Background: The ultimate goal of treating patients with abdominal aortic aneurysms (AAAs) is to repair them when the risk of rupture exceeds the risk of repair. Small AAAs demonstrate a low rupture ...risk, and recently, large AAAs just above the threshold (5.5–6.0 cm) seem to be at low risk of rupture as well. The present review aims to investigate the outcomes of AAAs under surveillance through a comprehensive systematic review and meta-analysis. Methods: PubMed, Embase, and the Cochrane Central Register were searched (22 March 2022; PROSPERO; #CRD42022316094). The Cochrane and PRISMA statements were respected. Blinded systematic screening of the literature, data extraction, and quality assessment were performed by two authors. Conflicts were resolved by a third author. The meta-analysis of prevalence provided estimated proportions, 95% confidence intervals, and measures of heterogeneity (I2). Based on I2, the heterogeneity might be negligible (0–40%), moderate (30–60%), substantial (50–90%), and considerable (75–100%). The primary outcome was the incidence of AAA rupture. Secondary outcomes included the rate of small AAAs reaching the threshold for repair, aortic-related mortality, and all-cause mortality. Results: Fourteen publications (25,040 patients) were included in the analysis. The outcome rates of the small AAA group (<55 mm) were 0.3% (95% CI 0.0–1.0; I2 = 76.4%) of rupture, 0.6% (95% CI 0.0–1.9; I2 = 87.2%) of aortic-related mortality, and 9.6% (95% CI 2.2–21.1; I2 = 99.0%) of all-cause mortality. During surveillance, 21.4% (95% CI 9.0–37.2; I2 = 99.0%) of the initially small AAAs reached the threshold for repair. The outcome rates of the large AAA group (>55 mm) were 25.7% (95% CI 18.0–34.3; I2 = 72.0%) of rupture, 22.1% (95% CI 16.5–28.3; I2 = 25.0%) of aortic-related mortality, and 61.8% (95% CI 47.0–75.6; I2 = 89.1%) of all-cause mortality. The sensitivity analysis demonstrated a higher rupture rate in studies including <662 subjects, patients with a mean age > 72 years, >17% of female patients, and >44% of current smokers. Conclusion: The rarity of rupture and aortic-related mortality in small AAAs supports the current conservative management of small AAAs. Surveillance seems indicated, as one-fifth reached the threshold for repair. Large aneurysms had a high incidence of rupture and aortic-related mortality. However, these data seem biased by the sparse and heterogeneous literature overrepresented by patients unfit for surgery. Specific rupture risk stratified by age, gender, and fit-for-surgery patients with large AAAs needs to be further investigated.
Little is known about burnout among European vascular surgeons (VSs). In this study, the prevalence of burnout and its associated risk factors were investigated among all VSs and vascular surgeons in ...training (VSTs) in Denmark.
An anonymous electronic survey was distributed to all clinical active VSs and VSTs on January 1, 2020. Validated assessment tools were used to measure burnout and aspects of the psychosocial work environment.
A total of 104 VSs and VSTs were invited to participate, and 82% (n = 85) completed the survey. The majority of the respondents were male (60%; n = 50) and VSs (67%; n = 61). Of the respondents, 82% (n = 70) reported either light (54%; n = 46), moderate (22%; n = 19), or severe (6%; n = 5) personal burnout. More than 50% (n = 47) reported work-related burnout, light (39%; n = 33), moderate (9%; n = 8), and severe (7%; n = 6), respectively, whereas 35% (n = 30) reported patient-related burnout, light (31%; n = 26), moderate (2%; n = 2), and severe (2%; n = 2), respectively. Respondents with more than four 24-hour on-call shifts per month had significantly higher work-related burnout scores, whereas respondents with home-living children and those aged 45 to 59 years showed significantly higher personal and patient-related burnout, respectively. There were strong associations between personal and work-related burnout and the psychosocial work environment, especially work organization and interpersonal relations, but not job demands. The prevalence of burnout was unevenly distributed across departments, with the most affected department having a burnout occurrence twice the least affected department.
Based on a national survey conducted among all clinical active VSs and VSTs in Denmark, more than 80% (n = 70) suffered from burnout, of whom 28% (n = 24) suffered from moderate to severe personal burnout. The strong association with the psychosocial work environment, and the significant differences between departments, suggest that burnout is modifiable through changes in the work environment.
Centralisation of Vascular Surgery: A Danish Perspective Eiberg, Jonas Peter; Mejnert Jørgensen, Trine Maria; Budtz-Lilly, Jacob W.
European journal of vascular and endovascular surgery,
June 2023, 2023-Jun, 2023-06-00, 20230601, Letnik:
65, Številka:
6
Journal Article
This study was aimed at quantifying the abdominal aortic aneurysm (AAA) compression phenomenon and assessing the use of a new tool to estimate transducer pressure in vivo. In this cross-sectional ...study, 47 participants with AAA and a median anterior-to-posterior (AP) AAA diameter of 46 mm (range: 30–76 mm) were included. The majority of the patients were overweight with body mass indexes >25 (33/47, 70%). A standardized ultrasound (US)–compatible gel pad, with a pre-defined thickness (15 mm) and mass (150 g), was interposed between the US transducer and participant to estimate the applied transducer pressure. A firm transducer pressure significantly lowered the median AP diameter from 46.1 mm (range: 29.7–76.3) to 39.4 mm (range: 21.7–67.5) (p = 0.001). The mean diameter bias between light and firm transducer pressure was 6.1 mm (95% confidence interval: 4.9–7.3). The applied transducer pressure varied significantly and could be measured by translating the deformation of a low-tech gel pad interposed between the US transducer and the participant.
Three-dimensional contrast-enhanced fusion ultrasound (CEFUS) of atherosclerotic carotid arteries provides spatial visualization of the vessel lumen, creating a lumenography. As in 3-D computed ...tomography angiography (CTA), 3-D CEFUS outlines the contrast-filled lumen. Plaque and vessel contours are distinguished in 3-D CEFUS, allowing plaque volume quantification as a valid estimate of carotid plaque burden. Three-dimensional CEFUS is unproven in intermodality studies, vindicating the assessment of 3-D CEFUS applicability and comparing 3-D CEFUS and 3-D CTA lumenography as a proof-of-concept study.
Using an ultrasound system with magnetic tracking, a linear array transducer and SonoVue contrast agent, 3-D CEFUS acquisitions were generated by spatial stitching of serial 2-D images. From 3-D CEFUS and 3-D CTA imaging, the atherosclerotic carotid arteries were reconstructed with lumenography in an offline software program for lumen and plaque volume quantification. Bland–Altman analysis was used for inter-image modality agreement.
The study included 39 carotid arteries. Mean lumen and plaque volume in 3-D CEFUS were 0.63 cm3 (standard deviation SD: 0.26) and 0.62 cm3 (SD: 0.26), respectively. Lumen volume differences between 3-D CEFUS and 3-D CTA were non-significant, with a mean difference of 0.01 cm3 (SD: 0.02, p = 0.26) and limits of agreement (LoA) range of ±0.11 cm3. Mean plaque volume difference was –0.12 cm3 (SD: 0.19, p = 0.006) with a LoA range of ±0.39 cm3.
There was strong agreement in lumenography between 3-D CEFUS and 3-D CTA. The interimage modality difference in plaque volumes was substantial because of challenging vessel wall definition in 3-D CTA. Three-dimensional CEFUS is viable in quantifying carotid plaque volume burden and can potentially monitor plaque development over time.
Endovascular procedures have become commonplace in vascular surgery. This development calls for new training strategies for future specialists. Most simulation-based education (SBE) programs have a ...monodisciplinary focus on physicians, although successful surgery is a multidisciplinary team effort. Mental stress impairs the learning process and surgical performance and heart rate variability (HRV) can be measured as a proxy for both mental and physical stress. This study aims to assess how SBE of endovascular scrub nurses affects team performance and HRV during endovascular aneurysm repair (EVAR).
Prospective interventional study in which EVAR-inexperienced scrub nurses followed a focused SBE EVAR program. During real-life EVAR procedures, HRV was continuously recorded with a wireless electrocardiogram patch and multidisciplinary team performance was assessed with the Imperial College Error CAPture (ICECAP) tool, before and after the SBE program, allowing each scrub nurse to serve as their own control. Eight scrub nurses with experience in lower limb endovascular procedures, but not EVAR, were invited to participate.
Seven participants completed the study. In five of seven scrub nurses, HRV-derived stress levels during real-time EVAR procedures were lower after SBE compared to before SBE. Mean HRV increased from 24 msec to 35 msec (P < 0.001), indicating stress level reduction. Before SBE, the mean number of errors/hour was 7.3 (standard deviation ± 1.8) compared to 3.6 (standard deviation ± 2.7) after SBE. Most errors were categorized as technical (58 %) and communicative (23 %).
SBE of scrub nurses may improve team performance and may lower mental stress during EVAR procedures. In this small study, we suggest using mental stress, as evaluated with HRV, and multidisciplinary team performance, as evaluated with ICECAP, to assess SBE effectiveness in real-case EVAR procedures. This SBE program and live ICECAP observations and electrocardiogram patches was well-accepted by scrub nurses and the entire team.
•Ultrasound is first choice in AAA surveillance, measuring the maximum AP diameter.•Ultrasound underestimates the AAA diameter up to 10 mm, in comparison to CTA.•During the US scan a firm pressure ...(transducer push) is applied to achieve optimal insonation.•Transducer push can be quantified in a lab-model with interposition of gel-pad.•Significant variation in transducer push is observed amongst experienced sonographers.
The study investigated ultrasound (US) transducer push, tantamount to applied transducer pressure, during abdominal aortic aneurysm (AAA) US scanning in a simulated non-clinical setup.
During an assessment of maximal AAA diameter on a three-dimensional print-based AAA phantom, US transducer push varied as much as 2000% (range: 0.52–12.45 kPa) amongst 16 experienced sonographers. The mean transducer push was 5.54 ± 3.91 kPa (CV = 0.71).
Deformation of a standardized gel-pad allowed for transducer push calculation based on US images; Young’s modulus of the gel-pad was estimated to 44,26 N/m2.
The method is theoretically validated in a safe and non-clinical environment. Future investigations with the aim of clinical validation of the gel-pad principle on AAA patients are suggested, including the objectification of the magnitude of an eventual transducer push-related error during US AAA diameter measurement.
Improving tissue perfusion can improve clinical outcomes in surgical patients, where monitoring may aid clinicians in detecting adverse conditions and guide interventions. Transcutaneous monitoring ...(TCM) of oxygen (tcpO
2
) and carbon dioxide (tcpCO
2
) is a well-proven technology and could potentially serve as a measure of local circulation, perfusion and metabolism, but the clinical use is not thoroughly explored. The purpose of this proof-of-concept study was to investigate whether TCM of blood gasses could detect changes in perfusion during major vascular surgery.
Ten patients with peripheral arterial disease scheduled for lower limb major arterial revascularization under general anaesthesia were consecutively included. TcpO
2
and tcpCO
2
were continuously recorded from anaesthesia induction until skin closure with a TCM monitor placed on both legs and the thorax. Peripheral oxygen saturation was kept ≥94% and mean arterial blood pressure ≥65 mmHg. The primary outcomes were changes in tcpO
2
and tcpCO
2
related to arterial clamping and declamping during the procedure and analyzed by paired statistics.
Femoral artery clamping resulted in a significant decrease in tcpO
2
(−2.1 kPa, IQR-4.2; −0.8), p=.017)), followed by a significant increase in response to arterial declamping (5.5 kPa, IQR 0-7.3), p=.017)). Arterial clamping resulted in a statistically significant increase in tcpCO
2
(0.9 kPa, IQR 0.3-5.4), p=.008)) and a significant decrease following declamping (−0.7 kPa, IQR −2.6; −0.2), p=.011)).
Transcutaneous monitoring of oxygen and carbon dioxide is a feasible method for detection of extreme changes in tissue perfusion during arterial clamping and declamping, and its use for improving patient outcomes should be explored. Clinical Trials identifier: NCT04040478. Registered on July 31, 2019.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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