Editor's Choice - Nationwide Analysis of Patients Undergoing Iliac Artery Aneurysm Repair in the Netherlands

OBJECTIVE

The new 2019 guideline of the European Society for Vascular Surgery (ESVS) recommends consideration for elective iliac artery aneurysm (eIAA) repair when the iliac diameter exceeds 3.5 cm, as opposed to 3.0 cm previously. The current study assessed diameters at time of eIAA repair and ruptured IAA (rIAA) repair and compared clinical outcomes after open surgical repair (OSR) and endovascular aneurysm repair (EVAR).

METHODS

This retrospective observational study used the nationwide Dutch Surgical Aneurysm Audit (DSAA) registry that includes all patients who undergo aorto-iliac aneurysm repair in the Netherlands. All patients who underwent primary IAA repair between 1 January 2014 and 1 January 2018 were included. Diameters at time of eIAA and rIAA repair were compared in a descriptive fashion. The anatomical location of the IAA was not registered in the registry. Patient characteristics and outcomes of OSR and EVAR were compared with appropriate statistical tests.

RESULTS

The DSAA registry comprised 974 patients who underwent IAA repair. A total of 851 patients were included after exclusion of patients undergoing revision surgery and patients with missing essential variables. eIAA repair was carried out in 713 patients, rIAA repair in 102, and symptomatic IAA repair in 36. OSR was performed in 205, EVAR in 618, and hybrid repairs and conversions in 28. The median maximum IAA diameter at the time of eIAA and rIAA repair was 43 (IQR 38-50) mm and 68 (IQR 58-85) mm, respectively. Mortality was 1.3% (95% CI 0.7-2.4) after eIAA repair and 25.5% (95% CI 18.0-34.7) after rIAA repair. Mortality was not significantly different between the OSR and EVAR subgroups. Elective OSR was associated with significantly more complications than EVAR (intra-operative: 9.8% vs. 3.6%, post-operative: 34.0% vs. 13.8%, respectively).

CONCLUSION

In the Netherlands, most eIAA repairs are performed at diameters larger than recommended by the ESVS guideline. These findings appear to support the recent increase in the threshold diameter for eIAA repair.

The value of duplex surveillance after endovascular intervention for femoropopliteal obstructive disease

OBJECTIVE

The objective of the present study was to assess prospectively whether serial Duplex examination was useful in identifying impending failure after endovascular interventions of the femoropopliteal arteries.

SETTING

Non-university hospital. Prospective clinical study.

METHODS

124 Patients were successfully treated by endovascular procedures during a 5 year period. The follow-up was by colour-flow Duplex examination at fixed intervals. At similar intervals clinical examination, including ankle blood pressure measurement was performed to assess the clinical/haemodynamic status of the patients according to the SVS/NAISCVS guidelines. For the diagnosis of impending failure the Duplex criterion was a peak systolic velocity ratio > 2.5 and the clinical/haemodynamic criterion was a level < +2. Actual failure of the vascular procedure was defined as the occurrence of an occlusion in the treated arterial segment or a recurrent stenosis causing symptoms severe enough to require a reintervention. No prophylactic reinterventions were performed on the basis of abnormal Duplex findings alone.

RESULTS

Abnormal Duplex findings indicating restenosis were observed in 52 patients. Duplex abnormalities predicted treatment failure with a sensitivity of 86% and a specificity of 75%, while clinical/haemodynamic assessment had a sensitivity of 93% and a specificity of 90%. The hypothetical management outcome if Duplex surveillance had been used as a basis for reintervention was assessed. It appeared that only one patient with failure would have received a redo endovascular procedure at the time he had a restenosis.

CONCLUSIONS

Clinical/haemodynamic assessment was more useful for the follow-up of endovascular interventions than Duplex surveillance.

Comparison of intravascular ultrasonography and intraarterial digital subtraction angiography after directional atherectomy of short lesions in femoropopliteal arteries

PURPOSE

In this study a group of patients undergoing directional atherectomy for localized occlusive disease in the femoropopliteal arteries, the value of intravascular ultrasonography (IVUS) to improve the efficacy of plaque removal was evaluated. The findings obtained by IVUS were correlated with intraarterial digital subtraction angiography (IA DSA) performed during the procedure. In addition, the patency rates at follow-up in patients undergoing atherectomy with and without IVUS were compared.

METHODS

Forty patients were treated by atherectomy because of segmental lesions of the femoropopliteal arteries causing intermittent claudication. Twenty-two patients underwent atherectomy, guided by biplane IA DSA only, and 18 patients were also studied by IVUS. The groups were divided by means of consecutive presentation, IVUS being used in the second part of the study period. The median follow up was 16 months (range, 0 to 40 months). Variables, measured by IVUS during the procedure, were the minimal transverse luminal diameter (MTLD) and the free luminal area. Patency rates at follow-up were determined by regular color flow duplex examinations. Color-flow duplex criteria for occlusions were absence of arterial flow and, for stenosis, a ratio of peak systolic velocities at the diseased segment and a normal segment of 2.5 or greater.

RESULTS

Qualitative IVUS assessment prompted additional atherotome passages because of insufficient atheroma removal or nonaesthetic appearance of the vessel lumen in 15 of the 18 patients who underwent this examination. Only in four of these patients would abnormalities at IA DSA have been a reason for further attempts of atheroma removal. As for the quantitative findings during AT, after a first series of atherectomy passes the mean MTLD of the reference lesion resulted in an increase of the MTLD from a mean of 3.3 +/- 0.7 mm to 3.7 +/- 0.6mm (p = 0.001), and the free luminal area increased from a mean of 11.2 +/- 4.8 mm2 to 12.5 +/- 4.5 mm2 (p = 0.001). However the occurrence of restenosis during follow-up was comparable in patients monitored during the intervention by IVUS (1-year patency rate, 57%) and patients not studied by IA DSA only (1-year patency rate, 64%). In addition, the presence of an intimal dissection or a plaque rupture at IVUS examination did not predict restenosis.

CONCLUSIONS

The application of IVUS resulted in an improved luminal enlargement by directional atherectomy but not in a better 1-year patency rate.

Laparoscopic cholecystectomy in a surgical training programme

OBJECTIVE

To assess the impact of the introduction of the laparoscopic cholecystectomy on surgical training, and the outcome of laparoscopic cholecystectomies performed by residents compared with those of surgeons.

DESIGN

Retrospective analysis.

SETTING

University hospital, The Netherlands.

SUBJECTS

943 Patients who underwent cholecystectomies from January 1987-December 1993 by residents and surgeons. In 527 patients the cholecystectomy was open and in 416 laparoscopic.

MAIN OUTCOME MEASURES

The percentage of cholecystectomies done by residents in the period 1987-1993. The outcome of laparoscopic cholecystectomies done by surgeons and residents in terms of duration of operation, conversion rate, postoperative complications, and hospital stay.

RESULTS

Before the laparoscopic era about 70% of all cholecystectomies were done by residents. After its introduction in 1990, the residents did 38% of the laparoscopic cholecystectomies in 1991, 39% in 1992, and 64% in 1993. There were no differences in outcome of laparoscopic cholecystectomy in terms of duration of operation, conversion rate, postoperative complications and hospital stay between surgeons and residents.

CONCLUSIONS

The introduction of laparoscopic cholecystectomy caused a temporary decline in the number of cholecystectomies done by residents. Laparoscopic cholecystectomy was integrated as a standard surgical procedure in the residents' training programme within two years of its introduction. The outcome of laparoscopic cholecystectomies done by supervised residents and surgeons was similar, and so laparoscopic cholecystectomy should be part of residents' training.

Outcome of 49 repairs of bile duct injuries after laparoscopic cholecystectomy

Treatment of bile duct injuries after laparoscopic cholecystectomy is still under discussion. The aim of this study was to evaluate the results of end-to-end or biliodigestive anastomosis for various types of bile duct injury. Patient charts of 49 (0.81%) classified bile duct injuries from a national survey of 6076 laparoscopic cholecystectomies in The Netherlands were analyzed. The median follow-up after repair was 183 days (range 14-570 days). Statistical analysis showed that an end-to-end anastomosis was preferred by the surgeons for less severe bile duct injuries and a biliodigestive repair for more severe injuries. Three patients died owing to a delayed detected bile duct injury. Twelve bile duct strictures occurred after repair, leading to a stricture rate of 25%. The time elapsed between repair and occurrence of a stricture was 134 days (range 13-270 days). The type of repair or the severity of the bile duct injury did not determine the outcome of the repair. Histologically proved cholecystitis predisposed a stricture at the repair site. It was concluded that treatment of bile duct injuries is associated with a high stricture rate at the repair site of the anastomosis. End-to-end anastomosis is mostly successful for the less severe injury detected during laparoscopic cholecystectomy. For all other cases this repair can at least be considered a temporary internal drainage procedure. The biliodigestive anastomosis can best be considered a delayed repair after a drainage procedure has resolved the local inflammatory status.

The cost-effectiveness of treatment of short occlusive lesions in the femoropopliteal artery: balloon angioplasty versus endarterectomy

OBJECTIVE

To compare the short- and long-term outcome and the costs involved in balloon angioplasty (BA) and thromboendarterectomy (EA) of short femoropopliteal occlusions.

DESIGN

Retrospective study.

PATIENTS AND METHODS

Forty-one lower limbs underwent EA from 1980 until 1988 and BA was performed in 62 limbs between 1988 and 1993. The two groups of patients were well matched for age, gender, cardiovascular risk-factors and the length of the femoropopliteal occlusions. In addition to clinical follow-up colour-Duplex scanning and intraarterial DSA were performed. Complete occlusions or significant restenoses were considered failure of the reconstruction. Actual costs were calculated by the hospital economic administration.

RESULTS

The 3-year primary patency in EA patients was 87% and in the BA group 44% (p = 0.0002). Redo procedures were required in seven (17%) patients with EA and in 24 (39%) with BA. Patency after redo procedures, i.e. tertiary patency, was 94% and 74% after 3 years in the EA and BA group respectively (p = 0.14). The mean cost of the primary treatment was higher in EA than in BA patients (p < 0.0001). Mean total treatment costs including the expenses involved with redo procedures were also higher in the group with EA than with BA (p < 0.001). However, the cost-effectiveness expressed as the total costs per month tertiary patency, was not significantly different for the two treatment groups; in patients with EA the ratio of total treatment costs and tertiary patency was NFl 309, and in patients with BA NFl 287.

CONCLUSION

Contrary to the general view the expenses associated with surgical treatment are comparable with those of an endovascular procedure, if the costs are expressed as a cost-to-patency ratio.

Directional atherectomy versus balloon angioplasty in segmental femoropopliteal artery disease: two-year follow-up with color-flow duplex scanning

PURPOSE

Directional atherectomy is an endovascular interventional technique for excision and removal of obstructive arterial lesions. To evaluate whether atherectomy would provide better results than conventional balloon angioplasty (BA) in symptomatic femoropopliteal disease, a prospective randomized study comparing the early and late outcomes of these techniques was conducted. The rate of restenosis or occlusion was assessed by use of color-flow duplex scanning during the follow-up period.

METHODS

Seventy-three patients were randomized between atherectomy (38 patients) and BA (35 patients). All patients had segmental lesions of the femoropopliteal arteries amenable to either technique. The median follow-up duration was 13 months (range 1 to 39). Follow-up comprised regular clinical and hemodynamic assessment and color-flow duplex examinations. Restenosis was defined on the basis of a peak systolic velocity ratio of 2.5 or greater, and occlusion of the treated segment was diagnosed if flow signals were absent, that is, loss of patency.

RESULTS

Residual stenoses (> or = 30% diameter reduction) resulted in five patients (13%) undergoing atherectomy and three patients (9%) undergoing BA. At 1 month clinical and hemodynamic improvement by Society for Vascular Surgery/International Society for Cardiovascular Surgery criteria for lower limb ischemia was observed in 34 patients (89%) treated with atherectomy and in 34 (97%) treated with BA. By life-table analysis the cumulative rate of clinical and hemodynamic success at 2 years was 52% in patients treated with atherectomy and 87% in patients treated with BA (p = 0.06). The patency rate at 2 years of treated segments was 34% in the atherectomy group and 56% in patients treated with BA (p = 0.07). In patients with lesions greater than 2 cm, the 1-year patency rate of AT was significantly lower than BA (p = 0.03).

CONCLUSIONS

Atherectomy does not result in an improved clinical and hemodynamic outcome. Furthermore atherectomy of segmental atherosclerotic femoropopliteal disease does not result in a better patency rate than BA, and, in lesions with greater length than 2 cm, the atherectomy results are significantly worse.

Risk factors for bile duct injury in laparoscopic cholecystectomy: analysis of 49 cases

Forty-nine bile duct injuries, representing 0.8 per cent of 6076 laparoscopic cholecystectomies performed in the Netherlands in 1990-1992, were reviewed. The aim of the study was to classify the injuries according to severity, to identify possible risk factors contributing to the aetiology of such injuries and to correlate these with the severity of the injury. On the basis of operative findings, bile duct injuries were classified from minor (classes I-IIIa) to extensive with loss of bile duct tissue (IIIb) or localization in the liver hilum (IV). Of 49 injuries, there were 11 in class I, six in class II, ten in class IIIa, 18 in class IIIb and four in class IV. In 16 patients the injury was detected during laparoscopic cholecystectomy and the procedure converted to laparotomy. The duct injury was minor (class I-IIIa) in 14 of these 16 patients. In 20 of the 33 patients in whom identification of the injury was delayed to a second or third operation, more severe types of injury (classes IIIb and IV) were observed. Delayed detection was associated with greater severity (P = 0.002). Of eight patients with histologically proven acute cholecystitis at cholecystectomy, seven suffered severe injury (class IIIb or IV). Surgical experience with laparoscopic cholecystectomy was an important factor in the incidence of bile duct injury.