Search

BackgroundThe erosion of the early mortality advantage of elective endovascular aneurysm repair (EVAR) compared with open repair of abdominal aortic aneurysm remains without a satisfactory explanation.MethodsAn individual-patient data meta-analysis of four multicentre randomized trials of EVAR versus open repair was conducted to a prespecified analysis plan, reporting on mortality, aneurysm-related mortality and reintervention.ResultsThe analysis included 2783 patients, with 14 245 person-years of follow-up (median 5·5 years). Early (0-6 months after randomization) mortality was lower in the EVAR groups (46 of 1393 versus 73 of 1390 deaths; pooled hazard ratio 0·61, 95 per cent c.i. 0·42 to 0·89; P = 0·010), primarily because 30-day operative mortality was lower in the EVAR groups (16 deaths versus 40 for open repair; pooled odds ratio 0·40, 95 per cent c.i. 0·22 to 0·74). Later (within 3 years) the survival curves converged, remaining converged to 8 years. Beyond 3 years, aneurysm-related mortality was significantly higher in the EVAR groups (19 deaths versus 3 for open repair; pooled hazard ratio 5·16, 1·49 to 17·89; P = 0·010). Patients with moderate renal dysfunction or previous coronary artery disease had no early survival advantage under EVAR. Those with peripheral artery disease had lower mortality under open repair (39 deaths versus 62 for EVAR; P = 0·022) in the period from 6 months to 4 years after randomization.ConclusionThe early survival advantage in the EVAR group, and its subsequent erosion, were confirmed. Over 5 years, patients of marginal fitness had no early survival advantage from EVAR compared with open repair. Aneurysm-related mortality and patients with low ankle : brachial pressure index contributed to the erosion of the early survival advantage for the EVAR group. Trial registration numbers: EVAR-1, ISRCTN55703451; DREAM (Dutch Randomized Endovascular Aneurysm Management), NCT00421330; ACE (Anévrysme de l'aorte abdominale, Chirurgie versus Endoprothèse), NCT00224718; OVER (Open Versus Endovascular Repair Trial for Abdominal Aortic Aneurysms), NCT00094575.

Aims: Performing simultaneous carotid endarterectomy (CE) and coronary artery bypass grafting (CABG) under general anaesthesia in those with severe combined disease is associated with a high incidence of neurological complications and mortality. This study examined the results of performing staged CE under local anaesthesia (LA) prior to CABG. Methods: Data on 40 consecutive patients undergoing 41 CEs under LA prior to cardiac surgery were prospectively collected. In addition to demographic data, operative details and complications, Parsonnet scores were calculated in order to stratify perioperative risk. Results: Patient ages ranged from 51 to 83 years (median 65), with 14 females and 26 males. Parsonnet scores ranged from 0 to 27 (mean 9.1) giving a predicted mortality rate of at least 5% and 17 (41·5%) patients were awaiting urgent CABG, indicative of the fact that this was a relatively highrisk group of patients. The median time from CE to CABG was 18 days (range 3-346 days). There were no deaths or neurological or myocardial events following CE. Following CABG, one patient (2·5%) died of multiple organ failure, and one patient (2·5%) suffered a stroke secondary to atrial fibrillation. Conclusions: In this small series, the incidence of stroke and death were markedly lower than predicted by Parsonnet scoring or that previously reported in the literature. Performing CE under LA as a staged procedure prior to CABG appears to be a safe approach even in relatively high-risk patients with severe combined disease. [ABSTRACT FROM AUTHOR]

Aim: It is widely accepted that autologous vein graft is the optimal conduit for femorocrural reconstruction. The purpose of this study was to compare the performance of vein and prosthetic grafts in a consecutive, non-randomized series of femoro-crural reconstructions performed within a single vascular firm. Methods: A 5-year series of 103 femoro-crural reconstructions in 97 patients (56 female, 41 male), median age 75 years (range 44–94 years), with critical ischaemia, performed by one surgeon, was analysed. A prosthetic conduit (PTFE or Heparin-bonded Dacron) was used if autologous vein was deemed inadequate on duplex scanning (< 3mm), or at the time of harvesting. All distal prosthetic graft anastomoses were performed using a vein cuff. Pre-operative run-off was scored on the basis of duplex imaging or angiography for each calf vessel minimum score 0, maximum score 6 for each limb. Duplex scanning or the presence of a palpable distal pulse confirmed graft patency. Results: Mean follow up was 3 years. There were 52 limbs with vein grafts and 51 limbs with prosthetic grafts. Median age was similar in the vein (78 years) and prosthetic groups (76 years) as were median pre-op run-off scores (3). 1-, 2-, 3- and 4-year vein and prosthetic cumulative primary patency rates were 61 per cent, 57 per cent, 57 per cent and 45 per cent and 68 per cent, 63 per cent 48 per cent and 48 per cent, respectively. Kaplan–Meier survival analysis showed no significant difference in cumulative primary patency rates between the two groups (P = 0.50 log rank statistic for equality of duration of patency). Conclusion: These data suggest that the difference between vein and prosthetic grafts for distal bypass may not be as great as expected. [ABSTRACT FROM AUTHOR]

Twelve patients undergoing elective aortic surgery had intraoperative autotransfusion using either the Haemonetics Cell Saver or the Solcotrans device. The 24-h post-transfusion survival of the patients' preoperative red cells, labelled with indium-111, was compared with the survival of salvaged red cells labelled with chromium-51. A correction coefficient for the instability of the indium-111 label was calculated from the study of red cell survival in six healthy volunteers. There was no significant difference in the volume of circulating red cells measured using each isotope, indicating that extensive early destruction of the autotransfused red cells does not occur. The percentage survival of autotransfused red cells at 24 h was similar to that of the red cells that had not undergone salvage. Both devices were comparable with respect to the effects of cell salvage on the 24-h survival rate of autotransfused red cells.