Ultra sound colored duplex sonography is the preferred method in diagnosing chronic venous disease. Data in children on incidence, indications, and results are lacking.From the total of 9180 duplex investigations performed in our hospital from 2009 to 2012, data on indication and results of the investigation as well as patient characteristics were evaluated retrospectively for the proportion of pediatric patients.Duplex investigations were performed 49 times in 38 children (6-18 years), with an average of 1.3 times (1-6 times) per child. Forty percent showed abnormalities: 17 times deep venous thrombosis was suspected; deep venous thrombosis was objectified in 18%. In the 21 investigations performed for varicosis-related complaints, varicose veins or venous malformations were objectified in 57%. Edema was never a symptom of chronic venous disease.Duplex investigation is not often performed in children. In children with established deep venous thrombosis, a family history with deep venous thrombosis is common. In general, edema was not seen in children with varicose veins and, therefore, does not seem a reliable clinical sign at young age.
The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR.Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented.A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications.The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.
The clinical consequences of re-occlusion after initially successful arterial revascularization procedures might be as important as patency when it comes to procedure selection. This study evaluates the clinical consequences of re-occlusion after initially successful remote superficial femoral artery endarterectomy (RSFAE), in particular the recurrence and severity of symptoms and the need for re-intervention or amputation.A total of 239 successful RSFAEs were performed with a mean endarterectomized segment of 30 cm (10 to 45 cm) between March 1994 and December 2003 in 214 patients (144 males, 163 procedures) with a median age of 63 years (39 to 89 years). Indications for operation were Rutherford category 3 in 174 procedures (73%), Rutherford category 4 in 27 procedures (11%), and Rutherford category 5 in 38 procedures (16%). The incidence and time interval of re-occlusion with the presenting symptoms were recorded as well as the therapeutic consequences.A total of 79 (33%) re-occlusions occurred (40 males, 41 procedures; 34 females, 38 procedures). Eighty percent of patients still had improved or unchanged symptoms following re-occlusion compared to the initial indication for operation, 18% had become worse and 2% were unknown. The mean time between RSFAE and re-occlusion was 17 months (1 day to 88 months). A total of 36 re-interventions were performed: 7 percutaneous recanalisations (one followed by thrombolysis), 5 percutaneous thrombolyses, 1 thrombectomy, 21 venous and 2 prosthetic femoropopliteal bypasses. A further three venous bypasses were planned. Five (14%) of these re-interventions were acute with an overall median time interval between re-occlusion and re-intervention of 41 days (0 to 68 months). Two below-knee amputations were performed: one the same day of re-occlusion, 44 months after RSFAE and one 11 days after re-occlusion, 30 days after RSFAE.The clinical consequences of re-occlusion after remote endarterectomy for long occlusive disease of the superfricial femoral artery, from a mixed patient population with 27% ischemic rest pain and gangrene, were mild with 31 elective and only five acute re-interventions and two below-knee amputations.
Diabetic foot ulcers, complicated by osteomyelitis, can be treated by surgical resection, dead space filling with gentamicin-loaded calcium sulphate-hydroxyapatite (CaS-HA) biocomposite, and closure of soft tissues and skin. To assess the feasibility of this treatment regimen, we conducted a multicenter retrospective cohort study of patients after failed conventional treatments. From 13 hospitals we included 64 patients with forefoot (n = 41 (64%)), midfoot (n = 14 (22%)), or hindfoot (n = 9 (14%)) ulcers complicated by osteomyelitis. Median follow-up was 43 (interquartile range, 20–61) weeks. We observed wound healing in 54 patients (84%) and treatment success (wound healing without ulcer recurrence) in 42 patients (66%). Treatment failures (no wound healing or ulcer recurrence) led to minor amputations in four patients (6%) and major amputations in seven patients (11%). Factors associated with treatment failures in univariable Cox regression analysis were gentamicin-resistant osteomyelitis (hazard ratio (HR), 3.847; 95%-confidence interval (CI), 1.065–13.899), hindfoot ulcers (HR, 3.624; 95%-CI, 1.187–11.060) and surgical procedures with gentamicin-loaded CaS-HA biocomposite that involved minor amputations (HR, 3.965; 95%-CI, 1.608–9.777). In this study of patients with diabetic foot ulcers, complicated by osteomyelitis, surgical treatment with gentamicin-loaded CaS-HA biocomposite was feasible and successful in 66% of patients. A prospective trial of this treatment regimen, based on a uniform treatment protocol, is required.
Today's patients increasingly desire a low-risk procedure with rapid return to functional status following surgery. Many patients actively seek a minimally invasive option. During the last decade, minimally invasive surgical and radiological procedures emerged from their infancy to become an integral part of the treatment strategy in both peripheral arterial occlusive disease and aneurysmal arterial disease. The trend towards restoration of luminal patency, using the vessel itself as a conduit, can also be termed restorative intervention. As radiological percutaneous transluminal angioplasty has thus far proven unsuccessful in the long term for iliac and femoropopliteal occlusive lesions exceeding 10 cm, a new endovascular surgical procedure has been developed. A modification to the original ringstripper, used in semiclosed endarterectomy, was made to enable the technique of remote endarterectomy.
Purpose: Octogenarians are known to have less-favorable outcomes following ruptured abdominal aortic aneurysm (rAAA) repair compared with their younger counterparts. Accurate information regarding perioperative outcomes following rAAA-repair is important to evaluate current treatment practice. The aim of this study was to evaluate perioperative outcomes of octogenarians and to identify factors associated with mortality and major complications after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of a rAAA using nationwide, real-world, contemporary data. Methods: All patients that underwent EVAR or OSR of an infrarenal or juxtarenal rAAA between January 1, 2013, and December 31, 2018, were prospectively registered in the Dutch Surgical Aneurysm Audit (DSAA) and included in this study. The primary outcome was the comparison of perioperative outcomes of octogenarians versus non-octogenarians, including adjustment for confounders. Secondary outcomes were the identification of factors associated with mortality and major complications in octogenarians. Results: The study included 2879 patients, of which 1146 were treated by EVAR (382 octogenarians, 33%) and 1733 were treated by OSR (410 octogenarians, 24%). Perioperative mortality of octogenarians following EVAR was 37.2% versus 14.8% in non-octogenarians (adjusted OR=2.9, 95% CI=2.8–3.0) and 50.0% versus 29.4% following OSR (adjusted OR=2.2, 95% CI=2.2–2.3). Major complication rates of octogenarians were 55.4% versus 31.8% in non-octogenarians following EVAR (OR=2.7, 95% CI=2.1–3.4), and 68% versus 49% following OSR (OR=2.2, 95% CI=1.8–2.8). Following EVAR, 30.6% of the octogenarians had an uncomplicated perioperative course (UPC) versus 49.5% in non-octogenarians (OR=0.5, 95% CI=0.4–0.6), while following OSR, UPC rates were 20.7% in octogenarians versus 32.6% in non-octogenarians (OR=0.5, 95% CI=0.4–0.7). Cardiac or pulmonary comorbidity and loss of consciousness were associated with mortality and major complications in octogenarians. Interestingly, female octogenarians had lower mortality rates following EVAR than male octogenarians (adjusted OR=0.7, 95% CI=0.6–0.8). Conclusion: Based on this nationwide study with real-world registry data, mortality rates of octogenarians following ruptured AAA-repair were high, especially after OSR. However, a substantial proportion of these octogenarians following OSR and EVAR had an uneventful recovery. Known preoperative factors do influence perioperative outcomes and reflect current treatment practice.
