Hoidon viiveen syyt ja seuraukset verisuonikirurgiassa

The obvious goals in vascular surgery are to operate patients with symptomatic carotid stenosis before stroke, to revascularise patients with diabetic foot ulcers (DFUs) before amputation is required and to operate patients with abdominal aortic aneurysms (AAAs) before aneurysm rupture. The aim of this thesis was to investigate the timing of treatment and the concurrent impact on the outcome in these three patient cohorts in Helsinki University Hospital (HUH). For symptomatic carotid stenosis the risk of ischemic stroke is the highest in the following weeks after ischemic symptoms, hence carotid surgery is recommended within two weeks. This goal was reached for only 11% of the patients in HUH during 2007-2008, which led to organisational changes in 2009. In 2010 37% of the symptomatic patients were operated on within two weeks and the median time from symptom to surgery had shortened from 47 to 19 days. Therefore, reaching the two-week target time is an achievable goal provided that in addition to the institutional changes, efforts are also made to improve the public awareness. No studies exist on the optimal timing of revascularization in patients with DFU. The whole treatment process from referral to revascularisation was analysed for patients with DFU referred to vascular surgeon in 2010-2011. Significant discovery was that in the treatment of DFUs delay more than two weeks from referral to revascularization was associated with inferior limb salvage. DFU always need prompt diagnostics of the possible underlying ischemia and rapid revascularization once detected. Also, the acceptable delay of elective AAA repair has not been determined, and conclusive evidence on the rupture risk of large aneurysms has been lacking. In HUH during the elective treatment process of AAAs in 2005 2010 21 (5.8%) emergency operations and 11 (3.0%) aneurysm ruptures occurred. In order to minimize aneurysm ruptures and emergency operations while waiting for surgery, guidelines for the timing of elective AAA treatment process are required and the fulfilment of these guidelines need to be followed up. Of the 154 patients excluded from operative treatment 33% died of an aneurysm rupture and 5 patients out of 12 undergoing emergency operation survived. Exclusion from elective aortic repair is a decision requiring careful consideration and collaboration between different specialities.Verisuonikirurgisten toimenpiteiden optimaalinen ajoitus on tärkeää, koska toimenpiteen oikea ajoitus merkitsee mm. aivoinfarktilta välttymistä, alaraajaan säästymistä sekä aneurysman puhkeamiselta välttymistä. Hoidon suunnittelun haasteiden voidaan odottaa kasvavan tulevaisuudessa, kun huomioidaan lisääntyvät potilasmäärät ja toisaalta rajalliset resurssit. Väitöskirjan tavoitteena on selvittää hoidon viivettä, syitä ja mahdollisia seurauksia kolmessa verisuonikirurgian potilasryhmässä: potilaat, joilla on oireinen kaulavaltimoahtauma, diabeettinen jalkahaavauma tai vatsa-aortan aneurysma l. pullistuma. Nykyiseen tutkimusnäyttöön perustuen suositus on leikata oireinen kaulavaltimoahtauma kahdessa viikossa oireen jälkeen. Vuosina 2008 2009 HYKSissä tämä tavoite toteutui 11 % potilaille, jonka vuoksi 2 leikkausaikaa lisättiin joka viikkoon ja mikäli vapaata aikaa ei löytynyt, suosituksena oli asettaa potilas päivystysleikkauslistalle. Vuonna 2010, muutosten jälkeen, 2 viikon aikatavoitteeseen ylsi jo 37 % potilaista ja mediaani aika oireesta leikkaukseen lyheni 47:stä 19 päivään. Diabeettisen jalkahaavan hoidon viiveestä on tutkimustietoa varsin vähän. Väitöskirjassa selvitetään koko hoitoketju lähetteen teosta verenkiertoa parantavaan toimenpiteeseen, pallolaajennukseen tai valtimoleikkaukseen. Diabetesta sairastavilla verenkiertoa parantavan toimenpiteen viivästyminen yli kaksi viikkoa lisää merkittävästi amputaation vaaraa verrattuna alle 2 viikossa leikattuihin. Diabetesta sairastamattomilla ei ollut eroa yli- ja alle 2 viikkoa odottaneiden välillä kunhan toimenpide tehtiin 4-6 viikon sisällä. Näin ollen erityisesti diabetesta sairastavien kohdalla on kiinnitettävä huomio siihen että leikkaus tehdään nopeasti. Vatsa-aortan aneurysman esiintyvyys kasvaa iän myötä, yli 65 v miehillä se on n 5. %. Suuri osa potilaista on monisairaita, jolloin erityisesti tulee arvioitavaksi leikkauksen riskit ja hyödyt. Vuosina 2000-2010 HYKSissä leikkaushoidon ulkopuolelle rajattiin 154 potilasta. Toisin kuin aikaisemmin on ajateltu, aneurysman repeämä oli yleisin kuolinsyy. Leikkaushoidon ulkopuolelle rajaaminen vaatii tämän vuoksi erityisen tarkkaa harkintaa. Leikkaushoitoon ohjatuille potilaille vuosina 2005 2010 tapahtui odotusaikana 11 aneurysman repeämää (3.0 %). Määrän minimoiminen edellyttää tavoiteaikataulujen käyttöä sekä niiden toteutumisen seurantaa

Response to "Re. Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss : Diabetic Patients Require Rapid Revascularisation"

Non peer reviewe

Bovine pericardial patch : A good alternative in femoral angioplasty

Objective: Bovine pericardial patch (BPP) is currently used in femoral angioplasty as an alternative for autologous vein patch (AVP), but studies comparing the results of the two methods are scarce. In this retrospective study, we aimed to discover the differences between BPP and AVP closure in long-term durability.Methods: This study consisted of all femoral endarterectomies with BPP closure performed in Helsinki University Hospital from January 1, 2014, to December 31, 2017. For comparison, the same number of consecutive patients who underwent femoral endarterectomy with AVP closure from January 1, 2014, to October 16, 2016, were reviewed. Follow-up ended December 31, 2020. The mean follow-up was 19 months (range, 0-74 months) in the BPP group and 22 months (range, 079 months) in the AVP group. The primary endpoint was primary patency. Secondary endpoints were restenosis at patch site detected by imaging or perioperatively, patch rupture, and deep surgical wound infection. Propensity score analysis was performed for adjustment of differences between the AVP and BPP groups.Results: Overall primary patency was superior in the AVP group compared with the BPP group: at 1 year, 96.5% vs 85.0% and at 5 years, 83.0% vs 72.3% (P =.04). In propensity score-matched pairs (n = 92), no difference was found between the groups in primary patency: 95.7% and 95.7% at 1 year and 92.5% and 78.6% at 5 years (P =.861) or in freedom from restenosis: 100% and 100% at 1 year and 89.1% and 84.0% at 5 years (P =.057). Deep wound infections occurred slightly more often after BPP closure (8%) than after AVP closure (4%), but the difference was not statistically significant (P =.144). There were no patch ruptures in the BPP group, but in the AVP group, there were five ruptures (3.5%) (P =.024).Conclusions: BPP is compatible to AVP in femoral endarterectomy in patency and can be regarded as the safer choice considering the risk of patch rupture.Peer reviewe

Analysis of the Elective Treatment Process for Critical Limb lschaemia with Tissue Loss : Diabetic Patients Require Rapid Revascularisation

Objectives: The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation. Methods: A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin. Results: For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population; with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients. Conclusions: Diabetic ulcers always require vascular evaluation, and when.ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.Peer reviewe

Three-year results of a randomized controlled trial comparing mechanochemical and thermal ablation in the treatment of insufficient great saphenous veins

Objective: Mechanochemical ablation (MOCA) is a nonthermal nontumescent method of treating saphenous vein insufficiency. The feasibility and short-term results of MOCA are good, but its long-term results are unknown. A randomized study was performed to compare MOCA with endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) in the setting of unilateral great saphenous vein (GSV) insufficiency. Methods: Venous outpatient clinic patients with varicose veins (CEAP class C2-C4) caused by GSV insufficiency were invited to participate in the study; in total, 132 patients met the inclusion criteria and were willing to participate. Patients were randomized to treatment (2:1:1 for MOCA, EVLA, and RFA, respectively). The state of the GSV with duplex Doppler ultrasound examination and the disease-specific quality of life were assessed at 1 month, 1 year, and 3 years after the treatment. Results: Some patients declined to continue in the study after randomization; in total, 117 patients underwent treatment. At 3 years, the occlusion rate was significantly lower with MOCA than with either EVLA or RFA (82% vs 100%; P = .005). Quality of life was similar between the groups. In the MOCA group, GSVs that were larger than 7 mm in diameter preoperatively were more likely to recanalize during the follow-up period. The partial recanalizations of proximal GSV observed at 1 year progressed during the follow-up. Conclusions: MOCA is a feasible treatment option in an outpatient setting, but its technical success rates are inferior compared with endovenous thermal ablation. Its use in large-caliber veins should be considered carefully.Peer reviewe

The "Woundosome" Concept and Its Impact on Procedural Outcomes in Patients With Chronic Limb-Threatening Ischemia

This editorial assembles endovascular specialists from diverse clinical backgrounds and nationalities with a global call to address key challenges to enhance revascularization in chronic limb-threatening ischemia (CLTI) patients.- Dedicated below-the-ankle (BTA) angiography and revascularization is underutilized in ischemic foot treatment. Existing guidelines do not address comprehensive BTA vessel analysis. CLTI trials also often lack data on in-line arterial flow to the ischemic lesion and BTA vessel evaluation, hindering outcome assessment.- Dedicated multi-planar angiographic evaluation of the distal microcirculation is key: Direct arterial flow or good-quality collaterals are crucial in influencing wound healing and need to be assessed diligently to the level of the distal ischemic wound territory, termed “woundosome.”- An important primary emphasis of future trials should be on validating technologies and strategies for assessing tissue perfusion before, during, and after revascularization undertaken to heal tissue loss in CLTI patients. This will allow determination of a potentially significant delta in tissue perfusion prior to and following intervention at the “woundosome” level. Once changes in arterial perfusion have been identified as positively correlated to wound healing, these could serve as a much-needed novel primary technical outcome measure for patients with tissue loss undergoing surgical, hybrid, or endovascular revascularization