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Introduction: Peripherally inserted central catheters are venous devices intended for short to medium periods of intravenous treatment. Positioning of the catheter tip at the cavoatrial junction is necessary for optimum performance of a peripherally inserted central catheter. In this study, safety, effectiveness and cost-effectiveness of electrocardiographic-guided peripherally inserted central catheter positioning in a Dutch teaching hospital were evaluated. Methods: All patients who received a peripherally inserted central catheter in 2016 using electrocardiographic guidance were compared to those where fluoroscopy guidance was used in a prospective non-randomized cohort study. Relevant data were extracted from electronic health records. Cost-effectiveness analysis was performed. Results: A total of 162 patients received a peripherally inserted central catheter using fluoroscopy guidance and 103 patients using electrocardiographic guidance in 2016. No significant difference was found in malposition, infection or other complications between these groups. Due to personnel reduction and omission of fluoroscopy costs, cost reduction for each catheter insertion was €120 in the first year and, as a result of discounted acquisition costs, €190 in subsequent years. Discussion: The positioning results and complication rate are comparable to the previously reported literature. The cost reduction may vary in different hospitals. Other benefits of the electrocardiographic-guided technique are omission of X-ray exposure and improved patient service. Conclusion: Implementation of electrocardiographic-guided tip positioning for peripherally inserted central catheter was safe and effective in this study and led to an improved high value and cost-conscious care.

Objective: The aim of this retrospective cohort study was to investigate the outcome of rectus femoris muscle flaps (RFFs) for deep groin wound complications in vascular surgery patients and to compare the outcome with a cohort of sartorius muscle flaps (SMFs) because the RFF is a promising alternative technique for groin coverage.Methods: All RFFs and SMFs performed by vascular surgeons in a regional collaboration in The Southern Netherlands were retrospectively reviewed. Primary outcomes were muscle flap survival, overall and secondary graft salvage, and limb salvage. Secondary outcomes were 30-day groin wound complications and mortality, donor site and vascular complications, 1-year amputation-free survival, overall patient survival, impaired knee extensor function, and length of hospital stay.Results: A total of 96 RFFs were performed in 88 patients (mean age, 68 years; 67% male) and compared with a cohort of 30 SMFs in 28 patients (mean age, 64 years; 77% male). At a mean follow-up of 29 months and 23 months, respectively, comparable flap survival (94% vs 90%), secondary graft salvage (80% vs 92%), and limb salvage (89% vs 90%) rates were found. The 30-day mortality rates were 12% and 17%, respectively, and the 1-year amputation-free survival was comparable between treatment groups (71% vs 68%).Conclusions: This study presents a large series of RFFs for deep groin wound complications after vascular surgery. We demonstrate that muscle flap coverage using the rectus femoris muscle by vascular surgeons is an effective way to manage complex groin wound infections in a challenging group of patients, achieving similarly good results as the SMF.

Objective The aim of this systematic review is to assess potential differences in effectiveness (graft loss and limb loss) between the sartorius muscle flap (SMF) and the rectus femoris muscle flap (RFF) coverage technique for deep groin wound infection following vascular surgery. Our hypothesis was that RFF reconstruction is more effective in groin coverage. Methods The PubMed, Embase, and Medline databases were systematically searched by two independent researchers for articles reporting effectiveness of both muscle flaps in the treatment of groin infections following vascular surgery. After quality assessment using the Newcastle-Ottawa Scale and Methodological Index for NOn-Randomized studies (MINOR) scores and data extraction, individual results of the included studies were reviewed. Weighted pooled outcome estimates were calculated. Results A total of 17 studies comprising 544 SMF reconstructions and 238 RFF reconstructions were included. The pooled flap survival rate was 100% in both groups, with a pooled amputation rate of 0% and 2%, respectively. In the RFF group, a pooled 30-day mortality rate of 0% was found, compared with 1% in the SMF group. Pooled graft loss rates were 2% in the RFF group and 21% in the SMF group. Only one head-to-head comparison between both muscle flaps was performed, finding no significant differences. Conclusions Deep groin infection after vascular surgery can be treated with debridement and local muscle flap coverage. In this systematic review, superiority of either muscle flap on amputation or mortality rates was not demonstrated; however, there was a lower rate of vascular graft loss after RFF reconstruction. These conclusions are based on low-quality evidence because of limited data. Local muscle flap reconstruction using both techniques is effective in the treatment of infected groin wounds, achieving good results in a fragile group of patients. Therefore, anatomical and patient characteristics, which were not assessed in this analysis, are critical in the decision-making process on which muscle flap reconstruction is the best treatment option for an individual patient.

IntroductionDespite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease.Methods and analysisThis multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1–3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves.Ethics and disseminationThis study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United ‘MEC-U’ (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally.Trial registration numberNTR7332; Pre-results.

Background: The Dutch Audit for Carotid Interventions (DACI) registers all patients undergoing interventions for carotid artery stenosis in the Netherlands. This study describes the design of the DACI and results of patients with a symptomatic stenosis undergoing carotid endarterectomy (CEA). It aimed to evaluate variation between hospitals in process of care and (adjusted) outcomes, as well as predictors of major stroke/death after CEA.Methods: All patients with a symptomatic stenosis, who underwent CEA and were registered in the DACI between 2014 and 2016 were included in this cohort. Descriptive analyses of patient characteristics, process of care, and outcomes were performed. Casemix adjusted hospital procedural outcomes as (30 day/in hospital) mortality, stroke/death, and major stroke/death, were compared with the national mean. A multivariable logistic regression model (backward elimination at p > 0.10) was used to identify predictors of major stroke/death.Results: A total of 6459 patients, registered by 52 hospitals, were included. The majority (4,832, 75%) were treated Conclusion: CEA in The Netherlands is associated with an overall low mortality and (major) stroke/death rate. Whereas the indicator time to intervention varied between hospitals, mortality and (major) stroke/death were not significantly distinctive enough to identify worse practices and therefore were unsuitable for hospital comparison in the Dutch setting. Additionally, predictors of major stroke/death at population level could be identified. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Background: Obtaining adequate lipid control (LDL-Cholesterol [LDL] Methods: A total of 616 patients had their LDL levels measured at 2 vascular specialty clinics in the Netherlands (March 2006-November 2011) during the evaluation of new PAD symptoms. A year following this evaluation, 417 (68%) patients had their LDL levels re-assessed. Information about patients’ demographic and clinical factors was systematically abstracted from medical records. Categories of patients were created based on the attainment of the recommended LDL target ( Results: Of the total group, 57% (351/616) were off target at initial evaluation and 81% (496/616) were on lipid-lowering drugs after the initial evaluation at the PAD specialty clinic. One year later, only 25% (103/417) got on target, while 35% (147/417) patients remained off target, and an additional 10% (43/417) saw an increase in LDL to become off target. A total of 30% (124/417) remained on target. Patients with hypertension, diabetes, a history of myocardial infarction, and a lower ankle-brachial index were less likely to be off target at initial evaluation. Predictors of being off target at 1-year follow-up were male sex, and having a higher ankle-brachial index ( Table ). Conclusion: About half of patients with PAD seen at vascular specialty clinics had above-target LDL levels both upon entry and 1 year later. Patients with existing cardiovascular risk factors were much better controlled, as compared with patients without such risk factors. Males and those with higher ankle-brachial indices were less likely to be on target 1 year following management at the specialty clinic. Reasons for poorly regulated lipids need to be further explored, and appropriate quality-of-care improvement strategies will likely be needed to optimize secondary prevention.

Introduction: The decision-making process for invasive treatment in lower-extremity peripheral arterial disease (PAD) is ambiguous. There is a lack of appropriateness criteria and limited information available on health status gains to be expected following invasive treatment. We compared 1-year health status outcomes by the receipt of invasive treatment among patients with PAD and evaluated whether baseline health status was indicative of the 1-year health status gains, assuming that patients with lower baseline health status scores would receive the highest benefit. Methods: Baseline and 1-year health status (SF-12, Physical Component Score [PCS]) was assessed in 380 patients with newly diagnosed PAD (Rutherford 1-3) enrolled from 2 Dutch vascular clinics (March ‘06-November ’10). The 1-year treatment strategy (invasive [endovascular, surgery] vs. non-invasive [exercise therapy]) and clinical information was abstracted. Mean 1-year health status scores were compared by invasive treatment. Propensity weights were calculated for the receipt of invasive treatment using baseline characteristics and included in a linear regression analysis to predict 1-year PCS scores, with 1-year treatment strategy, baseline PCS scores, and the interaction between 1-year treatment strategy and PCS scores as predictors, while adjusting for demographics, lesion location, clinical risk factors, and depression. Results: Invasive treatment was performed in 38% (192 of 380). Patients with baseline health status scores in the lowest quartile undergoing invasive treatment had the greatest health status improvement (11.6±10.5 vs. 4.2±8.1, P Conclusions: Although invasive treatment in lower-extremity PAD is associated with clinically relevant 1-year health status benefits, we found that patients with lower starting levels of their health status had more to gain. Whether or not this will imply that only patients below a certain health status threshold should be offered invasive treatment needs to be subject of further research.

Totally Extraperitoneal (TEP) hernia surgery is associated with little postoperative pain and a fast recovery, but is a technically demanding operative procedure. Apart from the surgeon’s expertise, patient characteristics and hernia-related variations may also affect the operative time and outcome. Patient-related factors predictive of perioperative complications, conversion to open anterior repair, and operative time were studied in a cohort of consecutive patients undergoing TEP hernia repair from 2005 to 2009. A total of 3,432 patients underwent TEP. The mean operative time was 26 min (SD ± 10.9), TEP was converted into an open anterior approach in 26 patients (0.8 %), and perioperative complications were observed in 55 (1.6 %) patients. Multivariable regression analysis showed that a history of abdominal surgery (OR 1.76, 95 per cent confidence interval 1.01–3.06; p = 0.05), and the presence of a scrotal (OR 5.31, 1.20–23.43; p = 0.03) or bilateral hernia (OR 2.25, 1.25–4.06; p = 0.01) were independent predictive factors of perioperative complications. Female gender (OR 5.30. 1.52–18.45; p = 0.01), a history of abdominal surgery (OR 3.96, 1.72– 9.12; p = 0.001), and the presence of a scrotal hernia (OR 34.84, 10.42–116.51, p

Contains fulltext : 80682.pdf (Publisher’s version ) (Open Access) BACKGROUND: Totally extraperitoneal (TEP) endoscopic hernia surgery is increasingly popular since it is associated with little postoperative pain and with early return to work. Previous appendectomy may preclude preperitoneal dissection in patients with right-sided hernias. The feasibility of TEP surgery in these patients was the subject of the present study. METHODS: Between January 2005 and February 2007 all consecutive patients undergoing TEP surgery were included in a prospective cohort study. The study group consisted of patients with right-sided and bilateral hernias. Operative times, conversions, complication rates, and return to daily activities were recorded. Patients were divided into two groups according to previous appendectomy. RESULTS: A total of 462 patients with right-sided hernias underwent TEP surgery: 421 patients without previous abdominal surgery (group 1) and 41 patients with previous appendectomy (group 2). The conversion rate was significantly higher in group 2: four patients (10%) were converted to open Lichtenstein repair versus five (1%) in group 1 (p = 0.005). However, we found no significant differences in complication rate, operative time, and return to daily activities. CONCLUSIONS: A right-sided (or bilateral) TEP procedure may be performed safely in patients after previous appendectomy. Despite a higher conversion rate, the vast majority of patients can be operated endoscopically.

Objective/BackgroundLimited information is available on expected health status gains following invasive treatment in peripheral arterial disease (PAD). One year health status outcomes following invasive treatment for PAD were compared, and whether pre-procedural health status was indicative of 1 year health status gains was evaluated.MethodsPre-procedural and 1 year health status (Short Form-12, Physical Component Score [PCS]) was prospectively assessed in a cohort of 474 patients, enrolled from 2 Dutch vascular clinics (March 2006–August 2011), with new or exacerbation of PAD symptoms. One year treatment strategy (invasive vs. non-invasive) and clinical information was abstracted. Quartiles of baseline health status scores and mean 1 year health status change scores were compared by invasive treatment for PAD. The numbers needed to treat (NNT) to obtain clinically relevant changes in 1 year health status were calculated. A propensity weight adjusted linear regression analysis was constructed to predict 1 year PCS scores.ResultsInvasive treatment was performed in 39% of patients. Patients with baseline health status scores in the lowest quartile undergoing invasive treatment had the greatest improvement (mean invasive 11.3 ± 10.3 vs. mean non-invasive 5.3 ± 8.5 [p = .001, NNT = 3]), whereas those in the highest quartile improved less (.8 ± 6.3 vs. –3.0 ± 8.2 [p = .025, NNT = 90]). Undergoing invasive treatment (p < .0001) and lower baseline health status scores (p < .0001) were independently associated with greater 1 year health status gains.ConclusionSubstantial improvements were found in patients presenting with lower pre-procedural health status scores, whereas patients with higher starting health status levels had less to gain by an invasive strategy.Keywords: Atherosclerosis, Peripheral vascular disease, Revascularization

Venous aneurysms have been reported in most major veins and are often asymptomatic but can cause serious complications. Three patients with symptomatic venous aneurysms of the internal jugular vein, portal vein, and popliteal vein are presented, and their treatment and outcomes are discussed. Furthermore, presentation and management of the most frequent venous aneurysms, based on available literature, are evaluated. The literature supports conservative treatment of asymptomatic and nonthrombotic jugular, subclavian, thoracic, and visceral venous aneurysms. Surgery should be considered only for symptomatic venous aneurysms or in case of progressive expansion on follow-up. Prophylactic surgery is recommended for all patients with lower extremity deep venous aneurysms, by means of tangential aneurysmectomy with lateral venorrhaphy, because of the increased risk of pulmonary embolization. Postoperative anticoagulation is recommended for a period of at least 3 months after operative treatment.

Three recent studies found that corticosteroids improve clinical outcome and mortality in tuberculous meningitis (TBM), although the exact mechanism of action of the drug remains speculative. A number of reports on the effect of corticosteroids on cerebrospinal fluid (CSF) findings in TBM have been published, often with conflicting results regarding serial cell counts and protein levels. As part of a controlled, randomized trial on the effect of oral prednisone on outcome in childhood TBM at our institution, CSF was collected and analysed weekly during the 1st month of treatment. We found no significant difference in serial CSF cell counts between the steroid and non-steroid groups in the study. However, the steroid group had significantly lower CSF protein and globulin levels after the 1st month of treatment, and a more steady rise in CSF glucose levels than the non-steroid group. Knowledge of the different CSF responses during the course of anti-tuberculosis therapy is important in clinical decision-making.