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The aim of the present study was to explore whether preoperative white blood cell (WBC) count may predict 30-day mortality and long-term survival following surgery for abdominal aortic aneurysm (AAA). Secondarily, we wanted to assess the potential sex differences in WBC in these patients.

Purpose: To study the feasibility of 3-dimensional (3D) teleradiology in surveillance of patients treated with stent-grafts for abdominal aortic aneurysm (AAA).Methods: Between April 2002 and November 2003, 8 AAA patients (7 men; median age 73 years, range 62–84) with stent-grafts had follow-up computed tomograms (CT) performed at their local hospital and transmitted without loss across a broadband connection to the university hospital. On both monitors, the radiologists were presented with the complete CT axial dataset, sagittal and coronal reformatted slices, and a 3D volume-rendered reconstruction. The two radiologists were then able to simultaneously perform measurements and real-time manipulations of the axial and 3D pictures, which were discussed over the telephone or using a videoconferencing unit. Patient satisfaction, the radiologists' evaluation of the method, and the potential cost savings were explored.Results: Twelve follow-up CT scans were performed on the 8 patients. The time for transmission over the teleradiological network averaged 5 minutes, and the evaluation required 15 minutes at the university hospital. The overall technical quality of the images was rated as good by the university radiologist. In 11 studies, the stent-grafts were satisfactory, but a type III endoleak was detected in one 5.5-year-old stent-graft. Neither radiologist had a problem identifying the endoleak. Patients had confidence that the examination at the local hospital was of good quality; they all felt that they received good care and were pleased with avoiding travel to the university hospital. From the economic analysis, an annual savings of 40,000 Euros (US$52,304) was projected, mostly due to avoiding hospital stays and outpatient consultations at the university hospital.Conclusions: The experiences from this study are encouraging, but a larger series will be necessary for a thorough evaluation of 3D teleradiology as a surveillance method for aortic stent-graft patients.

Purpose: To present an as yet unreported late complication of an Excluder thoracic endograft.Case Report: A 78-year-old man underwent surgery for a ruptured type V thoracoabdominal aortic aneurysm in 1996. Four years later, an aneurysm was detected in the proximal thoracic aorta and repaired with 2 Excluder endoprostheses. At 12 months, computed tomography showed an increase in the aneurysm sac diameter and a type III endoleak, which was traced to a hole in the stent-graft fabric on arteriography. No fracture of the metal components was detected in the stent-grafts. Another Excluder device was implanted within the distal endograft. Satisfactory exclusion of the leak has been maintained for 6 months.Conclusions: The risk of type III leaks must be minimized before stent-grafting can be regarded as a routine procedure in the treatment of thoracic aortic aneurysms.

Abstract. A review is given of endovascular treatment for AAA, thoracic aortic aneurysms, dissections as well as complications following previous aortic surgery. In several of these conditions endovascular treatment has advantages like a reduced operative trauma, shorter stay in hospital, and the possibility of treating patients who would have been unfit for open surgery. On the other hand, problems like endoleak, deformation of the endoprosthesis, retrograde filling of the aneurysmal sack, and graft limb occlusion need to be solved before the place of endovascular treatment can be defined. It is possible that the steadily improving quality of the implants as well as the introducer systems will widen the indications for endovascular surgery, but randomised clinical trials are warranted and a longer follow-up period is necessary to draw final conclusions.

Correspondence to: Tonje Strømholm, M.D. Department of Pathology, University Hospital of Trondheim, N-7006 Trondheim, Norway--> Abstract. The purpose of this study was to determine the plasma catecholamine response to cross-clamping of the descending thoracic aorta in pigs and to relate the plasma catecholamine response to cardiac output during cross-clamping. This prospective, controlled animal study was done at the University Hospital of Trondheim, Norway. Eight pigs (19–25 kg) underwent cross-clamping of the descending thoracic aorta for 30 minutes. The time course of plasma adrenaline, plasma noradrenaline, and ascending aortic blood flow were measured. It was found that the increase of plasma catecholamines during cross-clamping of the descending thoracic aorta in pigs was parallel to the increase of aortic blood flow during cross-clamping. Plasma adrenaline increased from 0.22 nmol/L to a maximum of 11.75 nmol/L and plasma noradrenaline increased from 0.17 nmol/L to a maximum of 46.92 nmol/L after 10 minutes of cross-clamping (p = 0.01). Ascending aortic blood flow increased from 2.6 L/minute to a maximum of 4.7 L/minute after 10 minutes of cross-clamping (p = 0.01). Our findings support the theory that increased plasma catecholamines might be a mechanism of increased cardiac output during cross-clamping of the descending thoracic aorta. The increase of plasma catecholamines during cross-clamping is most likely due to distal hypotension with increased sympathetic activity.

Starling pressures (interstitial fluid pressure, plasma and interstitial fluid colloid osmotic pressures) were measured in subcutaneous tissue at the ankle in 20 healthy controls and 27 patients with lower limb atherosclerosis. Subcutaneous interstitial fluid pressure (Pif) of the leg was also measured in seven patients with arterial emboli of the lower limb. Interstitial fluid was collected by implantation of nylon wicks and Pifwas measured by the ‘wick-in-needle’, technique.The calculated reabsorption pressure (equal to capillary pressure if no net filtration occurs) was 18.3 mmHg in the group with atherosclerosis, which was higher than in controls (15.8 mmHg, P< 0.05).Colloid osmotic pressure of interstitial fluid (COPif) was significantly lower in patients with atherosclerosis than in controls (5.9 v. 9.2 mmHg). This finding in itself could make those patients more susceptible to edema formation postoperatively. On the other hand, there was no correlation between COPifand ankle systolic blood pressure within the group of patients.There was a slight, but statistically significant positive correlation between ankle systolic blood pressure and Pifin patients with lower limb atherosclerosis although mean Pifwas not different from controls (-1.0 v. -0.8 mmHg). In patients with arterial emboli, however, Pifwas lower (mean -4.5 mmHg).

Purpose: To investigate the feasibility of regional anesthesia for endovascular repair of abdominal aortic aneurysms (AAAs).Methods: Since February 1995, 21 patients (17 men and 4 women; median age 67 years, range 49 to 80) have been treated with endovascular technique for true infrarenal AAA using Mialhe Stentor bifurcated grafts. A single dose of spinal anesthesia combined with epidural anesthesia was used in all procedures. Electrocardiography and arterial blood pressure were monitored.Results: No cases of emboli, hematoma, or graft migration were seen, and there were no reoperations or conversions to open operation. Arterial blood pressure was stable at a satisfactory level from induction of anesthesia throughout the procedure, and there was no period of clinically significant hypotension during any implantation. One patient died on the second postoperative day from cardiac and renal insufficiency. Three endoleaks were observed during the procedure; one healed spontaneously within 5 weeks, and the other two were repaired by endovascular techniques after 1 and 4 months, respectively. During follow-up, one patient died at 6 months from pancreatic carcinoma.Conclusions: The application of regional anesthesia is feasible for endovascular treatment of AAA. The arterial blood pressure remained stable throughout the procedure, and all patients, with two exceptions, were mobilized on the first day and placed on a regular diet. Based on these early results, it appears that regional anesthesia is feasible, effective, and safe for endovascular AAA repair.

EUROSTAR(EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair) was established for the purpose of combining and studying data on endovascular abdominal aortic aneurysm (AAA) repair. EUROSTAR is independent of any commercial interest and has as its ultimate goal an independent, scientifically reliable assessment of endovascular AAA grafting. A standardized case record form is used for data collection and transmission, and the database is maintained in a central registry office. A comprehensive set of clinical, imaging, technical, and laboratory data obtained at initial admission and follow-up are recorded; these data are analyzed periodically and reports generated on the collated experience.As a first priority, an observational study without controls was initiated in July 1996 to address the issues of procedural safety, device durability, and long-term effect upon the aneurysms. Several ancillary studies have been initiated, including a “Retrieval and Analysis Study” for the evaluation of explanted devices. While a randomized study does not seem feasible at present, this may be organized at the appropriate time when the devices and techniques become more standardized.

With help of a questionnaire with a 96% response rate, the exact number of arterial operations in Scandinavia has been established. In Sweden in 1980 it was 470 per million inhabitants and in Norway in 1981 it was 553 per million inhabitants, but regional differences within the countries were great. In only 14% of the hospitals were more than 100 arterial operations performed per year. The development of arterial surgery during a 10-year period in the cities of Malmö and Oslo, with active vascular centers, is also given. The increase in the two cities is similar and above 300%. Percutaneous transluminal angioplasty comprised 11% of the total number of arterial interventions in 1981.

The aim of this study was to evaluate subcutaneous transcapillary fluid balance during pulsatile and nonpulsatile extracorporeal circulation (ECC). Changes in the transcapillary fluid balance were studied by measuring subcutaneous interstitial fluid pressure (Pif) using the 'wick in needle' (WIN) method, as well as measuring subcutaneous interstitial fluid colloid osmotic pressure (COPif), using either the wick technique or the blister suction technique. The measurements were performed on the chest wall at the heart level. Simultaneous recordings of plasma colloid osmotic pressure (COPpl) were carried out. Nineteen male patients undergoing aortocoronary bypass grafting were subjected to nonpulsatile flow (group I, n= 11) or pulsatile flow (group II, n= 8) during ECC. Preoperatively there was no difference in the Starling forces between the two groups. During ECC the COP gradient (COPpl-COP if) was reversed to the same extent in the two groups. At three hours and six hours following ECC, COPifin the pulsatile group (12.1 mmHg and 11.4mmHg respectively) was significantly higher than in the nonpulsatile group (10.8mmHg and 10.3mmHg respectively). When weaning from ECC as well as three hours and six hours following ECC, Pifin the pulsatile group was significantly lower than in the nonpulsatile group. Conclusion: in the early postoperative period there is less dilution of the subcutaneous interstitial tissue following application of pulsatile flow during ECC compared to nonpulsatile flow.

With help of a questionnaire with a 96% response rate, the exact number of arterial operations in Scandinavia has been established. In Sweden in 1980 it was 470 per million inhabitants and in Norway in 1981 it was 553 per million inhabitants, but regional differences within the countries were great. In only 14% of the hospitals were more than 100 arterial operations performed per year. The development of arterial surgery during a 10-year period in the cities of Malmö and Oslo, with active vascular centers, is also given. The increase in the two cities is similar and above 300%. Percutaneous transluminal angioplasty comprised 11% of the total number of arterial interventions in 1981. La chirurgie artérielle s'est développée rapidement au cours de ces 25 dernières années. Si les indications de cette chirurgie sont assez bien définies, l'étude de divers rapports met en évidence d'importantes différences dans la fréquence des opérations vasculaires pratiquées. La majorité des chiffres rapportés étant le fait d'études entreprises aux Etats-Unis où le système de soins est très différent de celui de la Suède et de la Norvège. Le but de cet article est d'apprécier les besoins réels de la chirurgie vasculaire en Scandinavie pour la planifier et l'organiser en se basant sur des données locales rigoureusement précisées. El nÚmero exacto de operaciones arteriales realizadas en Escandinavia ha sido establecido mediante un cuestionario con una tasa de respuesta del 96%. En Suecia esta tasa fue de 470 por millón de habitantes en 1980, y en Noruega de 553 por millón de habitantes en 1981; las diferencias regionales dentro de los dos países fueron grandes. Sólo en el 14% de los hospitales se realizaron más de 100 operaciones arteriales por año. También se informa el desarrollo de la cirugía arterial durante un período de 10 años en las ciuda-des de Malmö y Oslo, las cuales poseen activos centros vasculares. El incremento en las dos ciudades es similar y superior al 300%. La angioplastia percutánea transluminal representó el 11% del nÚméro total de intervenciones arteriales en 1981.

Purpose: To evaluate different ultrasound modalities during implantation and follow-up of endovascular grafts for abdominal aortic aneurysm (AAA) exclusion.Methods: Between February 1995 and May 1996, 18 patients (14 men; aged 49 to 80 years, mean 67) were treated with endovascular intervention for infrarenal AAA. Seventeen patients received Mialhe Stentor bifurcated grafts, while one patient was treated with a straight graft for pseudoaneurysm. During and after the implantation, 3.25- and 5-MHz annular array ultrasound probes were used for transabdominal visualization of the endograft. Intravascular ultrasound was applied in combination with angiography for postoperative control.Results: Intraprocedurally, transabdominal two-dimensional (2D) ultrasound successfully monitored guidewire passage from the groin into the main part of the bifurcated endograft for implantation of the second limb. All implantation procedures were technically successful, but four endoleaks were identified intraprocedurally by 2D ultrasound and angiography. One healed spontaneously, two were treated with endovascular techniques at 1 and 4 months, and the last leak was scheduled for repair when the patient died of probable myocardial infarction at 2 months. During follow-up, 2D ultrasound successfully visualized all the endografts; no endoleaks were found in up to 18 months of surveillance.Conclusions: Transabdominal ultrasound imaging could be valuable in bifurcated endograft deployment both for guiding guidewire insertion and for controlling wire position before the second graft limb is connected to the main graft. Provided that satisfactory visualization of the entire endograft can be obtained, ultrasound examination may possibly replace arteriography and computed tomographic scanning as a follow-up investigation.

The intra- and postoperative variations of the transcapillary forces [colloid osmotic pressure of plasma (COPpl), colloid osmotic pressure of interstitial fluid (COPif), average hydrostatic pressure in the interstitium (Pif)] were studied in the subcutaneous tissue as a function of time in 13 patients operated on for coronary artery disease using extracorporeal circulation (ECC). The measurements were performed before operation, during ECC, and during the first 24 hours postoperatively. COPif was measured subcutaneously on the chest both by the wick method and by a noninvasive blister suction method. The latter technique allowed several consecutive measurements in the same individual during the postoperative period. Pif was measured by “wick-in-needle” technique in the same area as the COPif measurements. COPpl was measured in a blood sample collected from a cubital vein. COPpl was reduced about 50% during ECC returned to pre-ECC level within the first 6 hours postoperatively. During ECC COPif was higher than COPpl, reaching its minimum level 4 to 5 hours postoperatively. Measurements performed following ECC showed return of the transcapillary COP-gradient to the normal direction (COPpl > COPif). Pre-ECC level of COPif was not entirely obtained during the first postoperative day. Pif increased gradually during ECC and continued to increase the first 2 to 3 hours following ECC. Pre-ECC level was reached within 24 hours postoperatively. The present investigation has demonstrated major dynamic variations in the transcapillary forces in patients undergoing open heart surgery with ECC. There was an increased net capillary filtration (F) intraoperatively predisposing to interstitial edema formation in subcutaneous tissue until several hours following the termination of ECC.

Seven patients were operated on for thoracic (n=2) or thoracoabdominal (n=5) aortic aneurysms during cross-clamping of the aorta. Interstitial tissue fluid pressure was measured at the neck during cross-clamping of the descending thoracic aorta by the wick-in-needle technique, whereas control measurements were obtained prior to cross-clamping. The subcutaneous interstitial fluid pressure was significantly higher on the neck during cross-clamping of the thoracic aorta compared with control measurements (median 3.7 mmHg vs −0.6 mmHg, p<0.05). Increased subcutaneous interstitial tissue pressure of the upper part of the body is probably caused by increased capillary filtration rate induced by inhibited autoregulatory functions during aortic cross-clamping. The pressure measurements objectively confirm the problem of edema formation of the head and neck during these operations. The edema may occasionally affect the upper airways and represent a problem for intubation of the patient in the postoperative phase.