Revenneen vatsa-aortan pullistuman leikkaushoito pelastaa ihmishenkiä, on kustannustehokasta eikä huononna elämänlaatua

Ruptured abdominal aortic aneurysm (RAAA) is a life-threatening event, and without operative treatment the patient will die. The overall mortality can be as high as 80-90%; thus repair of RAAA should be attempted whenever feasible. The quality of life (QoL) has become an increasingly important outcome measure in vascular surgery. Aim of the study was to evaluate outcomes of RAAA and to find out predictors of mortality. In Helsinki and Uusimaa district 626 patients were identified to have RAAA in 1996-2004. Altogether 352 of them were admitted to Helsinki University Central Hospital (HUCH). Based on Finnvasc Registry, 836 RAAA patients underwent repair of RAAA in 1991-1999. The 30-day operative mortality, hospital and population-based mortality were assessed, and the effect of regional centralisation and improving in-hospital quality on the outcome of RAAA. QoL was evaluated by a RAND-36 questionnaire of survivors of RAAA. Quality-adjusted life years (QALYs), which measure length and QoL, were calculated using the EQ-5D index and estimation of life expectancy. The predictors of outcome after RAAA were assessed at admission and 48 hours after repair of RAAA. The 30-day operative mortality rate was 38% in HUCH and 44% nationwide, whereas the hospital mortality was 45% in HUCH. Population-based mortality was 69% in 1996-2004 and 56% in 2003-2004. After organisational changes were undertaken, the mortality decreased significantly at all levels. Among the survivors, the QoL was almost equal when compared with norms of age- and sex-matched controls; only physical functioning was slightly impaired. Successful repair of RAAA gave a mean of 4.1 (0-30.9) QALYs for all RAAA patients, although non-survivors were included. The preoperative Glasgow Aneurysm Score was an independent predictor of 30-day operative mortality after RAAA, and it also predicted the outcome at 48- hours for initial survivors of repair of RAAA. A high Glasgow Aneurysm Score and high age were associated with low numbers of QALYs to be achieved. Organ dysfunction measured by the Sequential Organ Failure Assessment (SOFA) score at 48 hours after repair of RAAA was the strongest predictor of death. In conclusion surgery of RAAA is a life-saving and cost-effective procedure. The centralisation of vascular emergencies improved the outcome of RAAA patients. The survivors had a good QoL after RAAA. Predictive models can be used on individual level only to provide supplementary information for clinical decision-making due to their moderate discriminatory value. These results support an active operation policy, as there is no reliable measure to predict the outcome after RAAA.Revenneen vatsa-aortan pullistuman leikkaushoito pelastaa ihmishenkiä, on kustannustehokasta eikä huononna elämänlaatua Vatsa-aortan pullistuman repeämä (ruptured abdominal aortic aneurysm = RAAA) on välittömästi henkeä uhkaava kirurginen hätätilanne. Potilaan hengen voi pelastaa vaativa leikkaus ja sitä seuraava onnistunut tehohoito. Vatsa-aortan pullistuma on yleinen sairaus, miehillä se aiheuttaa jopa 2% kaikista kuolemista teollistuneissa maissa. Repeämä on usein ensimmäinen oire pullistumasta. Helsingin ja Uudenmaan sairaanhoitopiirissä vuosittain noin 70 potilaalla todetaan RAAA (ilmaantuvuus 5,4/100 000 henkilöä/vuosi). Noin kolmannes näistä potilaista kuolee heti ja noin puolet ehtii sairaalaan. RAAA -potilaat ovat yleensä iäkkäitä ja hoidon mielekkyyttä on arvosteltu, etenkin kun elämänlaatua ja laatupainotettuja elinvuosia RAAA hoidon jälkeen ei ole Suomessa aiemmin mitattu. Tutkimuksessa RAAA-potilaiden keski-ikä oli 71 vuotta (vaihteluväli 43-94 vuotta). Tutkimuksessa todettiin, että toivuttuaan vaikeasta leikkauksesta ja usein pitkästä sairaalahoidosta potilaiden elämänlaatu on lähes yhtä hyvä kuin suomalaisessa ikä- ja sukupuolivakioidussa väestössä. Laatupainotettujen elinvuosien määrän avulla voitiin laskea kustannustehokkuus, ja todettiin, että leikkaushoito on kustannustehokasta myös yli 80-vuotiailla. Hoidon lopputulosta pyrittiin ennustamaan erilaisten menetelmien avulla hoidon eri vaiheissa, kuten päivystyspoliklinikalla ennen leikkausta (Glasgow Aneurysm Score) tai teho-osastolla 48 tuntia leikkauksen jälkeen (Sequential Organ Failure Assessment). Menetelmät ennustavat elossa säilymistä ja antavat näin hoitaville lääkäreille lisäinformaatiota päätöksentekoon. Helsingin ja Uudenmaan sairaanhoitopiirissä verisuonikirurgiset hätätilanteet on keskitetty Meilahden sairaalaan ja tämä on parantanut RAAA-potilaiden ennustetta tehohoidon ja päivystysjärjestelmän tehostamisen ohella. Kuolleisuus on laskenut merkitsevästi sairaala- ja väestötasolla organisatoristen muutosten jälkeen. Sairaalakuolleisuus oli 45% ja kuolleisuus väestötasolla 69% vuosina 1996-2004. Vuosina 2003-2004 sairaalakuolleisuus oli 28% ja väestötasolla 56%. Leikkaushoito on ainoa mahdollisuus pelastaa RAAA-potilaan henki. RAAA-potilaiden hoidon lopputuloksen ennustamiseen ei ole luotettavia menetelmiä yksilötasolla, joten leikkaushoitoa tulee tarjota alkuvaiheessa lähes kaikille RAAA-potilaille. Hoidon keskittämisellä on saatu hyviä tuloksia aikaan ja leikkaus on todettu kustannustehokkaaksi myös iäkkäillä

Ultraääniohjattu perkutaaninen endovaskulaarinen aneurysman korjaus lokaalianestesiassa on kultainen standardi

Vatsa-aortan aneurysma korjataan nykyään yleensä suonensisäisellä tekniikalla. Jos potilaan aneurysman ja aortan anatomia eivät sovi suonensisäiselle toimenpiteelle, harkitaan avoleikkausta. Suonensisäisessä korjauksessa aneurysma eristetään verenkierron ulkopuolelle stenttiproteesin avulla, joka viedään aorttaan perkutaanisesti nivusvaltimoiden kautta. Endovaskulaarinen hoito edellyttää myös sitä, että valtimoissa ei ole merkittävää kalkkista ahtaumaa tai mutkaisuutta, joka estäisi stentin kulun aorttaan. Femoraalisuonten sulkulaitteiden käyttö suonensisäisten aneurysman korjausleikkauksissa vähentää komplikaatioiden ilmenemistä, vähentää aikaa hemostaasiin, sekä mahdollistaa aikaisemman potilaan mobilisaation toimenpiteen jälkeen. Sulkulaitteiden asennukseen liittyy kuitenkin komplikaatioriskejä. Tavallisimmat komplikaatiot ovat vuoto, verenpurkauman kehittyminen, pseudoaneurysma ja suonen tukkiutuminen. Aikaisemmissa tutkimuksissa on todettu MANTA-sulkulaitteella olevan pienempi komplikaatioriski verrattuna ProGlide-sulkulaitteeseen. Tämä tutkimus tehtiin kuitenkin aikana jolloin sulkulaitteita ei asennettu ultraääniohjatusti. Tämän retrospektiivisen tutkimuksen tarkoituksena oli selvittää, vaikuttaako ultraäänilaitteen käyttö ProGlide-sulkulaitteen komplikaatioriskiin. Tutkimuksen aineisto koostui 2.1.2017-9.2.2022 välisenä aikana kerättyyn aineistoon HUSpotilastietojärjestelmästä. Potilaiden tapahtumia seurattiin toimenpiteestä kotiutumiseen koko sairaalaolon ajan. Kaikissa toimenpiteissä oli käytössä ultraäänilaite sulkulaitteen asennusvaiheessa. Lopullinen potilasaineisto koostui 637 potilaasta, joista 12 peruuntui sairastumisen vuoksi. Hoidettuja nivusia oli kokonaisuudessaan 1235, joista 1046 elektiivisiä, 129 stabiileja aneurysman ruptuuroita ja 60 epästabiileja aneurysman ruptuuroita. ProGlide-sulkulaitetta käytettiin elektiivisissä toimenpiteissä 973 kertaa, stabiileissa ruptuuroissa 119 kertaa ja epästabiileissa 32 kertaa. MANTA-sulkulaitetta käytettiin yhteensä 37 kertaa, Angioseal-sulkulaitetta 37 kertaa, suoraan avotoimenpiteeseen ilman sulkulaitteita päädyttiin 33 kertaa. ProGlide vaihdettiin toiseen sulkulaitteeseen 19 kertaa sekä konvertoitiin avoleikkaukseen 30 kertaa. Primaari päätetapahtuma on onnistunut sulkulaitteen käyttö ilman vaihtoa toiseen sulkulaitteeseen tai avoleikkaukseen. Sekundaari päätetapahtuma on femoraalisuonten jälkikorjausten määrä ja akuutin raajaiskemian tai infektion insidenssi toimenpiteen jälkeen. ProGlide-sulkulaittetta käytettiin ilman komplikaatioita elektiivisesti 936 kertaa (96,20%), stabiileissa RAAA-potilaissa 111 kertaa (93,28%), epästabiileissa RAAA-potilaissa 28 kertaa (87,50%). Tutkimuksen päätelmänä on, että ProGlide sulkulaite on turvallinen ja tehokas väline nivuspunktioiden sulkemiseen aortan aneurysmien hoidossa silloin, kun punktion yhteydessä käytetään ultraääniohjausta. Lisäksi todettiin että instabiileilla aneurysmaruptuuroilla sukulaitetta ei aina voida asentaa ennen aortan sulkupallon asennusta

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease

Background: Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symp-toms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. Methods: A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were per-formed in Helsinki University Hospital between January 2013 and December 2018. First, infor-mation about patients' baseline characteristics, indications and details of surgery and technical/ hemodynamic success, and complications and mortality were obtained from the vascular regis-try and patients records. Secondarily, a prospective assessment of mid-term patency was per-formed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed.Results: One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n = 144 occlusions recanalized). Primary technical success was somewhat lower in lesions > 90 mm (87.1%) compared to lesions shorter than 90 mm (95.7%; c2 P = 0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant resid-ual stenosis remained in 1.2% of cases. Median operative time was 4 hr 34 min (interquartile range 2 hr 43 min) and median estimated blood loss was 743 mL (interquartile range 500 mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any ma-jor cardiovascular event or stroke perioperatively. Primary patency at 30 day, 6 months, 1 year, and 2 years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoc-cluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Conclusions: Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this pop-ulation often suffers from universal atherosclerosis. The involvement of the aorta represents a sig-nificant determinant of worse long-term patency, although it did not preclude technical success.Peer reviewe

Routine Inferior Mesenteric Artery Embolisation is Unnecessary Before Endovascular Aneurysm Repair

Peer reviewe

Predicting risk of rupture and rupture-preventing reinterventions following endovascular abdominal aortic aneurysm repair

BackgroundClinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. The aim of this study was to develop a dynamic prognostic model to enable stratification of patients at risk of future secondary aortic rupture or the need for intervention to prevent rupture (rupture-preventing reintervention) to enable the development of personalized surveillance intervals. MethodsBaseline data and repeat measurements of postoperative aneurysm sac diameter from the EVAR-1 and EVAR-2 trials were used to develop the model, with external validation in a cohort from a single-centre vascular database. Longitudinal mixed-effects models were fitted to trajectories of sac diameter, and model-predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. ResultsSome 785 patients from the EVAR trials were included, of whom 155 (197 per cent) experienced at least one rupture or required a rupture-preventing reintervention during follow-up. An increased risk was associated with preoperative AAA size, rate of sac growth and the number of previously detected complications. A prognostic model using predicted sac growth alone had good discrimination at 2years (C-index 068), 3years (C-index 072) and 5years (C-index 075) after operation and had excellent external validation (C-index 076-079). More than 5years after operation, growth rates above 1mm/year had a sensitivity of over 80 per cent and specificity over 50 per cent in identifying events occurring within 2years. ConclusionSecondary sac growth is an important predictor of rupture or rupture-preventing reintervention to enable the development of personalized surveillance intervals. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow-up. Potential to tailor surveillancePeer reviewe

Routine Inferior Mesenteric Artery Embolisation is Unnecessary Before Endovascular Aneurysm Repair

Objective: A type II endoleak is the most common complication during surveillance after endovascular aneurysm repair (EVAR), and a patent inferior mesenteric artery (IMA) is a known risk factor for an endoleak. The effect of routine IMA embolisation prior to EVAR on overall outcome is unknown. The aim of the study was to compare two strategies: routine attempted IMA embolisation prior to EVAR (strategy in centre A) and leaving the IMA untouched (strategy in centre B). Methods: Patients were treated with EVAR in two centres during the period 2005 – 2015, and the data were reviewed retrospectively. The primary endpoints were re-intervention rate due to type II endoleaks and the late IMA embolisation rate. Secondary endpoints included EVAR related re-intervention, sac enlargement, aneurysm rupture, and open conversion rates. Results: Strategy A was used to treat 395 patients. The IMA was patent in 268 (67.8%) patients, and embolisation was performed in 164 (41.5%). The corresponding figures for strategy B were 337 patients with 279 (82.8%) patent IMAs, two (0.6%) of which were embolised. The mean duration of follow up was 70 months for strategy A and 68.2 months for strategy B. The re-intervention rates due to a type II endoleak were 12.9% and 10.4%, respectively (p = .29), with no significant difference in the rate of re-interventions to occlude a patent IMA (2.0% and 4.7%, respectively; p = .039). The EVAR related re-intervention rate was similar, regardless of strategy (24.1% and 24.6%, respectively; p = .93). Significant sac enlargement was seen in 20.3% of cases treated with strategy A and in 19.6% treated with strategy B (p = .82). The rupture and conversion rates were 2.5% and 2.1% (p = .69) and 1.0% and 1.5% (p = .40), respectively. Conclusion: The strategy of routinely embolising the IMA does not seem to yield any significant clinical benefit and should therefore be abandoned.publishedVersionPeer reviewe

Predicting risk of rupture and rupture-preventing re-interventions utilising repeated measures on aneurysm sac diameter following endovascular abdominal aortic aneurysm repair

Clinical and imaging surveillance practices following endovascular aneurysm repair (EVAR) for intact abdominal aortic aneurysm (AAA) vary considerably and compliance with recommended lifelong surveillance is poor. This study developed a dynamic prognostic model to enable stratification of patients at risk of future secondary rupture or rupture preventing re-intervention (RPR) to enable the development of personalised surveillance intervals. Baseline data and repeat measurements of post-operative aneurysm sac diameter from the EVAR-1 and EVAR-2 trials were used to develop the model with external validation in a cohort from Helsinki. Longitudinal mixed-effects models were fitted to trajectories of sac diameter and model-predicted sac diameter and rate of growth were used in prognostic Cox proportional hazards models. 785 patients from the EVAR trials were included of which 155 (20%) suffered at least one rupture or RPR during follow-up. An increased risk was associated with pre-operative AAA size, rate of sac growth, and the number of previously detected complications. A prognostic model using only predicted sac growth had good discrimination at 2-years (C-index = 0.68), 3-years (C-index= 0.72) and 5-years (C-index= 0.75) post-operation and had excellent external validation (C-indices 0.76 to 0.79). After 5-years post-operation, growth rates above 1mm/year had a sensitivity of over 80% and specificity over 50% in identifying events occurring within 2 years. Secondary sac growth is an important predictor of rupture or RPR. A dynamic prognostic model has the potential to tailor surveillance by identifying a large proportion of patients who may require less intensive follow-up