Abstract Background There is some evidence that patients with renal failure who have arterial procedures may have a poor outcome. This study compared the hospital mortality rate of arterial surgery in patients with chronic renal failure and those with normal renal function. Methods A consecutive series of 1718 patients undergoing arterial reconstructive surgery (excluding amputation) was entered prospectively on to a computerized database. Chronic renal failure was defined as a serum creatinine level over 400 µmol/l, or dialysis (either peritoneal or haemodialysis), or a successful renal transplant. Mortality was assessed at 30 days or in hospital. Results There were 69 patients (4·0 per cent) who were defined as having chronic renal failure. The mortality rate in this group was 23 per cent (16 patients) compared with 7·3 per cent (120 patients) of the 1649 patients without renal failure. The mortality rate was highest in patients undergoing urgent or emergency surgery and in those undergoing reconstruction for lower limb occlusive disease. The main causes of death were related to the cardiovascular system. Conclusion Patients with chronic renal failure undergoing arterial surgery have a poor outcome compared with those with normal renal function.
Abstract Background The Endovascular Aneurysm Repair trial of infrarenal aortic aneurysm repair requires 20 operations to be performed at each centre to eliminate learning curve errors. An analysis was undertaken of the authors' learning curve experience of commercially made thoracic stent grafts. Methods Stent grafting was attempted in 26 patients. Aortic pathology included 13 atheromatous aneurysms, six dissections, one coarctation, three false aneurysms and three transections. Successful deployment was performed in 24 patients (92 per cent), but failed in two women due to small iliac arteries. Stent grafts used were Gore Excluder (16 patients), AneuRx (six), Vanguard (one) and Stenford (one). Four patients required two stents, two needed three stents, and 18 had a single stent. Results Thirteen elective procedures were uneventful. Two deaths occurred in 11 urgent procedures, from pulmonary embolism and aortic rupture of an unsuspected false aneurysm. The overall in-hospital mortality rate was 8 per cent (two of 24 patients). One graft with a persistent endoleak was removed at open repair at 6 weeks. The subclavian artery origin was covered in three elderly patients, resulting in minor distal ischaemia. No spinal cord problems were seen. One patient died from pneumonia at 8 weeks, and another died from rupture at 28 months as a result of prolapse of the stent into the aneurysm sac. Conclusion Assessment of the diameter of the iliac arteries is important, especially in women, to ensure that they accommodate the size of the sheath. Patients with false aneurysms have a poor outcome, and treatment by stent grafting may not be durable. Covering the origin of the left subclavian artery can be undertaken in elderly patients with transient minor symptoms. The use of stent grafts in acute type B dissection should be the subject of a randomized trial. Continued surveillance is essential.
Abstract Background This study investigated the volume–outcome relationship for abdominal aortic aneurysm (AAA) surgery and quantified critical volume thresholds. Methods PubMed, EMBASE and the Cochrane library were searched for articles on the operation volume–outcome relationship in elective and ruptured AAA surgery. UK Hospital Episode Statistics data were also considered. Elective and ruptured AAA repairs were dealt with separately. The data were meta-analysed, and the odds ratios (95 per cent confidence interval) for mortality at higher- and lower-volume hospitals were compared. Volume thresholds were identified from each paper. Results The analysis included 421 299 elective and 45 796 ruptured AAA operations. Significant relationships between mortality and annual volume were noted for both groups. Overall, the weighted odds ratio was 0·66 (0·65 to 0·67) for elective repair at a threshold of 43 AAAs per annum and 0·78 (0·73 to 0·82) for ruptured aneurysm repair at a threshold of 15 AAAs per annum, both in favour of high-volume institutions. Conclusion Higher annual operation volumes are associated with significantly lower mortality in both elective and ruptured AAA repair. This suggests that AAA surgery should be performed only at higher-volume centres.
Abstract Background The primary closure of carotid arteriotomy has a high incidence of intraoperative residual stenosis following carotid endarterectomy. Methods Completion angiograms in a consecutive series of 197 patients undergoing carotid endarterectomy were reviewed. All operations were performed under general anaesthesia with routine shunt insertion and middle cerebral artery transcranial Doppler monitoring. The first 117 patients had primary closure of the arteriotomy and the last 80 all had patch closure. An independent radiologist, who was unaware of the procedure performed, randomly assessed the intraoperative angiograms. All patients have been followed by 3-monthly duplex screening for 1 year. Results were assessed with the χ2 test. Results The stroke and death rate of 7 per cent in the primary closure group was significantly higher than the 1 per cent stroke and death rate in the patched group (P < 0·05). Perioperative angiograms scored 0–20 per cent residual stenosis in 75 per cent of the primary closures, compared with 89 per cent in the patched group (P < 0·05). Some 25 per cent of the primary closures were considered unsatisfactory, compared with 11 per cent of the patched closures. Restenosis greater than 50 per cent at 1 year was significantly higher in the primary closure group (33 versus 19 per cent; P < 0·05). Conclusion Patch closure results in a better technical result than primary closure, as judged by radiological appearance, and reduces the overall stroke and death rate. Restenosis is significantly lower at 1 year.
Abstract Background Vascular surgical care has changed dramatically in recent years with little knowledge of the impact of system failures on patient safety. The primary aim of this multicentre observational study was to define the landscape of surgical system failures, errors and inefficiency (collectively termed failures) in aortic surgery. Secondary aims were to investigate determinants of these failures and their relationship with patient outcomes. Methods Twenty vascular teams at ten English hospitals trained in structured self-reporting of intraoperative failures (phase I). Failures occurring in open and endovascular aortic procedures were reported in phase II. Failure details (category, delay, consequence), demographic information (patient, procedure, team experience) and outcomes were reported. Results There were strong correlations between the trainer and teams for the number and type of failures recorded during 88 procedures in phase I. In 185 aortic procedures, teams reported a median of 3 (i.q.r. 2–6) failures per procedure. Most frequent failures related to equipment (unavailability, failure, configuration, desterilization). Most major failures related to communication. Fourteen failures directly harmed 12 patients. Significant predictors of an increased failure rate were: endovascular compared with open repair (incidence rate ratio (IRR) for open repair 0·71, 95 per cent c.i. 0·57 to 0·88; P =0·002), thoracic aneurysms compared with other aortic pathologies (IRR 2·07, 1·39 to 3·08; P < 0·001) and unfamiliarity with equipment (IRR 1·52, 1·20 to 1·91; P < 0·001). The major failure total was associated with reoperation (P =0·011), major complications (P = 0·029) and death (P = 0·027). Conclusion Failure in aortic procedures is frequently caused by issues with team-working and equipment, and is associated with patient harm. Multidisciplinary team training, effective use of technology and new-device accreditation may improve patient outcomes.
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