Carotid Stenting versus Endarterectomy : The Evidence is Evident. Or is it?

Non peer reviewe

Karotispoukaman aktivaatio hoitoresistentin kohonneen verenpaineen hoidossa

English summaryPeer reviewe

Ensimmäisen päivystyspisteen erikoisala vaikuttaa potilaan hoitotuloksiin akuutissa mesenteriaali-iskemiassa : lähetekäytäntöjen ja triagen tärkeys

Tutkimuksen tarkoitus: Äkillinen suoliston verenkiertovajaus (akuutti mesenteriaali-iskemia (AMI)) on edelleen, kehittyneistä hoitomuodoista huolimatta, korkean kuolleisuuden tauti. Yksi olennainen hoidon tuloksiin vaikuttava tekijä on viive ensimmäisestä terveydenhuollon pisteestä leikkaukseen (leikkausviive), mutta tämän viiveen syyt ovat huonosti tunnettuja. Tämän tutkimuksen tarkoitus oli etsiä viiveeseen vaikuttavia tekijöitä, erityisesti hoitoketjun osalta. Aineisto ja menetelmät: Kyseessä on retrospektiivinen tutkimus, jossa tutkittiin 2006- 2015 Meilahden sairaalassa leikattuja AMI-potilaita. Poissuljimme tutkimuksesta potilaat, joilla oli pitkäaikainen, puoliäkillinen, paksusuoleen rajoittunut, laskimoperäinen tai verisuonia tukkimaton mesenteriaali-iskemia. Potilaat jaettiin kahteen alaryhmään sen mukaan, oliko ensimmäinen terveydenhuollon piste, jonka he kohtasivat kirurginen päivystys (KP) vai ei-kirurginen päivystys (ei-KP). Ensisijainen päätemuuttuja oli leikkausviive ja toissijaiset päätemuuttujat olivat sairaalahoidon kesto ja 90-päivän kuolleisuus. Tulokset: Lopullisessa tutkimuspotilasjoukossa oli 81 potilasta. Ei-KP ensimmäisenä hoitokontaktina oli itsenäisesti yhteydessä yli 12 tunnin leikkausviiveeseen (OR 3.7 (95% luottamusväli 1.3-10.2), mediaani viive 15.2 tuntia (IQR 10.9-21.2) vs. 10.1 tuntia (IQR 6.9-18.5), p = 0.025). Sairaalahoidon kesto oli lyhyempi (mediaani 6.5 päivää (4.0-10.3) vs. 10.8 päivää (7.0-22.3), p = 0.045) ja 90-päivän kuolleisuus matalampi KP-ryhmässä (50.0% vs. 74.5%, p = 0.025). Johtopäätökset: Ensimmäinen erikoisala johon potilas lähetetään, vaikuttaa oleellisesti AMI-potilaan leikkausviiveeseen ja kuolleisuuteen. Hoitoketjun sujuvoittaminen niin, että potilas pääsee mahdollisimman nopeasti hoitoon vatsaelin- ja verisuonikirurgiseen yksikköön, voi parantaa AMI:n hoidon tuloksia. (200 sanaa

Catheter-Directed Thrombolysis Versus Pharmacomechanical Thrombectomy for Upper Extremity Deep Venous Thrombosis : A Cost-Effectiveness Analysis

Background: Upper extremity deep vein thrombosis represents (UEDVT) 2-3% of all deep vein thrombosis. Catheter directed thrombolysis (CDT) was replaced largely by pharmacomechanical thrombolysis (PMT) in our institution. In this study we compared the immediate and 1-year results as well as the total hospital costs between CDT and PMT in the treatment of UEDVT. Methods: From 2006 to 2013, 55 patients with UEDVT were treated with either CDT or PMT at Helsinki University Hospital. Of them, 43 underwent thoracoscopic rib resection later to relieve phlebography-confirmed vein compression. This patient cohort was prospectively followed up with repeated phlebographies. CDT was performed to 24 patients, and 19 had PMT with a Trellis (TM) device. Clinical evaluation and vein patency assessment were performed with either phlebography or ultrasound 1 year after the thrombolysis. Primary outcomes were immediate technical success, 1-year vein patency, and costs of the initial treatment. Results: The immediate overall technical success rate, defined as recanalization of the occluded vein and removal of the fresh thrombus, was 91.7% in the CDT group and 100% in the PMT group (n.s.). The median thrombolytic time was significantly longer in CDT patients than that in PMT patients (21.1 vs. 0.33 hr, P <0.00001). There were no procedure-related complications. The 1-year primary assisted patency rate was similar in both the groups (91.7% and 94.7%). There were no recurrences of clinical DVT. The hospital costs for the acute period were significantly lower in the PMT group than those in the CDT group (medians: 11,476 (sic) and 5,975 (sic) in the CDT and PMT groups, respectively [P <0.00001]). Conclusions: The clinical results of the treatment of UEDVT with CDT or PMT were similar. However, PMT required shorter hospital stay and less intensive surveillance, leading to lower total costs.Peer reviewe

The Efficacy of Carotid Surgery by Subgroups : The Concept of Stroke Prevention Potential

Objective: Considering carotid endarterectomy (CEA), reporting treatment delay, symptom status, and surgical complication rates separately gives an incomplete picture of efficacy; therefore, the aim was to combine these factors and develop a reporting standard that better describes the number of potentially prevented strokes. With a real life cohort and theoretical inclusion scenarios, the aim was to explore the stroke prevention potential of different carotid practices. Methods: Landmark studies for symptomatic and asymptomatic patients were revisited. By using published estimates of treatment effect, a simplified calculator was designed to assess the five year stroke prevention rate per 1000 CEAs (stroke prevention potential [SPP], range 0-478), including the presence and recentness of symptoms, sex, increasing stenosis severity, and complication rates. Patients operated on for carotid stenosis at Helsinki University Hospital (HUH) between 2008 and 2016 were collected from a vascular registry (HUSVASC) and categorised according to the model. The local annual complication rate was re-evaluated and added to the model. The HUH patient cohort was incorporated into the SPP model, and changes over time analysed. Finally, theoretical changes in patient selection were compared in order to explore the theoretical impact of patient selection and shortening of the delay. Results: Fifteen hundred and five symptomatic and 356 asymptomatic carotid stenoses were operated on with stroke plus death rates of 3.6% and 0.3%, respectively. The proportion of CEAs performed within two weeks of the index event increased over the follow up period, being 77% in 2016. The SPP increased from 123 in 2008 to 229 in 2016. Theoretically, 350 ischaemic strokes were prevented in the period 2008-16, with 1861 CEAs. Conclusions: National and international comparison of different CEA series is irrelevant if the inclusion criteria are not considered. A calculator that is easy to apply to large scale high quality registered data was developed and tested. SPP was found to increase over time, which is a probable sign of improved patient selection and an increased number of strokes prevented by the CEAs performed.Peer reviewe

Kaulavaltimokirurgia : a posse ad esse non valet consequentia

According to a large body of evidence, carotid endarterectomy (CEA) can prevent strokes, provided that appropriate inclusion criteria and high-quality perioperative treatment methods are utilised with low complication rates. From the patient s perspective, it is of paramount importance that the operation is as safe and effective as possible. From the community s point of view, it is important that CEA provision prevents as many strokes as possible. In order to define the stroke preventing potential of CEA in different communities, a comparison between eight European countries and Australia was performed including 53 077 carotid interventions. A more detailed evaluation was performed in Finland, the United Kingdom and Egypt. It could be estimated that many potentially preventable strokes occur due to insufficient diagnostics and CEA provision. The number of CEAs should be at least doubled in the Helsinki region. The theoretical power of CEA provision in stroke prevention varied significantly between the countries. Delay from symptom to surgery has been identified as one of the most important factors influencing the effectiveness of CEA. In 2008 only 11% of CEAs in Helsinki university central hospital (HUCH) were performed within the recommended14 days. Registered data of 673 CEAs in HUCH during 2000-2005 was analyzed. There was no systematic error that would have changed the outcome analysis. However it is important that registers are audited regularly and cross matching of different registries is possible. A previously unpublished method of combining medial mandibulotomy, neck incision and carotid artery interposition was carried out as a collaboration of maxillofacial, ear, nose and throat and vascular surgeons. Five patients were operated on with a technique that was feasible and possible to perform with little morbidity, but due to the significant risks involved, this technique should be reserved for carefully selected cases. In stroke prevention, organisational decisions seem far more important than details in interventional procedures when CEA is performed with low complication rates, as was the case in the present study. A TIA clinic approach with close co-operation between the on-call vascular surgeons, neurologists and radiologists should be available at all centres treating these patients. Patients should have a direct and fast admission to the hospital performing CEA.Kaulavaltimokirurgia a posse ad esse non valet consequentia Arviolta 10-16% Suomen noin 15 000:sta vuosittaisesta aivoinfarktista on kaulavaltimoahtaumaan liittyviä. Varoitussignaaleja, kuten ohimeneviä halvausoireita, ohimenevää sokeutumista tai lieviä aivoinfarkteja esiintyy 30-40%:ssa verenkierron tukkeutumisesta johtuvista aivoinfarkteista. Nämä varoitusoireet tarjoavat mahdollisuuden ehkäistä aivoinfarkteja kaulavaltimon puhdistusleikkauksella, mutta leikkaus ei ole riskitön. Yksilön kannalta on oleellista, että leikkaus on aiheellinen ja mahdollisimman turvallinen. Yhteisön kannalta on lisäksi tärkeää, että tähän toimintaan osoitetut resurssit käytetään siten, että mahdollisimman moni uhkaava aivoinfarkti jää toteutumatta. Kaulavaltimokirurgiaa on tutkittu perusteellisesti satunnaistetuissa kansainvälisissä tutkimuksissa ja niiden pohjalta on luotu kansallisia ja kansainvälisiä hoitosuosituksia. On kuitenkin jossain määrin epäselvää miten tämä teoreettinen mahdollisuus heijastuu käytäntöön. Tutkimuksessa selvitettiin neljässä osajulkaisussa kaulavaltimokirurgian käytäntöä Helsingin yliopistollisessa keskussairaalassa (HYKS), sekä vertailtiin tuloksia kansallisesti ja kansainvälisesti. Lisäksi tutkimuksessa esiteltiin aikaisemmin julkaisematon tekniikka hankalien kallonpohjaa kohti leviävien kaulavaltimoon liittyvien muutosten leikkaushoitoon. Rekisteripohjaisen tiedon luotettavuutta ja soveltuvuutta terveydenhuollon suunnitteluun arvioitiin. Vuosina 2000-2005 HYKS:ssä suoritetut 673 kaulavaltimoleikkausta todettiin suoritetun turvallisesti ja nämä toimenpiteet oli rekisteröity hyväksyttävällä tarkkuudella. Mikäli kaikki oireita aiheuttaneet yli 70%:n kaulavaltimoahtaumat olisi löydetty olisi leikkauksia kuitenkin pitänyt tehdä vähintään kaksinkertainen määrä. Toiminta on tehokkaimmillaan, mikäli leikkaus onnistutaan toteuttamaan 2 viikon sisällä oireesta. Vuosina 2007-2008 vain 11% toteutuneista toimenpiteistä täytti tämän kriteerin. Kansainvälisessä rekisterivertailussa analysoitiin 53 077 Euroopassa ja Australiassa tehtyä kaulavaltimotoimenpidettä. Vaikka kaulavaltimokirurgia toteutui hyväksyttävällä turvallisuudella kaikissa maissa, oli sen tehokkuudessa huomattavia eroja. Kaulavaltimokirurgian toteutuman vaihteluväli eri maissa oli 6.0-13.5 leikkausta/100 000 asukasta kaikilla potilailla ja 3.6 -11.1/100 000 asukasta oireisilla potilailla. Tämä osoittaa maiden välisen suuren eron diagnostiikassa ja hoitoprosesseissa. Organisaatiotason päätökset ja potilasohjaus vaikuttavat oleellisesti kaulavaltimokirurgian tehokkuuteen. Varoitusoireita saaneet potilaat tulisi ohjata kiireellisesti toimenpiteitä suorittaviin yksiköihin

The association of endothelial injury and systemic inflammation with perioperative myocardial infarction

Background Major surgery predisposes to endothelial glycocalyx injury. Endothelial glycocalyx injury associates with cardiac morbidity, including spontaneous myocardial infarction. However, the relation between endothelial glycocalyx injury and the development of perioperative myocardial infarction remains unknown. Methods Fifteen perioperative myocardial infarction patients and 60 propensity-matched controls were investigated in this prospective study. The diagnosis of perioperative myocardial infarction was based on repeated cardiac troponin T measurements, electrocardiographs and recordings of ischaemic signs and symptoms. We measured endothelial glycocalyx markers - soluble thrombomodulin, syndecan-1 and vascular adhesion protein 1 - and an inflammatory marker, namely interleukin-6, preoperatively and 6 h and 24 h postoperatively. We calculated the areas under the receiver operating characteristics curves (AUCs) to compare the performances of the different markers in predicting perioperative myocardial infarction. The highest value of each marker was used in the analysis. Results The interleukin-6 concentrations of perioperative myocardial infarction patients were significantly higher preoperatively and 6 and 24 h postoperatively (P = 0.002, P = 0.002 and P = 0.001, respectively). The AUCs (95% confidence intervals) for the detection of perioperative myocardial infarction were 0.51 (0.34-0.69) for soluble thrombomodulin, 0.63 (0.47-0.79) for syndecan-1, 0.54 (0.37-0.70) for vascular adhesion protein 1 and 0.69 (0.54-0.85) for interleukin-6. Conclusions Systemic inflammation, reflected by interleukin-6, associates with cardiac troponin T release and perioperative myocardial infarction. Circulating interleukin-6 demonstrated some potential to predict perioperative myocardial infarction, whereas endothelial glycocalyx markers did not.Peer reviewe

Clinical evaluation of a wearable sensor for mobile monitoring of respiratory rate on hospital wards

Publisher Copyright: © 2021, The Author(s).A wireless and wearable system was recently developed for mobile monitoring of respiratory rate (RR). The present study was designed to compare RR mobile measurements with reference capnographic measurements on a medical-surgical ward. The wearable sensor measures impedance variations of the chest from two thoracic and one abdominal electrode. Simultaneous measurements of RR from the wearable sensor and from the capnographic sensor (1 measure/minute) were compared in 36 ward patients. Patients were monitored for a period of 182 ± 56 min (range 68–331). Artifact-free RR measurements were available 81% of the monitoring time for capnography and 92% for the wearable monitoring system (p 20 (tachypnea) with a sensitivity of 81% and a specificity of 93%. In ward patients, the wearable sensor enabled accurate and precise measurements of RR within a relatively broad range (6–36 b/min) and the detection of tachypnea with high sensitivity and specificity.Peer reviewe

Diabeetikon jalkahaava

•Diabeetikon jalkahaavan taustalla ovat neuropatia, valtimonkovettumistauti ja infektio, yhdessä tai erikseen. •Riskipotilaiden tunnistaminen ja varhaisvaiheen tehokas ehkäisevä hoito voivat auttaa välttämään vaikeampia haavaongelmia. •Jokaisen potilaan verenkierto tulee arvioida säännöllisesti, tarvittaessa verisuonilaboratoriossa, sillä nilkka-olkavarsipainesuhteen (ABI) mittaus ei ole diabeetikoilla luotettava. •Yksilöllisesti suunniteltu kevennyshoito on neuropaattisen jalkahaavan hoidon kulmakivi. •Kirurgisilla hoidoilla ja alaraajan valtimoverenkiertoa korjaavilla toimenpiteillä voi olla ratkaiseva merkitys, jos haavan paraneminen konservatiivisen hoidon keinoin näyttää epätodennäköiseltä. •Akuutti diabeettinen jalka vaatii kiireellistä päivystyshoitoa ja -kirurgiaa erikoissairaanhoidossa.Peer reviewe

Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms

Objective: Difficulties in distributing endovascular experience among all operating room (OR) personnel prevented full-scale use of endovascular aneurysm repair (EVAR) in emergencies. To streamline the procedure of EVAR for ruptured aneurysm (rEVAR) and to provide this method even to unstable patients, we initiated regular simulation training sessions. Methods: This is an observational study of 29 simulation sessions performed between January 2015 and December 2017. We analyzed the development of time from OR door to aortic balloon occlusion during simulations and OR door to needle times in real-life rEVARs as well as the outcome of the 185 ruptured abdominal aortic aneurysm (rAAA) patients who arrived at the university hospital between January 2013 and December 2017. A questionnaire was sent for simulation attendants before and after the simulation session. Results: In the first simulations, the door to occlusion time was 20 to 35 minutes. After adding a hemodynamic collapse to the simulation protocol, the time decreased to 10 to 13 minutes in the 10 recent simulations, including a 5-minute cardiopulmonary resuscitation (P = .01). The electronic questionnaire performed for attendees before and after the simulation session showed significant improvement in both confidence and knowledge of the OR staff regarding rEVAR procedure. In the real-life rEVARs, 75 of the 185 patients with rAAAs underwent EVAR. Among rEVAR patients, the median OR door to needle time was 65 minutes before and 16 minutes after the onset of simulations (P = .000). The overall 30-day mortality among all rAAA patients was 44.8% and 30.6% accordingly (P = .046). When patients who were turned down from the emergency surgery were excluded, the 30-day operative mortality was 39.2% and 25.1% during the periods, respectively (P = .051). The 30-day mortality was 16.2% after rEVAR and 40.6% after open surgery (P = .001). Conclusions: Simulation training for rEVAR significantly improves the treatment process in real-life patients and may enhance the outcome of rAAA patients.Peer reviewe