Selected Abstracts from the August Issue of the
European Journal of Vascular and Endovascular Surgery
Piergiorgio Cao, MD, FRCS, Editor-in-Chief, and Jean-Baptiste Ricco, MD, PhD, Senior Editor
Process of Care Partly Explains the Variation in Mortality Between
Hospitals After Peripheral Vascular Surgery
Hoeks S.E., Scholte op Reimer W.J.M., Lingsma H.F., van Gestel Y., van
Urk H., Bax J.J., Simoons M.L., Poldermans D. Eur J Vasc Endovasc Surg
Objectives: The aim of this study is to investigate whether variation in
mortality at hospital level reflects differences in quality of care of peripheral
vascular surgery patients.
Design: Observational study.
surgery patients were enrolled.
Methods: Multilevel logistic regression models were used to relate
patient characteristics, structure and process of care to mortality at 1 year.
The models were constructed by consecutively adding age, sex and Lee
index, then remaining risk factors, followed by structural measures for
quality of care and finally, selected process of care parameters.
Results: Total 1-year mortality was 11%, ranging from 6% to 26% in
different hospitals. Large differences in patient characteristics and quality
indicators were observed between hospitals (e.g., age ? 70 years: 28–58%;
beta-blocker therapy: 39–87%). Adjusted analyses showed that a large part
of variation in mortality was explained by age, sex and the Lee index
(Akaike’s information criterion (AIC) ? 59, p ? 0.001). Another substan-
tial part of the variation was explained by process of care (AIC ? 5,
p ? 0.001).
Conclusions: Differences between hospitals exist in patient character-
the patient population at risk, a substantial part of the variation in mortality
can be explained by differences in process measures of quality of care.
Heterotopic Ossifications in Midline Abdominal Scars: A Critical Re-
view of the Literature
Koolen P.G.L., Schreinemacher M.H.F., Peppelenbosch A.G. Eur J Vasc
Endovasc Surg 2010;40:155–9.
Heterotopic ossification (HO) is the formation of bone outside the
skeletal system, including old incisions. Although a well-known complica-
tion after orthopaedic surgery, it is still considered an uncommon phenom-
enon after vascular surgery. Recent data, however, show that up to 25% of all
patients develop HO after midline abdominal surgery. In this article, we
reconstruction for an abdominal aortic aneurysm. Furthermore, we review
current insights into the aetiology and show bone morphogenetic proteins
to play a crucial role. Treatment options are also reviewed, but lacking any
supportive evidence for other therapies, surgical excision with primary
closure is the treatment of choice.
Dual Antiplatelet Therapy Prior to Carotid Endarterectomy Reduces
Post-operative Embolisation and Thromboembolic Events: Post-
operative Transcranial Doppler Monitoring is now Unnecessary
Sharpe R.Y., Dennis M.J.S., Nasim A., McCarthy M.J., Sayers R.D., Lon-
don N.J.M., Naylor A.R. Eur J Vasc Endovasc Surg 2010;40:162–7.
Background: Thrombotic stroke following carotid endarterectomy
(CEA) is preceded by high-grade embolisation (detected using transcranial
Doppler (TCD)) and can be prevented by incremental doses of Dextran.
However, this strategy is labour intensive and Dextran manufacture has now
ceased. A randomised trial has suggested that a single 75 mg dose of
Clopidogrel (administered the night before surgery in addition to daily
75 mg Aspirin) significantly reduces post-CEA embolisation. We hypothe-
sized that this model of dual antiplatelet therapy might significantly reduce
the need for adjuvant Dextran therapy.
Methods: Retrospective audit of prospectively acquired data in 297
patients undergoing CEA between 01.08.2006 and 30.07.2009. All re-
ceived routine Aspirin (75 mg daily) in addition to a single 75 mg dose of
Clopidogrel the night before surgery. All underwent completion angioscopy
and those with a temporal window (n ? 270) underwent intra- and
post-operative TCD monitoring.
10 min period) occurred in only 1/270 patients (0.4%), significantly less
than the 3.2% rate in historical controls where Clopidogrel was not admin-
istered. There were no peri-operative deaths, but 3/297 patients suffered
non-disabling strokes (intra-operative extension of a pre-existing deficit,
haemorrhage into lentiform nucleus after hypertensive crisis, contralateral
embolic stroke). The overall 30-day death/stroke rate (1.0%) was not-
Conclusions: 75 mg Clopidogrel administered the night before sur-
gery (in addition to daily 75 mg Aspirin) was associated with a significant
reduction in post-operative embolisation and Dextran utilisation. No ipsi-
lateral thromboembolic ischaemic events occurred in this series. As a conse-
quence of this audit, one dose of 75 mg Clopidogrel will continue to be
given pre-operatively (in addition to daily 75 mg Aspirin) and routine
post-operative TCD monitoring has now ceased.
Anatomical Suitability For Endovascular AAA Repair May Affect Out-
comes following Rupture
Perrott S., Puckridge P.J., Foreman R.K., Russell D.A., Spark J.I. Eur J Vasc
Endovasc Surg 2010;40:186–90.
Objectives: Single centre series have suggested that endovascular an-
eurysm repair (EVAR) for ruptured abdominal aortic aneurysms (rAAA)
the only randomized controlled trial, leading to suggestion that anatomical
suitability for rEVAR may independently improve prognosis of rAAA. Our
aim was to assess the outcome of open rAAA repair in patients dependant on
their suitability for rEVAR on pre-operative computed tomography (CT)
Methods: A retrospective review of all ruptured aneurysms presenting
to our unit since January 1998 was performed. Patients were grouped based
on anatomical suitability for rEVAR by pre-operative CT.
Results: Of 118 patients presenting with rAAA, 48 underwent pre-
operative CT. Of these 9 scans had been “culled” and were excluded. 16
patients were suitable for rEVAR and 23 unsuitable. The groups were well
matched demographically with no difference in Glasgow Aneurysm Score
between groups. There was a non-significant trend towards reduction in
30-day mortality for patients suitable for EVAR (suitable 6.9% versus un-
suitable 30.4%; P ? 0.066) with no difference in operative time, transfusion
requirement, length of stay or in-hospital morbidity.
Conclusions: Anatomical suitability for EVAR seems to beneficially
affect outcome following open repair for ruptured AAA. Further study is
required to confirm these findings.
Morphological and Mechanical Changes in Juxtarenal Aortic Segment
and Aneurysm Before and After Open Surgical Repair of Abdominal
Majewski W., Stanišic ´ M., Pawlaczyk K., Marszałek A., Seget M., Biczysko W.,
Krasin ´ski Z. Eur J Vasc Endovasc Surg 2010;40:202–8.
Objective: The aim of study was to assess how the ultrastructure of the
wall of aortic aneurysms, sac and neck influences aortic wall distensibility and
proximal dilatation 2 years after open repair.
Methods: Biopsies for electron microscopy were taken from aneurys-
mal sac and neck of 30 patients. Patients were assessed by computed
tomography (CT) and ultrasound for aneurysm diameter and distensibility
Results: Postoperative CT of the aortic stump distinguished two
groups. Group I (n ? 11) with little enlargement, median 1 mm (1–3 mm)
and group II (n ? 19) with significant aortic enlargement, median 5.2 mm
(4–12 mm). In group II, changes in elastic fibres in the aneurysm neck were
comparable to, but as extreme as in the aneurysm sac. For group I, the
at the renal arteries. For group II, the distensibility in both the neck and sac
was significantly lower than at the juxtarenal segment (p ? 0.01). The
biopsies of group II patients showed the extensive degeneration of normal
architecture, which was associated with altered wall distensibility in both the
aneurysmal neck and sac.
Conclusions: Disorganisation and destruction of normal aortic archi-
tecture at the ultrastructural level are associated with decreasing aortic
dilatation at 2 years postoperatively.