Objective Primary postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality around the world. Most patients can be managed conservatively, but patients with intractable ...bleeding require more aggressive treatment. In these cases uterine artery embolisation (UAE) has proven to be a useful tool to control PPH. The reported success rate of UAE is over 90% with only minor complications. In this case series we studied the effectiveness and complications of UAE.
Design Retrospective analysis of a case series.
Setting Case series in a large peripheral hospital in the Netherlands.
Sample Eleven patients who were treated with UAE for intractable PPH from November 2004 to February 2008.
Methods In this paper we review the results of all patients treated with UAE for intractable PPH in our hospital and focus on the two cases with adverse outcomes.
Main outcome measures Effectiveness, causes of failure of UAE, complications.
Results Nine out of eleven patients were treated successfully with UAE. One patient needed an emergency hysterectomy for intractable bleeding. In the aftermath she developed a vesicovaginal fistula (VVF). Another patient suffered a major thrombo‐embolic event of the right leg, for which she underwent embolectomies and despite fasciotomy a necrotectomy.
Conclusions UAE is a valuable tool in managing major PPH and in most cases it can replace surgery and thus prevent sacrification of the uterus. However, due to blood supply of the uterus by one of the ovarian or aberrant arteries, UAE might fail to control the bleeding. In addition, serious complications such as a thrombo‐embolic event or VVF may occur. We hereby present a case of migration of an embolus from the site of re‐embolisation into the femoral artery requiring immediate intervention to prevent the loss of the lower leg. This complication demonstrates that gelatine sponge particles could migrate from the internal iliac artery into the external iliac artery.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Long‐term survival is similar after open or endovascular repair of abdominal aortic aneurysm. Few data exist on the effect of either procedure on long‐term health‐related quality of life ...(HRQoL) and health status.
Methods
Patients enrolled in a multicentre randomized clinical trial (DREAM trial; 2000–2003) in Europe of open repair versus endovascular repair (EVAR) of abdominal aortic aneurysm were asked to complete questionnaires on health status and HRQoL. HRQoL scores were assessed at baseline and at 13 time points thereafter, using generic tools, the Medical Outcomes Study 36‐Item Short‐Form Health Survey (SF‐36®) and EuroQol 5D (EQ‐5D™). Physical (PCS) and mental component summary scores were also calculated. Follow‐up was 5 years.
Results
Some 332 of 351 patients enrolled in the trial returned questionnaires. More than 70 per cent of questionnaires were returned at each time point. Both surgical interventions had a short‐term negative effect on HRQoL and health status. This was less severe in the EVAR group than in the open repair group. In the longer term the physical domains of SF‐36® favoured open repair: mean difference in PCS score between open repair and EVAR −1·98 (95 per cent c.i. −3·56 to −0·41). EQ‐5D™ descriptive and EQ‐5D™ visual analogue scale scores for open repair were also superior to those for EVAR after the initial 6‐week interval: mean difference −0·06 (−0·10 to −0·02) and −4·09 (−6·91 to −1·27) respectively.
Conclusion
In this study EVAR appeared to be associated with less severe disruption to HRQoL and health status in the short term. However, during longer‐term follow‐up to 5 years, patients receiving open repair appeared to have improved quality of life and health status.
Long‐term quality of life better following open repair
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Objective It is well-known that vasodilatator function is affected in patients with renal failure. We hypothesized impaired venous forearm distensibility in haemodialysis patients. The ...purpose of this study was to investigate which provocation method generated ‘maximal’ venous distensibility in the forearm of haemodialysis patients compared to healthy volunteers by using duplex ultrasound. Design The study group consisted of haemodialysis patients ( n = 30) and healthy volunteers ( n = 30). In each participant ultrasound measurements of the venous diameter were performed by using 3 different provocation methods. Methods The applied provocation methods were: 1) hydrostatic pressure, 2) venous congestion and 3) hydrostatic pressure and warmth. Significance of differences in mean diameter changes within the groups was assessed with the paired t -test. Significance of differences in mean diameter changes between the groups was compared by using multivariate regression analysis. Results In haemodialysis patients, the increase in mean diameter after the different methods was: 29% after methods 2 versus 1, 23% after methods 3 versus 2 and 59% after methods 3 versus 1. In healthy volunteers, the mean diameter increase was: 27% after methods 2 versus 1, 29% after methods 3 versus 2 and 64% after methods 3 versus 1. The greatest increase in the mean internal venous diameter among the haemodialysis patients and the healthy volunteers was after the provocation method which combined hydrostatic pressure with warmth (mean difference: 1 mm, 95% CI: .57, 1.36; P < .001 and mean difference: 1.4 mm, 95% CI: .88, 1.78; P < .001, respectively). After adjustment for the baseline variables, both groups demonstrated a non-significant mean diameter difference for each of the provocation methods. Conclusion Hydrostatic pressure combined with warmth generates the greatest venous distensibility in the lower arm in haemodialysis patients in a sitting position and is not significantly different compared to healthy volunteers. Without the superior provocation method, venous diameters of haemodialysis patients can be assessed as false-negatives yielding that a primary radio cephalic arteriovenous fistula (RCAVF) at wrist level (the first choice) in these patients will be withheld.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Objective Techniques for surgical repair of Trans-Atlantic Inter-Society Consensus (TASC) C and D lesions of the superficial femoral artery (SFA) are supragenicular bypass grafting or the ...less invasive remote endarterectomy (RSFAE). This trial compares the patency rates of both techniques. Design Randomized, multicenter trial. Materials and methods 116 patients were randomized to RSFAE ( n = 61) and supragenicular bypass surgery ( n = 55). Indications for surgery were claudication ( n = 77), rest pain ( n = 21), or tissue loss ( n = 18). Results Median hospital stay was 4 days in the RSFAE group compared with 6 days in the bypass group ( p = 0.004). Primary patency after 1-year follow-up was 61% for RSFAE and 73% for bypass ( p = 0.094). Secondary patency was 79% for both groups. Subdividing between venous ( n = 25) and prosthetic grafts ( n = 30) shows a primary patency of 89% and 63% respectively at 1-year follow-up ( p = 0.086). Conclusion RSFAE is a minimally invasive adjunct in the treatment of TASC C and D lesions of the SFA, with shorter admittance and a comparable secondary patency rate to bypass. The venous bypass is superior to both RSFAE and PTFE bypass surgery, but only 45% of patients had a sufficient saphenous vein available. This study is registered with ClinicalTrials.gov , number NCT00566436.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
OBJECTIVE:The aim of this was to analyze differences between saccular-shaped abdominal aortic aneurysms (SaAAAs) and fusiform abdominal aortic aneurysms (FuAAAs) regarding patient characteristics, ...treatment, and outcome, to advise a threshold for intervention for SaAAAs.
BACKGROUND:Based on the assumption that SaAAAs are more prone to rupture, guidelines suggest early elective treatment. However, little is known about the natural history of SaAAAs and the threshold for intervention is not substantiated.
METHODS:Observational study including primary repairs of degenerative AAAs in the Netherlands between 2016 and 2018 in which the shape was registered, registered in the Dutch Surgical Aneurysm Audit (DSAA). Patients were stratified by urgency of surgery; elective versus acute (symptomatic/ruptured). Patient characteristics, treatment, and outcome were compared between SaAAAs and FuAAAs.
RESULTS:A total of 7659 primary AAA-patients were included, 6.1% (n = 471) SaAAAs and 93.9% (n = 7188) FuAAAs. There were 5945 elective patients (6.5% SaAAA) and 1714 acute (4.8% SaAAA). Acute SaAAA-patients were more often female (28.9% vs 17.2%, P = 0.007) compared with acute FuAAA-patients. SaAAAs had smaller diameters than FuAAAs, in elective (53.0 mm vs 61 mm, P = 0.000) and acute (68 mm vs 75 mm, P = 0.002) patients, even after adjusting for sex. In addition, 25.2% of acute SaAAA-patients presented with diameters <55 mm and 8.4% <45 mm, versus 8.1% and 0.6% of acute FuAAA-patients (P = 0.000). Postoperative outcomes did not significantly differ between shapes in both elective and acute patients.
CONCLUSIONS:SaAAAs become acute at smaller diameters than FuAAAs in DSAA patients. This study therefore supports the current idea that SaAAAs should be electively treated at smaller diameters than FuAAAs. The exact diameter threshold for elective treatment of SaAAAs is difficult to determine, but a diameter of 45 mm seems to be an acceptable threshold.
Vascular graft/endograft infection is a rare but life-threatening complication of cardiovascular surgery and remains a surgical challenge. Several different graft materials are available for the ...treatment of vascular graft/endograft infection, each having its own advantages and disadvantages. Biosynthetic vascular grafts have shown low reinfection rates and could be a potential second best after autologous veins in the treatment of vascular graft/endograft infection. Therefore, the aim of our study was to evaluate the efficacy and morbidity of Omniflow® II for the treatment of vascular graft/endograft infection.
A multicenter retrospective cohort study was performed to evaluate the use of Omniflow® II in the abdominal and peripheral region to treat vascular graft/endograft infection between January 2014 and December 2021. Primary outcome was recurrent vascular graft infection. Secondary outcomes included primary patency, primary assisted patency, secondary patency, all-cause mortality, and major amputation.
Fifty-two patients were included with a median follow-up duration of 26.5 (10.8–54.8) months. Nine (17%) grafts were implanted in intracavitary position and 43 (83%) in peripheral position. Most grafts were used as femoral interposition (n = 12, 23%), femoro-femoral crossover (n = 10, 19%), femoro-popliteal (n = 8, 15%), and aorto-bifemoral (n = 8, 15%) graft. Fifteen (29%) grafts were implanted extra-anatomically and 37 (71%) in situ. Eight patients (15%) presented with reinfection during follow-up, most of these patients received an aorto-bifemoral graft (n = 3, 38%). Intracavitary vascular grafting had a 33% (n = 3) reinfection rate and peripheral grafting 12% (n = 5; P = 0.025). The estimated primary patencies at 1, 2, and 3 years were 75%, 72%, and 72% for peripherally located grafts and 58% (at all timepoints) for intracavitary grafts (P = 0.815). Secondary patencies at 1, 2, and 3 years were 77% (at all timepoints) for peripherally located prostheses and 75% (at all timepoints) for intracavitary prostheses (P = 0.731). A significantly higher mortality during follow-up was observed in patients who received an intracavitary graft compared to patients with a peripheral graft (P = 0.003).
This study highlights the efficacy and safety of the Omniflow® II biosynthetic prosthesis for the treatment of vascular graft/endograft infection, in absence of suitable venous material, with acceptable reinfection, patency, and freedom of amputation prevalences, especially in replacing peripheral vascular graft/endograft infection. However, a control group with either venous reconstruction or another alternative graft is needed to make firmer conclusions.
•A series of 52 patients who received an Omniflow® II were included in this study.•This study is the largest study on Omniflow® II used for the treatment of VGEI.•Omniflow® II showed acceptable reinfection-, patency-, and amputation prevalences.•Omniflow® II can be used in absence of a suitable vein for the treatment of VGEI.
Intimal hyperplasia develops preferentially in regions where the blood flow is stagnant and wall shear stress low. The small amplitude helical geometry of the SwirlGraft™ was designed to ensure ...physiological-type swirling flow, and thus suppress the triggers. We report the first conceptual testing of the SwirlGraft™. Primary, assisted primary and secondary patency rates at 6 months in 20 patients were 57.9 ± 11.4%, 84.4 ± 8.3% and 100 ± 0.0%. There was angiographic evidence of reduction of helical geometry in a proportion of the grafts. The helical graft is associated with high assisted primary and secondary patency. Elaboration of the surgical implantation techniques and an improved SwirlGraft™ design can be expected to exploit the advantages of the helical concept.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Evidence regarding the outcomes of Omniflow
II prosthesis in peripheral arterial revascularization at different anatomical sites and for different indications is scarce. Therefore, the aim of this ...study was to evaluate the outcomes of the Omniflow
II used at various positions within the femoral tract both in infected and non-infected setting.
Patients who underwent reconstructive lower leg vascular surgery with implantation of an Omniflow
II from 2014 until 2021 at five medical centers were retrospectively included (N.=142). Patients were subdivided into the following categories: femoro-femoral crossover (N.=19), femoral interposition (N.=18), femoro-popliteal (above-the-knee N.=25; AK or below-the-knee N.=47; BK), and femoro-crural bypass grafts (N.=33). Primary outcome was primary patency and secondary outcomes included primary assisted patency, secondary patency, major amputation, vascular graft infection, and mortality. Outcomes were compared according to different subgroups and the surgical setting (infected versus non-infected).
The median follow-up was 35.0 (17.5-54.3) months. Three years primary patency of 58% was observed for femoro-femoral crossover bypass, 75% for femoral interposition graft, 44% for femoro-popliteal above-the-knee bypass, 42% for femoro-popliteal below-the-knee bypass, and 27% in the femoro-crural position (P=0.006). Freedom from major amputation at three years were 84% for femoro-femoral crossover bypass, 88% for femoral interposition bypass, 90% for femoro-popliteal AK bypass, 83% for femoro-popliteal BK bypass, and 50% for femoro-crural bypass (P<0.001).
This study demonstrates the safety and feasibility of the use of Omniflow
II for femoro-femoral crossover-, femoral interposition-, and femoro-popliteal (AK and BK) bypass. Omniflow
II seems to be less suitable for femoro-crural bypass with a significantly lower patency compared to other positions.
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).
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.
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).
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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background: The benefit of carotid endarterectomy (CEA) in patients with a significant (>70%) (a)symptomatic stenosis has been proven thoroughly in major trials. It is unknown whether, after ...cross-clamping the carotid artery, the time interval between determination that a shunt is needed and the actual functioning of the shunt, defined as the need for shunt-to-shunt time (NST), influences 30-day morbidity and mortality rate after CEA. Methods: Experienced vascular surgeons performed 851 CEAs with a selective shunting protocol based on perioperative transcranial Doppler measurement and electroencephalographic findings, and data were analyzed retrospectively. The study included 156 shunted patients. Results: Longer NST was associated with an increase in the 30-day stroke/death rate. A binary logistic regression model was used to determine a 2-tailed P value of .004 and an odds ratio of 1.5/min increase of the NST. There was no influence on stroke-death rate of gender, age, symptomatic or asymptomatic stenosis, the use of a patch or not, or the number of periprocedural microembolic signals. Conclusion: If CEA is performed with a selective shunting protocol, a longer NST increases the 30-day stroke/death rate. These results support a strong recommendation that shunt placement should be as quick as possible.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
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