Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

PTFE-vein composite grafts for critical limb ischaemia: a valuable alternative to all-autogenous infrageniculate reconstructions

OBJECTIVES

to analyse the long-term results of primary composite bypass grafts comparing them to PTFE and vein grafts.

DESIGN

a retrospective observational study.

MATERIALS AND METHODS

between 1980 and 1996, 568 primary infrageniculate bypass procedures were performed; a saphenous-vein graft was used in 428 procedures, a PTFE graft in 44 and a composite PTFE-saphenous-vein graft in 96. Thirty-six composite grafts were below the knee and the remaining 60 extended more distally. Twenty-one bypass grafts from the latter group were sequential. Mean follow-up was 45.6 months. Five-year primary and secondary patency and limb salvage rates were compared by life-table analysis.

RESULTS

cumulative 5-year primary patency for composite grafts was 58% and for saphenous-vein grafts 74%, while secondary patency rate was 75% and 82%, respectively (p <0.05). The 5-year limb salvage rate was 80% for composite grafts and 88% for saphenous-vein grafts (p >0.05). The primary and secondary patency and limb salvage rate for PTFE grafts was 24%, 31% and 40%, respectively.

CONCLUSION

Composite grafts of PTFE and saphenous vein are significantly superior to PTFE graft alone and should be used in patients who lack sufficient length of saphenous vein.

Surgical treatment of carotid body tumours

OBJECTIVE

To evaluate our results of the treatment of patients with carotid body tumours.

DESIGN

Retrospective study.

SETTING

University hospital, Greece.

SUBJECTS

17 patients operated on for a carotid body tumour during the past 20 years.

MAIN OUTCOME MEASURES

Hospital mortality and morbidity, long-term outcome.

RESULTS

3 patients had temporary cranial nerve lesions postoperatively, all of which resolved within three months. One patient developed a severe stroke and died seven days postoperatively. During follow-up that ranged from 7 months to 20 years, two patients died of unrelated causes. 5 patients were lost to follow up, and the remaining 10 were doing well with no signs of recurrence at the time of writing.

CONCLUSION

Excision of a carotid body tumour is recommended at the time of initial diagnosis in good-risk patients to avoid the difficulty of subsequent excision of an enlarging and highly vascular tumour with possible encasement of the carotid artery.

Is endoluminal abdominal aortic aneurysm repair using an aortoaortic (tube) device a durable procedure?

Endoluminal repair of abdominal aortic aneurysm (AAA) is being adopted as a less invasive alternative to conventional open repair in many centers worldwide. Although the initial results are encouraging, the long-term durability of this procedure remains unknown. Endoluminal AAA repair in 29 patients using three different devices (EVT tube Endograft(R), aortouniiliac device, and Stentortrade mark bifurcated system) is described. Overall, 24 procedures (83%) were completed successfully. Complications included two deaths due to microembolization, five early conversions, two chest infections, three patients with buttock claudication, and three patients with trashed foot. Perigraft leaks were detected in four patients (three proximal, one distal) treated with the EVT tube Endograft. Continued aneurysm expansion was observed in three of the patients. One of the leaks was discovered at the 1-year follow-up. In this patient the aneurysmal process was not retarded by endoluminal repair. The findings in this patient may have implications for the durability of this technique. Therefore, careful long-term evaluation of this procedure is recommended prior to its widespread use.

Comparison of computed tomography and duplex imaging in assessing aortic morphology following endovascular aneurysm repair

BACKGROUND

Computed tomography (CT) has been used to assess patients following endovascular aneurysm repair to determine the need for secondary endoluminal or operative procedures. This prospective study compared CT and duplex imaging to evaluate aneurysm morphology following endoluminal aortic grafting.

METHODS

Twenty patients were evaluated at regular intervals following successful endoluminal aneurysm repair. CT and duplex scanning were compared in their ability to determine aneurysm and aortic diameter, the presence of perigraft extravasation (endoleaks) and technical defects in the endograft.

RESULTS

In 20 patients who were assessed 6 months after operation, duplex imaging identified four endoleaks (two early, two late; one proximal, three distal). In three cases, the aneurysm diameter progressively increased after operation. In patients with a thrombosed aneurysm sac, the aneurysm regressed at a median of 0.40 (range 0.13-0.8) cm per year. The CT findings were similar (median regression 0.43 (range 0-1.0) cm per year), although CT was unable to predict the site of the leak as accurately as duplex imaging. CT demonstrated that the diameter of the juxtarenal aorta increased following endografting.

CONCLUSION

Duplex imaging is a less invasive, less costly alternative to CT in the follow-up of patients after endoluminal aortic surgery. Increase in size of the aneurysm sac following endovascular aneurysm repair strongly suggests the presence of an endoleak.

Secondary aortoduodenal fistulae

Secondary aortoenteric fistula (SAF) is a rare but fatal complication of reconstructive aortoiliac surgery. The prevention, diagnosis and treatment of this complication remains a challenging problem in everyday practice. Nine cases of secondary aortoduodenal fistulae during the period of 1980 to 1992 are presented. Their main symptom was bleeding of the upper gastrointestinal tract. The mean time interval since the aortic surgical procedure was 32 months. Removal of the old graft and closure of the duodenal defect was the first stage of the operative procedure. One patient underwent replacement of the old graft, with a new graft, while in the remaining three patients extranatomical bypass was not necessary because of satisfactory circulation in the lower extremities. In five patients extranatomical revascularization of the lower limbs was performed postoperatively at various intervals. Three patients died postoperatively. Follow-up of the remaining patients ranged from one month to 8 years. Bleeding of the upper gastrointestinal tract in patients with a history of intrabdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existance of SAF unless the diagnostic procedure, mainly exploratory laparotomy, excludes this possibility.

Anomalous inferior vena cava complicating abdominal aortic aneurysmectomy

Variations in the site and course of the inferior vena cava (IVC), although relatively infrequent, can have important surgical implications, especially during surgery for abdominal aortic aneurysm. We report two cases of left-sided IVC encountered during aneurysmectomy. In both cases, the anomaly was not detected during preoperative ultrasound examination, but was identified by CT scan in one case. Careful mobilization of the IVC and left iliac vein allow retraction of the IVC to the right, after which the aneurysm can be approached in the usual manner.

The validity of current vascular imaging methods in the evaluation of aortic anastomotic aneurysms developing after abdominal aortic aneurysm repair

The aim of this cross-sectional study was to evaluate the validity of current imaging methods for diagnosing anastomotic false aneurysms (AFA) of the aorta. One hundred four patients who had undergone elective abdominal aortic aneurysm repair between January 1, 1985, and May 31, 1991, were studied. All of them were investigated for potential development of an aortic anastomotic aneurysm by B-mode ultrasonography, CT scanning, digital subtraction arteriography, and MRI. These findings were compared with results of color-coded Doppler imaging, which is considered the "gold standard," and were subsequently classified as true positive or true negative. The accuracy of color Doppler ultrasound was independently evaluated by clinical examination of the patients, which was carried out for a mean period of 77.5 months during follow-up. On the basis of the data obtained and observations made during follow-up (mean 36.4 months), the sensitivity and specificity of the preceding imaging methods were estimated. Aortic anastomotic aneurysms were detected in two patients (1.9%). The sensitivity of all methods was 100% and specificity was as follows: 74.2% for ultrasound, 59.8% for nonenhanced CT scans, 85.4% for enhanced CT scans, and 99% for digital subtraction arteriograms. Color Doppler and MRI were 100% specific for ruling out aortic anastomotic aneurysms. In a comparison of the accuracy, estimated cost, safety, and the availability of each method, color Doppler appeared to be the diagnostic method of choice for identifying aortic anastomotic aneurysms after abdominal aortic aneurysm repair.

Abdominal aortic aneurysm and left sided inferior vena cava. A case report

The co-existence of abnormalities of the inferior vena cava (IVC) and abdominal aortic aneurysm (AAA) is a rare condition but with surgical significance. With the development of various imaging technics and the routine use of computerized tomography for the examination of the abdomen and/or the investigation of AAA these venous abnormalities can be disclosed. A male patient with AAA and left sided IVC is presented.

Arterial aneurysms in Behçet's disease

Six cases of arterial aneurysms, due to "Behçet's disease" located in various arteries are presented. Surgical reconstruction included: Resection of the lesions and replacement with corresponding grafts with satisfactory results. In spite of the macroscopic similarity of the aneurysms found in "Behçet's disease" as compared to those of mycotic origin, the presence of any microorganism could not be detected in various cultures or pathological specimens. Meticulous diagnosis on the nature of the aneurysm, close follow-up and careful postoperative anticoagulant treatment, is imperative for satisfactory immediate and late results.