Emergency Visceral Hybrid Procedure for Ruptured Thoraco-Abdominal Aortic Aneurysms: A Case Report

AbstractRupture of a thoraco-abdominal aortic aneurysm (TAAA) is usually lethal. Patients with contained ruptures, who reach the hospital, have traditionally been subjected to open reconstructive surgery. However, especially in older patients, open surgery has a high mortality and morbidity rate. We describe a case of an 82-year-old man with a contained rupture of a Crawford type IV TAAA, whom we successfully treated with endovascular exclusion after visceral and renal re-vascularisation (a visceral hybrid procedure (VHP))

Computed tomographic angiographic imaging of abdominal aortic aneurysms: implications for transfemoral endovascular aneurysm management

PURPOSE: To describe anatomic features pertinent to patient selection and graft design for transfemoral endovascular aneurysm management (TEAM) of the infrarenal aorta using computed tomographic (CT) angiography. METHODS: A prospective noncomparative analysis of 102 spiral CT scans of the abdominal aorta of patients with abdominal aortic aneurysms was performed. From the original CT data set, slices were reconstructed perpendicular to the vessel axis (central lumen line) at a 10 mm interval. In these reconstructed slices, diameter measurements were performed. Vessel length was measured along the central lumen line. In each patient possibilities for TEAM were analyzed. RESULTS: Because of technical reasons, 36 scans were excluded from the analysis. Of the remaining 66 patients, 18 could potentially be treated with a bifurcated endovascular device. The infrarenal aortic diameter-to-iliac artery diameter ratio was less than 2 in most patients. The vessel segments judged to be adequate for endovascular graft anchoring had a noncylindrical shape in the majority of cases. CONCLUSION: Only a minority of patients with abdominal aortic aneurysms can at this stage be treated with an endovascular graft. The ideal endovascular graft should be a combination of rigid and flexible components. The proximal and distal attachment systems should have some flexibility with an intrinsic maximum diameter while the midsection of the graft can be relatively rigi

Value of risk scores in the decision to palliate patients withruptured abdominal aortic aneurysm

Background: The aim of this study was to develop a 48‐h mortality risk score, which included morphology data, for patients with ruptured abdominal aortic aneurysm presenting to an emergency department, and to assess its predictive accuracy and clinical effectiveness in triaging patients to immediate aneurysm repair, transfer or palliative care. Methods: Data from patients in the IMPROVE (Immediate Management of the Patient With Ruptured Aneurysm: Open Versus Endovascular Repair) randomized trial were used to develop the risk score. Variables considered included age, sex, haemodynamic markers and aortic morphology. Backwards selection was used to identify relevant predictors. Predictive performance was assessed using calibration plots and the C‐statistic. Validation of the newly developed and other previously published scores was conducted in four external populations. The net benefit of treating patients based on a risk threshold compared with treating none was quantified. Results: Data from 536 patients in the IMPROVE trial were included. The final variables retained were age, sex, haemoglobin level, serum creatinine level, systolic BP, aortic neck length and angle, and acute myocardial ischaemia. The discrimination of the score for 48‐h mortality in the IMPROVE data was reasonable (C‐statistic 0·710, 95 per cent c.i. 0·659 to 0·760), but varied in external populations (from 0·652 to 0·761). The new score outperformed other published risk scores in some, but not all, populations. An 8 (95 per cent c.i. 5 to 11) per cent improvement in the C‐statistic was estimated compared with using age alone. Conclusion: The assessed risk scores did not have sufficient accuracy to enable potentially life‐saving decisions to be made regarding intervention. Focus should therefore shift to offering repair to more patients and reducing non‐intervention rates, while respecting the wishes of the patient and family

Community? What do you mean? An investigation into how differing understandings of the term ‘community’ shapes care-leavers’ move to independence

We explored the ways in which a performance-led approach to community formation and personal development can inform care-leavers’ move to independence. We adopted a case study approach, working with two groups of participants: young people leaving care and their support workers in Devon County Council’s Children in Care team (DCCCCS). The project was co-designed and co-developed with participants from both groups and our colleagues from Exstream Theatre Company. In this action–research project all researchers acted as participant-observers. It had two key objectives: first, to better understand how the term ‘community’ shaped the processes that the participating young people engaged with, and second, to take a practice-led approach to explore if, and how, performance-based methods and principles could be used to support the participants as they left care. A number of findings challenged our early assumptions, in particular the complexity of working with people with unstable and unpredictable lives. By working with the young people and DCCCCS managers and support workers, we developed a new way of using the creation of a theatrical performance, a deeply-supportive, peer-enabled environment and a theatre company, to enable a space in which participants could reimagine both their sense of self and community. The development and implementation of this model raises further research questions relating to how new communities might be formed, as well as suggesting a number of uses that may inform the future development of the Connected Communities community engagement strategy

Aortoiliac reconstructive surgery based upon the results of duplex scanning

Objective:to evaluate whether duplex scanning can replace angiography in patients operated for aortoiliac obstructive disease.Design:retrospective.Materials and methods:between January 1995 and October 1996, 44 patients underwent vascular surgery of the aortoiliac tract. The study population was divided into two groups; patients operated upon the results of duplex scanning only and patients who also underwent angiography prior to surgery. The additional value of angiography and the differences between both groups concerning unexpected peroperative findings, early postoperative failures and the need for additional radiological or surgical interventions in the first three postoperative months were studied.Results:Duplex scan group: 22 patients were operated upon the results of duplex scanning only. In two patients surgical strategy had to be changed. Early postoperative graft occlusion occurred in one case. A haemodynamically significant graft stenosis within 3 months of surgery occurred in one patient. Duplex/angiography group: 22 patients underwent both duplex scanning and angiography. Six patients underwent diagnostic angiography after failed duplex scanning. In 10 patients angiography was part of percutaneous transluminal angioplasty prior to surgery. In six patients angiograms were performed after successful duplex scanning. Angiography failed in two patients and added information in four of 16 patients. Unexpected findings at operation occurred in four patients. Graft stenosis within 3 months was detected in three patients.Conclusion:after successful duplex scanning information obtained by angiography has only a limited impact on therapeutic decision-making. In the majority of patients vascular reconstructive surgery of aortoiliac arteries can be planned based on duplex scanning only

Interobserver Variation of Colour Duplex Scanning of the Popliteal,Tibial and Pedal Arteries

AbstractObjectives: to determine interobserver variation in the measurement of Peak Systolic Velocity (PSV) and grading of disease by means of Duplex scanning (DS) in the popliteal, tibial and pedal arteries. Design: prospective validation study. Materials twenty-four consecutive patients with severe claudication (n=6), ischaemic rest pain (n=11) and tissue loss (n=7). Methods two vascular technologists independently examined the popliteal, tibial and pedal arteries. The PSV was recorded in 15 arterial segments that were graded with B-mode and Doppler parameters as fully patent, severely diseased or occluded. Concordance in PSV recordings was expressed as intraclass correlation coefficients (ICC). Agreement in artery assessment was expressed as weighted κ-values. Results the ICC for PSV measurements was 0.90 (95% CI, 0.86 to 0.93) within the popliteal and tibial arteries and 0.64 (95% CI, 0.37 to 0.81) within the pedal arteries. Agreement for grading disease was good within the popliteal and tibial arteries (κ 0.66, 95% CI, 0.58 to 0.74), and moderate within the pedal arteries (κ 0.54, 95% CI 0.33 to 0.74). The presence of diabetes or stage of disease did not influence interobserver agreement. Conclusion interobserver agreement of DS is good within the popliteal and tibial arteries and moderate within the pedal arteries

Delphi study to reach international consensus among vascular surgeons on major arterial vascular surgical complications

BackgroundThe complications discussed with patients by surgeons prior to surgery vary, because no consensus on major complications exists. Such consensus may improve informed consent and shared decision-making. This study aimed to achieve consensus among vascular surgeons on which complications are considered major' and which minor,' following surgery for abdominal aortic aneurysm (AAA), carotid artery disease (CAD) and peripheral artery disease (PAD).MethodsComplications following vascular surgery were extracted from Cochrane reviews, national guidelines, and reporting standards. Vascular surgeons from Europe and North America rated complications as major or minor on five-point Likert scales via an electronic Delphi method. Consensus was reached if >= 80% of participants scored 1 or 2 (minor) or 4 or 5 (major).ResultsParticipants reached consensus on 9-12 major and 6-10 minor complications per disease. Myocardial infarction, stroke, renal failure and allergic reactions were considered to be major complications of all three diseases. All other major complications were treatment specific or dependent on disease severity, e.g., spinal cord ischemia, rupture following AAA repair, stroke for CAD or deep wound infection for PAD.ConclusionVascular surgeons reached international consensus on major and minor complications following AAA, CAD and PAD treatment. This consensus may be helpful in harmonizing the information patients receive and improving standardization of the informed consent procedure. Since major complications differed between diseases, consensus on disease-specific complications to be discussed with patients is necessary