. Readmission rates and primary and secondary diagnoses associated with each readmission were analyzed and recorded.

RESULTS

From 2003 to 2008, there were 15,736 operations for elective AAA repair, comprising 9356 EVARs (60%) and 6380 open repairs (40%). At 1 year postoperatively, the readmission rate was 52.1% after open repair and 55.4% after EVAR (P=.0003). The three most common principle diagnoses associated with readmission after any type of AAA repair were failure to thrive, cardiac issues, and infection. When stratified by repair type, patients who underwent open repair were more likely to be readmitted with primary diagnoses associated with failure to thrive, cardiac complications, and infection compared with EVAR (all P<.001). Those who underwent EVAR were more likely, however, to be readmitted with primary diagnoses of device-related complications (P=.05), cardiac complications, and infection.

CONCLUSIONS

Total readmission rates within 1 year after elective AAA repair are greater after EVAR than after open repair. Reasons for readmission vary between the two cohorts but are related to the magnitude of open surgery after open repair, device issues after EVAR, and the usual cardiac and infectious complications after either intervention. Systems-based analysis of these causes of readmission can potentially improve patient expectations and care after elective aneurysm repair.

Risk factors associated with surgical site infections following vascular surgery at a German university hospital

Surgical site infection (SSI) after vascular surgery is a serious complication increasing morbidity, mortality, and costs for healthcare systems. A 4-year retrospective cohort study was performed in a university hospital with patients who had undergone arterial vascular surgery below the aortic arch. Investigated variables included demographics and clinical data. Forty-four of 756 patients experienced SSI, 29 of which were superficial, five were deep, and 10 had organ/space infections. Coagulase-negative staphylococci (22%), enterococci (20%), and Staphylococcus aureus (18%) were the most common pathogens. Independent risk factors for SSIs were femoral grafting [odds ratio (OR) 6·7], peripheral atherosclerotic disease, Fontaine stages III–IV (OR 4·1), postoperative drainage >5 days (OR 3·6), immunosuppression (OR 2·8), duration of operation >214 min (OR 2·8), and body mass index >29 (OR 2·6). The application of perioperative antibiotic prophylaxis was an independent protective factor (OR 0·2). Patients with certain risk factors for SSIs warrant special attention for infection prevention.

Techniques in endovascular aneurysm repair

Endovascular repair of infrarenal abdominal aortic aneurysms (EVARs) has revolutionized the treatment of aortic aneurysms, with over half of elective abdominal aortic aneurysm repairs performed endoluminally each year. Since the first endografts were placed two decades ago, many changes have been made in graft design, operative technique, and management of complications. This paper summarizes modern endovascular grafts, considerations in preoperative planning, and EVAR techniques. Specific areas that are addressed include endograft selection, arterial access, sheath delivery, aortic branch management, graft deployment, intravascular ultrasonography, pressure sensors, management of endoleaks and compressed limbs, and exit strategies.

Incidence and Survival Outcome Following Femoral Artery Reconstruction During Endovascular Abdominal Aortic Aneurysm Repair

Background: Planned or unplanned reconstruction of the common femoral artery (femoro-femoral crossover and/or patch closure) may be required following endovascular abdominal aortic aneurysm repair (EVAR) stent graft deployment for arterial closure or maintenance of limb perfusion. The aim of this study was to examine the incidence of common femoral artery reconstruction (FAR) following EVAR and examine the effect on patient survival. Methods: A total of 178 patients undergoing EVAR were studied retrospectively. Results: In all, 31 patients (17.4%) underwent FAR; 16 (51.6%) femoro-femoral crossover, and 15 (48.4%) endarterectomy and patch closure. All cause survival in patients undergoing FAR was significantly poorer than those undergoing direct closure (P = .010).A total of 3 factors: the need for FAR (hazard ratio [HR] = 0.435, P = .006), chronic obstructive pulmonary disease ([COPD] HR = 0.424, P = .002), and abdominal aortic aneurysm (AAA) size (HR = 1.414, P = .005) were significantly and independently associated with survival on forward conditional analysis. Conclusions: Femoral artery reconstruction was performed in almost 1 in 5 patients undergoing EVAR and associated with decreased survival. Multidisciplinary teams should be aware of these findings when planning EVAR, especially in borderline candidates.

Five Years' Experience of Transverse Groin Incision for Femoral Artery Access in Arterial Reconstructive Surgery: Parallel Observational Longitudinal Group Comparison Study

Vertical groin incisions (VGIs) have been used to access femoral vessels, but reports allude to wound complications. Our aim was to compare VGI with transverse groin incision (TGI) for femoral artery exposure. Over a 5-year interval, 196 patients with 284 femoral artery exposures for supra- and infrainguinal procedures were studied. Primary endpoints were surgical skin site wound infection, seroma, haematoma formation, and major lower limb amputation. Secondary endpoints were graft patency, wound paresthesias, and length of hospital stay. There were 160 TGIs and 124 VGIs. The demographics and risk factor profile were not statistically different between groups. Seroma developed in 4.4% of TGIs and 13.7% of VGIs ( p = .005). The complicated skin and soft tissue infection rate was five times greater with VGI ( p = .001). The VGI group had a significantly higher rate of major amputation ( p = .0005). Significantly higher graft failure rates were observed in the VGI group ( p = .011). No paresthesia was reported in any TGI wound. The mean hospital stay was also significantly shorter in the TGI group ( p = .006). The study data support and expound on the theory that an alternative incision to VGI offers lower short- and long-term morbidity. Our findings sustain the selection of the TGI in femoral artery surgery for both supra- and infrainguinal procedures without compromise of vessel exposure.

Lymphorrhea responds to negative pressure wound therapy

Lymphoceles and lymph fistulas are common complications of femoral exposure for vascular procedures. Three patients who required readmission after their vascular interventions were treated with negative pressure wound therapy. Once adequate control of the drainage was obtained, the patients were discharged home with a portable suction unit. The mean time to stop lymph leak was 14 days, and the mean length of hospital stay was 7.3 days. This method of management offers early control of fluid drainage, rapid control of the wound, earlier closure, and the potential for reduced length of stay. Patient acceptance and convenience may be enhanced by outpatient management and return to work in appropriately motivated individuals.