RESUMEN
AIM: Abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). This paper reports on an experience of using preoperative medical criteria and a list of intraoperative factors for selective use of the ICU. These criteria were evaluated in relation to their impact on the safety and short term results after open AAA repair. METHODS: All elective open infrarenal AAA repairs during a 9 year period (1994-2003), following a specific algorithm towards selective use of the ICU, were retrospectively evaluated. Patients were clinically evaluated, before the operative procedures, and divided into categories according to their medical risk (cardiac and pulmonary status). Patients with an ejection fraction <30% and a FVC or FEV1 <50% of the predicted value were transferred immediately from the operating room to the ICU. A list of intraoperative factors: 1) prolonged operative time; 2) prolonged aortic clamping time; 3) suprarenal clamping; 4) quantity of blood transfusion; 5) intraoperative acute renal failure; 6) intraoperative hemodynamic instability; 7) intraoperative cardiac dysfunction were also considered criteria for transfer from the operating room to the ICU. Patients who did not meet any of the above criteria were extubated and transferred to the surgical floor. RESULTS: Elective AAA repair was performed on 602 patients, among whom, 551 (91.5%) were extubated in the operating room and thereafter treated in the surgical floor and 51 (8.5%) were transferred from the operating room to the ICU. However, later transfer from the floor to the ICU was required in 7 more patients (1.1%), increasing the total percentage of patients treated in the ICU to 9.6%. (51 patients initially and 7 later on). The total postoperative 30 days mortality rate was 0.7% (4 patients) and the morbidity rate was 18.8% in this series. The mean length of in-hospital stay was 9.9 days and the mean ICU length of stay was 4.2 days. CONCLUSION: Elective AAA repair with selective use of the ICU can be a considerable safe policy in a single high volume hospital. It can reduce resource use without a negative impact on the quality of care.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/estadística & datos numéricos , Cuidados Críticos/métodos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Cuidados Posoperatorios/métodos , Anciano , Anciano de 80 o más Años , Algoritmos , Implantación de Prótesis Vascular/mortalidad , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND: Sophisticated methods of determining cerebral blood flow have reduced the use of shunting in carotid endarterectomy in 6-25% of cases. However teaching university hospitals still have to provide their young vascular surgeons with experience in the shunting procedure. Since complications of shunting have been related to the surgeon's experience in the technique, our study aimed to evaluate a policy of the routine use of shunting in carotid endarterectomy by vascular surgeons in training. In addition to concluding how this policy would affect the optimum outcome of our patients. The probable reduction of hospital charges was also evaluated. METHODS: A prospective audit of the results of 423 consecutive carotid endarterectomies performed by a senior vascular surgeon (the first 97 cases) and a vascular surgeon in training under the supervision of a senior vascular surgeon (326 cases), with routine use of an indwelling intraluminal shunt, in a university hospital in Athens. RESULTS: During the study period, 337 patients admitted to our department were managed surgically independently of any demanding surgery due to the anatomy and the extension of internal carotid artery disease. The perioperative stroke/death rate at 30 days was 0.47%, but the stroke rate alone was 0%. Minor complications amounted to 5.4%, with an increased but not significant difference in patients presenting contralateral internal carotid occlusion. There was no difference in complication rates when a young surgeon performed the shunting procedure compared with the experienced senior surgeon's results, but this was achieved after training in the method in the first 97 cases. The reduction of the total cost was related to avoidance of cost of the devices necessary for determination of the cerebral circulation during carotid clamping and the cost of specially trained personnel. Our policy resulted in only eight patients having to be treated in the intensive care unit for a total of 13 days. CONCLUSIONS: Experience in a large number of shunting procedures are required for a young vascular surgeon's training, in order to achieve optimum results. This can be done in teaching hospitals by using the method more frequently than required. Moreover in the contest of continuing changes in the practice of carotid endarterectomy and the economic restrictions on health expenditure, the routine use of shunting resulted in cost saving without jeopardizing the patients' outcome.
Asunto(s)
Endarterectomía Carotidea , Anciano , Anciano de 80 o más Años , Derivación Arteriovenosa Quirúrgica , Control de Costos , Endarterectomía Carotidea/economía , Endarterectomía Carotidea/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Factores de Riesgo , Procedimientos Quirúrgicos Vasculares/educaciónRESUMEN
Rupture of abdominal aortic aneurysms (AAA) is a life-threatening condition and a leading cause of death in various countries. In spite of increased awareness of most physicians for an early diagnosis of the rupture, the performance of surgery in an early stage and special care in the Intensive Care Unit, postoperative mortality is still high in most medical centers as well as in our Clinic. Two series of patients operated in our Clinic during the last 17 years are analysed. The applied surgical technics are presented and morbidity and mortality are analysed. A distinction between the general mortality was made based on all the inhospital deaths and the postoperative mortality rate including only the deaths after the operation during the postoperative period. Among the other conclusions it is also stressed that a real improvement in the mortality rate depends on elective surgery of all the disclosed AAA larger than 4 cm in diameter.
Asunto(s)
Aneurisma de la Aorta/cirugía , Rotura de la Aorta/cirugía , Aorta Abdominal , Aneurisma de la Aorta/mortalidad , Rotura de la Aorta/mortalidad , Humanos , Complicaciones Posoperatorias/mortalidad , Tasa de SupervivenciaRESUMEN
Although the earliest possible embolectomy is still correlated with best rates of limb salvage, we consider, as do most other authors, that the only critical criterion for operability must be the viability of the ischemic limb. Even in the presence of gangrene of the foot relief of arterial occlusion is recommended in order to secure a more distal amputation. Arterial embolectomy seems to be a simple surgical procedure; however, in the presence of atherosclerotic arteries or in the cases of acute arterial thrombosis the operative procedure needs considerable experience in vascular surgical techniques to secure a successful outcome. Finally, the prevention and early treatment of the revascularization syndrome together with appropriate cardiopulmonary management in a strict intensive-care unit can improve the mortality significantly in cases of acute arterial occlusion of the extremities.
Asunto(s)
Arteriopatías Oclusivas/cirugía , Trombosis/cirugía , Enfermedad Aguda , Adulto , Anciano , Amputación Quirúrgica , Anticoagulantes/uso terapéutico , Aorta , Arteriopatías Oclusivas/epidemiología , Arteriopatías Oclusivas/mortalidad , Arteria Axilar , Arteria Braquial , Endarterectomía , Extremidades/irrigación sanguínea , Femenino , Arteria Femoral , Heparina/administración & dosificación , Humanos , Arteria Ilíaca , Masculino , Persona de Mediana Edad , Arteria Poplítea , Cuidados Posoperatorios , Cuidados PreoperatoriosRESUMEN
During a nine-year period, 201 profundoplasties were performed on 152 patients; of these, 83 were simple and the remaining 132 combined with other inflow or outflow by-pass procedures. Immediate postoperative results were satisfactory whereas late results of 63 simple profundoplasties carried a patency rate of 78% and a limb salvage of 70% was detected eight years postoperatively. Profundoplasty alone or in combination with proximal or distal angioplastic procedures is a very effective method for the revascularization of ischemic lower extremities.