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- Ersryd, Samuel, et al.
(author)
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Editor's Choice - Abdominal Compartment Syndrome After Surgery for Abdominal Aortic Aneurysm : A Nationwide Population Based Study
- 2016
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In: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 52:2, s. 158-165
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Journal article (peer-reviewed)abstract
- Objective/Background: The understanding of abdominal compartment syndrome (ACS), and its importance for outcome, has increased over time. The aim was to investigate the incidence and clinical consequences of ACS after open (OR) and endovascular repair (EVAR) for ruptured and intact infrarenal abdominal aortic aneurysm (rAAA and iAAA, respectively). Methods: In 2008, ACS and decompression laparotomy (DL) were introduced as variables in the Swedish vascular registry (Swedvasc), offering an opportunity to study this complication in a prospective, population based design. Operations carried out in the period 2008-13 were analysed. Of 6,612 operations, 1,341 (20.3%) were for rAAA (72.0% OR) and 5,271 (79.7%) for iAAA (41.9% OR). In all, 3,171 (48.0%) were operated on by OR and 3,441 by EVAR. Prophylactic open abdomen (OA) treatment was validated through case records. Cross-matching with the national population registry secured valid mortality data. Results: After rAAA repair, ACS developed in 6.8% after OR versus 6.9% after EVAR (p = 1.0). All major complications were more common after ACS (p<.001). Prophylactic OA was performed in 10.7% of patients after OR. For ACS, DL was performed in 77.3% after OR and 84.6% after EVAR (p=.433). The 30 day mortality rate was 42.4% with ACS and 23.5% without ACS (p <.001); at 1 year it was 50.7% versus 31.8% (p <.001). After iAAA repair, ACS developed in 1.6% of patients after OR versus 0.5% after EVAR (p <.001). Among those with ACS, DL was performed in 68.6% after OR and in 25.0% after EVAR (p=.006). Thirty day mortality was 11.5% with ACS versus 1.8% without it (p <.001); at 1 year it was 27.5% versus 6.3% (p <.001). When ACS developed, renal failure, multiple organ failure, intestinal ischaemia, and prolonged intensive care were much more frequent (p <.001). Morbidity and mortality were similar, regardless of primary surgical technique (OR/EVAR/iAAA/rAAA). Conclusion: ACS and OA were common after treatment for rAAA. ACS is a devastating complication after surgery for rAAA and iAAA, irrespective of operative technique, emphasizing the importance of prevention.
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| 2. |
- Ersryd, Samuel, et al.
(author)
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Editor's Choice - Abdominal Compartment Syndrome after Surgery for Abdominal Aortic Aneurysm : Subgroups, Risk Factors, and Outcome
- 2019
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In: European Journal of Vascular and Endovascular Surgery. - : W B SAUNDERS CO LTD. - 1078-5884 .- 1532-2165. ; 58:5, s. 671-679
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Journal article (peer-reviewed)abstract
- Objectives: Abdominal compartment syndrome (ACS) is a serious complication after abdominal aortic aneurysm (AAA) repair. The aim was to investigate outcome among subgroups and factors associated with outcome, with emphasis on the duration of intra-abdominal hypertension before treatment.Methods: Since 2008, ACS and decompressive laparotomy (DL) after AAA repair are registered prospectively in the Swedish vascular registry (Swedvasc). Registry data and case records were reviewed. Subgroups were defined by main pathophysiological finding at DL, timing of DL after AAA repair, and treatment modality.Results: During 2008-2015, 120 of 8765 patients undergoing surgery for infrarenal AAA developed postoperative ACS (1.4%). Eighty-three followed ruptured AAA (rAAA); 45 open surgical repairs (OSR) and 38 endovascular (EVAR), and thirty-seven after intact AAA (iAAA); 30 OSR and seven EVAR. The main pathophysiological findings at DL were bowel ischaemia in 27 (23.3%), post-operative bleeding in 34 (29.3%), and general oedema in 55 (47.4%). DL was performed <24 hours after AAA repair in 56 (48.7%), 24-48 hours in 30 (26.1%), and >48 hours in 29 patients (25.2%). The overall 90 day mortality was 50.0%, neither different depending on main pathophysiological finding, nor on the timing of DL. In multivariable regression analysis, age was a predictor of mortality (p = .017), while duration of intra-abdominal hypertension (IAH) prior to DL predicted the need for renal replacement therapy (RRT) (p = .033). DL was performed earlier after EVAR compared with OSR in rAAA (p < .001).Conclusions: Mortality in ACS was high, irrespective of the main pathophysiological finding and timing of DL. The duration of IAH prior to DL predicted the need for RRT. DL was performed earlier after EVAR than after OSR for rAAA, underlining the importance of monitoring IAP after EVAR for rAAA.
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| 3. |
- Gunnarsson, Kim, et al.
(author)
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Endovascular Versus Open Repair as Primary Strategy for Ruptured Abdominal Aortic Aneurysm : A National Population-based Study
- 2016
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In: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 51:1, s. 22-28
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Journal article (peer-reviewed)abstract
- OBJECTIVE/BACKGROUND: In randomized trials, no peri-operative survival benefit has been shown for endovascular (EVAR) repair of ruptured abdominal aortic aneurysm (rAAA) when compared with open repair. The aim of this study was to investigate the effect of primary repair strategy on early and midterm survival in a non-selected population based study.METHODS: The Swedish Vascular Registry was consulted to identify all rAAA repairs performed in Sweden in the period 2008-12. Centers with a primary EVAR strategy (treating > 50% of rAAA with EVAR) were compared with centers with a primary open repair strategy. Peri-operative outcome, midterm survival, and incidence of rAAA repair/100,000 inhabitants aged > 50 years were assessed.RESULTS: In total, 1,304 patients were identified. Three primary EVAR centers (pEVARc) operated on 236 patients (74.6% EVAR). Twenty-six primary open repair centers (pORc) operated 1,068 patients (15.6% EVAR). Patients treated at pEVARc were more often referrals (28.0% vs. 5.3%; p < .01), had a higher rate of respiratory comorbidity (36.5% vs. 21.9%; p < .01), and higher pre-operative systolic blood pressure (84.3 vs. 72.3 mmHg; p < .01). There was no difference in mortality based on primary treatment strategy at 30 days (pEVARc 28.0%, n = 66; pORc 27.4%, n = 296 [p = .87]), 1 year (pEVARc 39.9%, n = 93; pORc 34.7%, n = 366 [p = .19]), or 2 years (42.1%, n = 94; 38.3%, n = 394 [p = .28]), either overall or in subgroups based on age or referral status. Overall, patients treated with EVAR were older (mean age 76.4 vs. 74.0 years; p < .01), and had a lower 30 day mortality (EVAR 21.6%, n = 74; odds ratio 29.6%, n = 288 [p = < .01]). Incidence of rAAA repair was lower in pEVARc regions (6.07, 95% confidence interval [CI] 5.01-7.13) when compared with pORc regions (8.15, 95% CI 7.64-8.66).CONCLUSION: There was no difference in mortality after rAAA repair among centers with a primary EVAR approach when compared with a primary open repair strategy, either peri-operatively or in the midterm. The study supports the early findings of the randomized controlled trials in a national population based setting.
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| 4. |
- Jonsson, M., et al.
(author)
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Near Infrared Spectroscopy as a Predictor for Shunt Requirement During Carotid Endarterectomy
- 2017
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In: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 53:6, s. 783-791
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Journal article (peer-reviewed)abstract
- Objective/Background: Near infrared speCtroscopy (NIRS) continuously monitors regional cerebral oxygenation (rSO2) in the frontal lobes. This method may be used in patients during carotid endarterectomy to indicate the need for shunting. The aim of the study was to evaluate the value of NIRS in determining the need for selective shunting during CEA. A secondary aim was to compare NIRS with stump pressure.Methods: Between January 2013 and October 2016, 185 patients from two vascular units, undergoing CEA under local anaesthesia were prospectively included. All patients gave informed consent to participate; there were no exclusion criteria. A Foresight® oximeter was used for rSO2 measurement, which was compared with stump pressure. Receiver operating characteristic curve analysis was used to identify optimal cutoff points, and sensitivity, specificity, and positive and negative predictive values were calculated.Results: Twenty patients (10.8%) developed neurological symptoms during clamping. Mean stump pressure was lower in the group that developed neurological symptoms than in the group who did not (34 +/- 19 mmHg vs. 55 +/- 17 mmHg [p < . 01]). Corresponding NIRS results for the decrease in rSO2 on the ipsilateral side was 15 +/- 7% versus 4 +/- 6% (p < .01). Using stump pressure <= 50 mmHg as cutoff value for predicting symptoms, the sensitivity was 85% (95% confidence interval [CI] 64-95) and specificity 54% (95% CI 46-61). With a relative decrease in NIRS saturation (triangle rSO2) of 9%, sensitivity was 95% (95% CI 76-99), and specificity 81% (95% CI 74-86) to predict ischaemic symptoms during carotid clamping. Neurological deterioration during carotid clamping was detected in one patient with a relative decrease in rSO2 of <9% compared with three patients with a stump pressure >50 mmHg.Conclusion: NIRS allows continuous non-invasive monitoring of cerebral oxygenation during CEA, with high sensitivity and acceptable specificity in predicting cerebral ischaemia and the need for shupting, which makes it an attractive alternative to stump pressure.
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| 5. |
- Thorbjörnsen, Knut, et al.
(author)
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Editor's Choice - Long-term Outcome After EndoVAC Hybrid Repair of Infected Vascular Reconstructions
- 2016
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In: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1078-5884 .- 1532-2165. ; 51:5, s. 724-732
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Journal article (peer-reviewed)abstract
- Objective/Background: Vascular graft infection is a serious and challenging complication. In situations when neither traditional radical surgery nor conservative negative pressure wound therapy (VAC) alone, are considered feasible or safe, for example due to bleeding, adverse anatomy, or severe comorbidity, a novel hybrid procedure was developed. The EndoVAC technique consists of (i) relining of the infected reconstruction with a stent graft; (ii) surgical revision (without clamping the reconstruction); and (iii) VAC therapy, to permit granulation and secondary delayed healing, and long-term antibiotic treatment. The aim of the study is to report long-term follow up data of this new treatment modality. Methods: From November 2007 to June 2015, 17 EndoVAC procedures were performed in 16 patients (eight men, aged 16-91 years): six infected carotid patches after carotid endarterectomy, three infected neck deviations, two infected femoro-popliteal bypasses, three infected patches after femoral thrombo-endarterectomy, and two infected vascular accesses. Surveillance was performed routinely every 3-6 months and included clinical examination, hematologic tests, duplex ultrasonography, and imaging techniques, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography. Results: Primary technical success rate was 100%. Antibiotics were prescribed for a median of 3 months (range 1-20 months). The median duration of VAC treatment was 14 days (range 9-57 days). Complications included early, transient stroke (n = 1), temporary hypoglossal palsy (n = 1), and late, asymptomatic occluded bypasses (n = 2), stent graft thrombosis (n = 1), and moderate carotid stenosis (n = 1). After a median of 5 years (range 1-90 months) of follow up, all patients had healed graft infections with no recurrence was observed. Eight patients died as a result of severe comorbidities, unrelated to the infection or hybrid procedure, 1 month 7 years after treatment. Conclusion: The EndoVAC technique is an alternative, less invasive, option for treatment of infected vascular reconstructions in selected cases, when neither traditional radical surgery, nor conservative simple negative pressure wound therapy are considered feasible or safe. The exact indications for this alternative hybrid treatment need to be established.
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| 6. |
- Thorbjörnsen, Knut, et al.
(author)
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Prevalence and natural history of and risk factors for subaneurysmal aorta among 65-year-old men
- 2019
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In: Upsala Journal of Medical Sciences. - : TAYLOR & FRANCIS LTD. - 0300-9734 .- 2000-1967. ; 124:3, s. 180-186
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Journal article (peer-reviewed)abstract
- Background: The aims of this study were to determine the prevalence of screening-detected subaneurysmal aorta (SAA), i.e. an aortic diameter of 2.5-2.9 cm, its associated risk factors, and natural history among 65-year-old men.Methods: A total of 14,620 men had their abdominal aortas screened with ultrasound and completed a health questionnaire containing information on smoking habits and medical history. They were categorized based on the aortic diameter: normal aorta (n = 14,129), SAA (2.5-2.9 cm; n = 258), and abdominal aortic aneurysm (AAA) (>= 3.0 cm; n = 233). The SAA-group was rescanned after 5 years. Associated risk factors were analyzed.Results: The SAA-prevalence was 1.9% (95% confidence interval 1.7%-2.1%), with 57.0% (50.7%-63.3%) expanding to >= 3.0 cm within 5 years. Frequency of smoking, coronary artery disease, hypertension, hyperlipidemia, and claudication were significantly higher in those with SAA and AAA compared to those with normal aortic diameter. Current smoking was the strongest risk factor for SAA (odds ratio [OR] 2.8; P < 0.001) and even stronger for AAA (OR 3.6; P < 0.001). Men with SAA expanding to AAA within 5 years presented pronounced similarities to AAA at baseline.Conclusions: Men with SAA and AAA presented marked similarities in the risk factor profile. Smoking was the strongest risk factor with an incremental association with disease severity, and disease progression. This indicates that SAA and AAA may have the same pathophysiological origin and that SAA should be considered as an early stage of aneurysm formation. Further research on the cost-effectiveness and potential benefits of surveillance as well as smoking cessation and secondary cardiovascular prevention in this subgroup is warranted.
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