Uncategorized

What explains the persistent increase in aneurysm following a ‘sealed off’ Type I endoleak?

02/01/2015
ref: EJVES Volume 49, Issue 1, January 2015, Pages 104

Re: ‘“Spontaneous Delayed Sealing in Selected Patients With a Primary Type Ia Endoleak After Endovascular Aneurysm Repair.” Does Correcting the Picture Save the Life?’

In the original paper (1), All but one of the 15 primary type Ia endoleaks sealed spontaneously within 5 months. The disappearance of type Ia endoleaks resulted from improved graft wall apposition due to neck remodelling or thrombosis of the non-apposed neck segment.

However, although ruptures were not detected in the 14 patients, sac growth occurred in four (28.5%).1 In these patients known causes of sac growth were not detected by CT. 

Biomechanical explanation (which does make sense indeed) is that If the barrier between the aneurysm sac and the systemic arterial circulation consists of thrombus only, systemic pressure can be transmitted through a clot, and it is known that mural thrombus on the surface of the aneurysm sac does not prevent rupture.(2) For this reason, a thrombotic barrier on the neck segment may eliminate type Ia endoleak but may not prevent rupture. 

Solution – Maybe by introducing a stiff barrier that prevent from transferring the pressure down into the sac. Feng et al.3 documented results of patients treated by fibrin glue injection: one aneurysm related death and four aneurysm sac growths were detected in 48 cases during 45 months follow up.
_________________________________________
  • 1) F.B. Gonçalvez, H.J.M. Verhagen, K. Vasanthananthan, H.J.A. Zandvoort, F.L. Moll, J.A. van Herwaarden
  • Spontaneous delayed sealing in selected patients with a primary type Ia endoleak after endovascular aneurysm repair
    Eur J Vasc Endovasc Surg, 48 (2014), pp. 53–59
  • 2) F.J. Veith, R.A. Baum, T. Ohki, M. Amor, M. Adiseshiah, J.D. Blankensteijn, et al.
  • Nature and significance of endoleaks and endotension: summary of opinions expressed at an international conference
  • J Vasc Surg, 35 (2002), pp. 1029–1035
  • 3) J.X. Feng, Q.S. Lu, Z.P. Jing, Y. Yang, B. Nie, J.M. Bao, et al.
  • Fibrin glue embolization treating intra-operative type I endoleak of endovascular repair of abdominal aortic aneurysm: long-term result
  • Zhonghua Wai Ke Za Zhi, 49 (10) (2011), pp. 883–887
Uncategorized

Predicting mortality in ruptured AAA

01/22/2015
source:

External Validation of Models Predicting Survival After Ruptured Abdominal Aortic Aneurysm Repair

EJVES Jan2015

What models are available nowadays, and how accurate they are? 
Three models are been tested: updated Glasgow Aneurysm Score (GAS), the Vancouver scoring system, the Edinburgh Ruptured Aneurysm Score (ERAS), and the Hardman index

449 patients in ten hospitals with a RAAA (intervention between 2004 and 2011)

The updated GAS score –  calculated with the formula: age (years) + 7 for cardiac comorbidity (defined as previous history of myocardial infarction, cardiac surgery, angina pectoris or arrhythmia) + 10 for cerebrovascular comorbidity (defined as previous history of stroke or transient ischemic attack) + 17 for shock (defined as an in hospital systolic blood pressure <80 mmHg) + 14 for renal insufficiency (defined as a pre-operative serum creatinine >160 μmol/L) + 7 for OR

|–| Click if POSITIVE Cardiac History – cardiac value:

|–| Click if POSITIVE cerebrovascular History – cerebrovascular value:

|–| Click if POSITIVE SHOCK status – SHOCK value:

|–| Click if POSITIVE RENAL Insufficiency status – RENAL value:

|–| Click if POSITIVE OR status – OR value:

Age:

GAS score:
GAS Predicted Mortality:

|–| Click to get GAS Predicted Mortality rate:

predicted mortality rate (%) =

and the performance of GAS is as follows:  



The Vancouver score –  calculated with the formula: age (years)*0.062 + loss of consciousness (yes = 1/no = −1)*1.14 + cardiac arrest (yes = 1/no = −1)*0.6
predicted mortality rate (%) =



and the performance of Vancouver is as follows:  




The ERAS score –  calculated with the formula: +1 for best recorded in hospital Glasgow coma scale (GCS) <15, +1 for in hospital systolic blood pressure <90 mmHg, +1 for pre-operative hemoglobin level <5.6 mmol/L. A score of 0 or 1 corresponded with a predicted death rate of 30%, a score of 2 with a predicted death rate of 50%, and a score of 3 with a predicted death rate of 80%.
The Hardman index – calculated with the formula: +1 for age >76 years, +1 for in hospital loss of consciousness, +1 for a pre-operative serum creatinine >190 μmol/L, +1 for pre-operative serum hemoglobin level <5.6 mmol/L, +1 for electrocardiographic (ECG) ischemia (defined as ST segment depression greater than 1 millimeter or an associated T wave change determined by a senior cardiologist [RJGP]). A score of 3 or more corresponded with a predicted death rate of 100%.

OVERALL RESULTS: 
The AUC of the updated GAS was 0.71 (95% confidence interval [CI] 0.66–0.76), of the Vancouver score was 0.72 (95% CI 0.67–0.77), and of the ERAS was 0.58 (95% CI 0.52–0.65). 

After recalibration, predictions by the updated GAS slightly overestimated the death rate, with a predicted death rate 60% versus observed death rate 54% (95% CI 44–64%). 

After recalibration, predictions by the Vancouver score considerably overestimated the death rate, with a predicted death rate 82% versus observed death rate 62% (95% CI 52–71%). 

Performance of the Hardman index could not be assessed on discrimination and calibration, because in 57% of patients electrocardiograms were missing.


Decision making

The decision to withhold intervention in patients with a RAAA can be very difficult. Only extremely reliable models can be useful in clinical decision making and in identifying patients in whom withholding intervention might be considered. 
For this purpose, a cut-off value for the predicted death rate was set at ≥95%. If the death rate was to be predicted accurately at 95%, the number needed to treat (NNT) would be 20. This cut-off value is arbitrary and could also have been 90% (NNT of 10) or 99% (NNT of 100). Different cut-off values can be used depending on the clinical situation. 
None of the prediction models met the criterion of identifying patients in whom to withhold intervention. This disappointing conclusion is in agreement with previous validation studies.21, 22 and 23 
Currently, the prediction models have insufficient accuracy to evaluate the chances of successful intervention and future studies should focus on improvement towards this aim. The usefulness of current prediction models lies in case mix comparisons between hospitals, and in a tailored prognosis for patients and relatives.




Uncategorized

Never underestimate the MENTAL PRACTICE

01/20/2015
Based on: BJS Jan 2015

Randomized clinical trial to evaluate mental practice in enhancing advanced laparoscopic surgical performance
Mental practice, the cognitive rehearsal of a task without physical movement, is known to enhance performance in sports and music. This is now tested (in a randomised trial setting) on performing laparoscopic surgery in bariatric. and .. there is a difference between the operator’s performance; which is significant enough (p=0.011). 

Uncategorized

Resect or leave alone: current trends in managing invasive HBP cancers into IVC/Portal veins

01/20/2015
Source of discussion: BJS Jan 2015

Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery. 
In old days, once a cancer has invaded the IVC/portal vein, it is palliative treatment only -mortality rate of resection was 6% and 5yr survival was 27% (1999). However, recent reports from major vascular centres (Leads, Paris) has shown much better outcome, with mortality rate of 11-14% and survival rate of 40% in 5yrs following IVC resection. Technical point: IVC can be ligated unless there is not enough collateral developed in before, or there is haemodynamic instability. Portal vein resection as part of pancreatectomy is now widely regarded as a safe and feasible procedure with acceptable morbidity and mortality rates. Combined portal vein resection with pancreatectomy should be considered where there is a suspicion of invasion of the portal vein to achieve clear resection margins on the basis of preoperative imaging rather than making the decision purely on operative findings. Unlike the situation with hepatic resections, combined arterial resections involving the coeliac axis, at least in the context of distal pancreatectomy, have been reported without a marked increase in surgical mortality. A variety of substitutes for venous reconstruction have been reported. Jugular, external iliac vein, great saphenous vein, left renal and umbilical veins, as well as synthetic grafts have all been used for portal vein reconstruction.here are few diagrams of the technique: 




Uncategorized

How can you estimate the risk of renal failure following contrast angioplasty

06/30/2014
Source:

  1.  Mehran R, Aymong ED, Nikolsky E, et al. (2004). “A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation”. J. Am. Coll. Cardiol. 44 (7): 1393–9. doi:10.1016/j.jacc.2004.06.068. PMID 15464318.

You can do that using a simplified scoring system as follows (tested mainly on coronary angioplasty though): [ excel file is provided also)

Risk Factors:
  • Systolic blood pressure <80 mm Hg – 5 points
  • Intraarterial balloon pump – 5 points
  • Congestive heart failure (Class III-IV or history of pulmonary edema) – 5 points
  • Age >75 y – 4 points
  • Hematocrit level <39% for men and <35% for women – 3 points
  • Diabetes – 3 points
  • Contrast media volume – 1 point for each 100 mL
  • Renal insufficiency:
    • Serum creatinine level >1.5 g/dL – 4 points
or
    • 2 for 40–60 mL/min/1.73 m2
    • 4 for 20–40 mL/min/1.73 m2
    • 6 for < 20 mL/min/1.73 m2
Scoring:
5 or less points
  • Risk of CIN – 7.5
  • Risk of Dialysis – 0.04%
6–10 points
  • Risk of CIN – 14.0
  • Risk of Dialysis – 0.12%
11–16 points
  • Risk of CIN – 26.1*
  • Risk of Dialysis – 1.09%
>16 points
  • Risk of CIN – 57.3
  • Risk of Dialysis – 12.8%
carotid artery disease carotid in geriatrics

do you expect to have similar stroke rate if you operate on a nice talkative active person and on a tired non-talkative and inactive one? is it your technical skills that determines the risk of stroke?

06/24/2014
Reference:
http://stroke.ahajournals.org/content/early/2014/04/30/STROKEAHA.113.003956.abstract

Activities of Daily Living Is a Critical Factor in Predicting Outcome After Carotid Endarterectomy in Asymptomatic Patients

  1. James G. Reeves, MD

Stroke, STROKEAHA.113.003956


NOT REALLY!!!! 
This study showed THREE times risk of stroke when the patient is dependent preoperatively! If you see such a patient, never quote your outcome for stroke; but rather quote three times your figures .. and be careful: how much benefits you expect to achieve if you operate on this patient: balancer it carefully to be on the safe and correct side.
Here are their findings:
Of 19 748 CEAs, 19 348 (97.97%) were functionally independent, 377 (1.99%) were functionally partially dependent, and 23 (0.12%) were functionallydependent. 

In functionally independent group, there were 196 (1.01%) strokes, 84 (0.43%) deaths, and 1416 (7.17%) other complications, 

whereas in the functionally partially dependent group, there were 14 (3.71%) strokes, 10 (2.65%) deaths, and 80 (21.22%) other complications. 

In multivariable risk-adjusted model, using functionally independent as reference, functionally partially dependent was associated with death (odds ratio, 3.3; 95% confidence interval, 1.6–6.8; P<0.001), stroke (odds ratio, 3; 95% confidence interval, 1.7–5.4;P<0.001), and other complications (odds ratio, 2.5; 95% confidence interval, 1.9–3.2; P<0.001).
Intermittent claudication; Exercise; Physical activity; Accelerometer; Energy expenditure Structured_Exercises

How active claudicants are usually? can you depend on them to do the structured exercises?

06/23/2014
source of discussion:

Physical Activity Monitoring in Patients with Intermittent Claudication
G.J. Laureta, b, H.J.P. Fokkenrooda, b, B.L. Bendermachera, M.R.M. Scheltingac, d, J.A.W. Teijinka, b, Corresponding author contact information,
EJVES June 2014

The answer is: No, they are not active at all … and they are therefore likely to fail in any advice for self exercising (it appears)!!

their conclusions:

Methods

Before initiating treatment, 94 patients with newly diagnosed IC and 36 healthy controls were instructed to wear a tri-axial seismic accelerometer for 1 week. Daily PA levels (in metabolic equivalents, METs) were compared with the ACSM/AHA public health PA minimum recommendations (≥64 METs·min·day, in bouts of ≥10 minutes). A subgroup analysis assessed the effect of functional impairment on daily PA levels.

Results

Data from 56 IC patients and 27 healthy controls were available for analysis. Patients with IC demonstrated significantly lower mean daily PA levels (±SD) than controls (387 ± 198 METs·min vs. 500 ± 156 METs·min, p = .02). This difference was solely attributable to a subgroup of IC patients with the largest functional impairment (WIQ-score < 0.4). Only 45% of IC patients met the public health physical activity guidelines compared with 74% of the healthy controls (p = .01).

Conclusions

More than half of patients with IC do not meet recommended standards of PA. Considering the serious health risks associated with low PA levels, these findings underscore the need for more awareness to improve physical exercise in patients with IC.
Hyperbaric oxygen wound healing

would you fight to get a Hyperbaric oxygen in difficult to heal diabetic foot ulcers, or would you consider primary amputation?

06/23/2014
source of discussion:

Hyperbaric Oxygen for the Treatment of Diabetic Foot Ulcers: A Systematic Review
R.M. Stoekenbroeka, Corresponding author contact information, E-mail the corresponding author, T.B. Santemaa, D.A. Legematea, D.T. Ubbinka, A. van den Brinka, b, M.J.W. Koelemaya

EJVES June 2014

Their conclusions:

Two RCTs in patients with ischaemic ulcers found increased rates of complete healing at 1-year follow-up (number needed to treat (NNT) 1.8 (95% CI: 1.1 to 4.6) and 4.1 (95% CI: 2.3 to 19)), but found no difference in amputation rates. A third trial in ischaemic ulcers found significantly lower major amputation rates in patients with HBOT (NNT 4.2, 95% CI: 2.4 to 17), but did not report on wound healing. None of the RCTs in non-ischaemic ulcers reported differences in wound healing or amputation rates. Two trials with unknown ulcer types reported beneficial effects on amputation rates, although the largest trial used a different definition for both outcomes. HBOT did not influence the need for additional interventions.

Conclusion

Current evidence shows some evidence of the effectiveness of HBOT in improving the healing of diabetic leg ulcers in patients with concomitant ischaemia. Larger trials of higher quality are needed before implementation of HBOT in routine clinical practice in patients with diabetic foot ulcers can be justified.

This is very interesting topoic. Looking on the table and results, the trials did show a significant difference in the healing rate for a fairly low NNT; but interesting enough, this didn’t reflect on the final amputaion rate (minor or major) that significantly. But who said that the amputation is only related to wound healing?
So the answer to the question above is: yes, use it if available; there is some good evidence for its benefits; but don’t get over excited!

vein harvesting; endocopic harvesting

are you happy to expose the whole leg for a vein to be harvested, or would you consider mini-invasive endoscopic vein harvest?

06/23/2014
reflection on:

Endoscopic Vein Harvesting in Lower Extremity Arterial Bypass: A Systematic Review

Well; the results are certainly NOT ENCOURAGING: the endoscopic harvesting is damaging the vein and is reducing the patency, SIGNIFICANTLY!!!
Any increased effect on infection rate: nop!!

See their results:

We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03–1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61–1.08). There was a lack of strong evidence to support the secondary outcomes of EVH.


HOWEVER, I am still UNHAPPY with slicing the leg like this … Is there any thing creative, please?? 

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