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This study aimed to investigate the correlation between aneurysm sac behaviour and time to re-intervention after endovascular aneurysm repair (EVAR). A retrospective observational cohort study of patients who underwent EVAR at a single centre between January 2008 and November 2011 and who were followed up for a mean of 6.6 ± 2.9 years was conducted. Based on sac appearances on pre-operative imaging and imaging at the end of follow up, patients were stratified into two groups: (1) sac regression; and (2) no sac regression. The no sac regression group was further subdivided into stable sac group and sac expansion group. Sac regression and expansion throughout follow up were defined as a decrease or increase in the abdominal aortic aneurysm sac diameter of ≥ 5 mm compared with the pre-operative size. A Cox proportional hazards model using multiple failure per subject data was used to identify sac behaviour as a predictor of re-intervention free time. Patients with sac regression had a higher probability of freedom from re-intervention compared with those with a stable or expanding aneurysm sac (94%, 57%, and 16% at 12 years, respectively; log rank, p <.001). Mean time to re-intervention was 11.3 years for the sac regression group, 8.8 years for the stable sac group, and 5.0 years for the sac expansion group (p <.001). In the stable sac group, the risk of re-intervention increased sharply six years after EVAR, whereas in the sac expansion group a sharp rise in re-intervention was noted 3.5 years after EVAR, reaching a plateau after year 6. A time dependent correlation between aneurysm sac behaviour and re-intervention was found. Such findings have implications for surveillance strategies. [ABSTRACT FROM AUTHOR]

Prosthetic valve endocarditis (PVE) is the most severe form of infective endocarditis associated with a high mortality rate. Whether PVE affects biological and mechanical aortic valves to the same extent remains controversial. This study aimed to compare the incidence of re-intervention because of PVE between bioprosthetic and mechanical valves. Patients undergoing isolated surgical aortic valve replacement (AVR) or combined AVR in a single cardiac surgery centre between January 1998 and December 2019 were analysed. All patients who underwent re-intervention because of PVE were identified. The primary endpoint was the rate of explants. Freedom from re-intervention and variables associated with re-intervention were analysed using Cox regression analysis including correction for competing risk. During the study period, 5,983 aortic valve prostheses were implanted, including 3,620 biological (60.5%) and 2,363 mechanical (39.5%) prostheses. The overall mean follow-up period was 7.3±5.3 years (median, 6.5; IQR 2.9–11.2 years). The rate of re-intervention for PVE in the biological group was 1.5% (n=54) compared with 1.7% (n=40) in the mechanical group (p=0.541). Cox regression analysis revealed that younger age (HR 0.960, 95% CI 0.942–0.979; p<0.001), male sex (HR 2.362, 95% CI 1.384–4.033; p=0.002), higher creatinine (HR 1.002, 95% CI 0.999–1.004; p=0.057), and biological valve prosthesis (HR 2.073, 95% CI 1.258–3.414; p=0.004) were associated with re-intervention for PVE. After correction for competing risk of death, biological valve prosthesis was significantly associated with a higher rate of re-intervention for PVE (HR 2.011, 95% CI 1.177–3.437; p=0.011). According to this single-centre, observational, retrospective cohort study, AVR using biological prosthesis is associated with re-intervention for PVE compared to mechanical prosthesis. Further investigations are needed to verify these findings. [ABSTRACT FROM AUTHOR]

Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI. Randomised controlled trials and observational studies (1990 – 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI. The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle–Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis. Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 – 97%, p =.28, I 2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 – 4%, p =.93, I 2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 – 92%, p <.010, I 2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 – 25%, p =.010, I 2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 – 31%, p <.010, I 2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 – 37%, p <.010, I 2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes. Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes. [ABSTRACT FROM AUTHOR]

In patients with transposition of the great arteries and an arterial switch operation (TGA-ASO) right ventricular outflow tract (RVOT) obstruction is a common complication requiring one or more RVOT interventions. We aimed to assess cardiopulmonary exercise capacity and right ventricular function in patients stratified for type of RVOT intervention. TGA-ASO patients (≥16 years) were stratified by type of RVOT intervention. The following outcome parameters were included: predicted (%) peak oxygen uptake (peak VO2), tricuspid annular plane systolic excursion (TAPSE), tricuspid Lateral Annular Systolic Velocity (TV S′), right ventricle (RV)-arterial coupling (defined as TAPSE/RV systolic pressure ratio), and N-terminal proBNP (NT-proBNP). 447 TGA patients with a mean age of 25.0 (interquartile range (IQR) 21–29) years were included. Patients without previous RVOT intervention (n = 338, 76%) had a significantly higher predicted peak VO2 (78.0 ± 17.4%) compared to patients with single approach catheter-based RVOT intervention (73.7 ± 12.7%), single approach surgical RVOT intervention (73.8 ± 28.1%), and patients with multiple approach RVOT intervention (66.2 ± 14.0%, p = 0.021). RV-arterial coupling was found to be significantly lower in patients with prior catheter-based and/or surgical RVOT intervention compared to patients without any RVOT intervention (p = 0.029). TGA patients after a successful arterial switch repair have a decreased exercise capacity. A considerable amount of TGA patients with either catheter or surgical RVOT intervention perform significantly worse compared to patients without RVOT interventions. • TGA patients after a successful arterial switch repair have a decreased exercise capacity. • Lower excercise capacity was seen in ASO patients after RVOT intervention compared to patients without RVOT intervention. • RV-arterial coupling emerged as the most sensitive hemodynamic parameter for RV performance after RVOT intervention. [ABSTRACT FROM AUTHOR]

Treatment of left ventricular outflow-obstruction (LVOTO) in hypertrophic obstructive cardiomyopathy (HOCM) by short atrio-ventricular delay pacing has long-term hemodynamic results that are not inferior to myectomy, but publications comparing long-term morbidity following those treatments are lacking. A search for HOCM-patients attending all ten hospitals in the West Götaland Region, Sweden, from 2002 through 2013, identified 251 patients (42 treated with myectomy, 88 with pacing and 121 conservatively). As the age at procedure was significantly lower in the myectomy-group compared to the pacing-group, morbidity was compared by case-control methodology, matching patients for age, maximal wall thickness and LVOT-gradient. We found 31 pairs who constituted the comparison-groups. Post-intervention median follow-up was 15.4 and 10.4 years in pacing- and myectomy-group, respectively. Post-procedural and long-term complications and re-interventions, length of stay, and cost of hospitalization were documented. Both treatments improved New York Heart Association class and LVOT-gradients significantly. There were fewer peri-procedural complications in the pacing-group compared to myectomy-group (3.2% and 35.5% p < 0.001). During follow-up pacemaker was implanted in 35.5% of myectomy-group for atrio-ventricular block, 9.7% peri-operatively, and 25.8% during late-follow-up. Furthermore, the pacing group had a superior freedom from all re-interventions, 90.3% versus 61.3% in myectomy-group (p = 0.003). Pacing patients had a shorter in-hospital stay (median 4 [IQR = 2] days) compared to myectomy 11 [7] days; P < 0.001). The mean cost of hospitalization was 74,000 ± 16,000 SEK for pacing and 310,000 ± 180,000 SEK for myectomy, p < 0.001. Pacing is a simple and reliable treatment for drug-refractory HOCM-patients with low rate of complications and costs. • Pacing is a simple, reliable, useful, and cost-effective treatment for drug-refractory hypertrophic obstructive cardiomyopathy. • The hospital costs for myectomy are about four times that of the cost of pacing therapy. • Patients treated with myectomy have a high late need for re-interventions, and a high late need for pacemaker implantation. • Short AV-delay pacing ought to be considered a reasonable first-line treatment option. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the long term results of endovascular aneurysm repair (EVAR) in patients with abdominal aortic aneurysm (AAA) and ectatic common iliac arteries (CIAs). In a retrospective analysis of a prospectively collected database in two high volume centres, patients with AAAs undergoing elective standard EVAR were divided into two groups: those with both CIA diameters <18 mm, and those with at least one ectatic iliac artery (CIA ≥ 18 mm). Patients with an intentional external iliac artery landing zone were excluded. Primary outcomes were survival and freedom from re-intervention. Secondary end points were EVAR failure and iliac related endoleak and iliac re-intervention. From 2000 to 2015, 648 patients were included in the study, 277 (43%) had at least one CIA ≥ 18 mm. Pre-operative risk factors were similar between the two groups, with the exception of chronic renal insufficiency (p =.010) and cerebrovascular events (p =.040), which were higher in the ectatic CIA group. At 30 days from primary procedure, there was a higher rate of type Ib endoleak in patients with ectatic iliacs (p =.020). A statistically significant increase in the incidence of late type Ib endoleak in patients with ectatic iliac arteries was confirmed at a mean follow up of 74.8 months (p =.01). The need for iliac related re-intervention was higher in patients with CIAs ≥18 mm (odds ratio 1.94; 95% confidence interval 1.1–3.2). Ectatic iliac arteries are considered suitable landing zones for EVAR, although there is an increased risk of secondary interventions in time mainly due to late CIA dilation and secondary type Ib endoleak. Patients receiving EVAR with flared iliac limbs may benefit a more intensive surveillance to avoid late failures. [ABSTRACT FROM AUTHOR]

Surgical reoperation is still a standard procedure performed for degenerated aortic bioprostheses. On the other hand femoral minimally invasive valve-in-valve implantation (femTAVI-VIV) is an intriguing alternative. This clinical study was design to compare the early and late outcomes of redo-surgery (Redo-AVR) and femTAVI-VIV procedures for failed aortic bioprostheses. We retrospectively reviewed 108 patients with degenerated aortic bioprostheses qualified for isolated Redo-AVR (n = 40) or femTAVI-VIV (n = 68) between 2003 and 2018. Both cohorts were divided into intermediate and high-risk groups according to the EuroSCORE II (4–9% and >9%). Propensity score matching selected 20 pairs in Intermediate-risk group and 10 pairs in High-risk group for the final comparison. Patients qualified for femTAVI-VIV were older (79.2 vs 72.9 years, p < 0.001) and at higher risk (EuroSCORE II 10.9 vs 7.8%, p = 0.005) than Redo-AVR subjects. Overall survival in femTAVI-VIV and Redo-AVR was comparable at 30-days, 1- and 5-years, respectively (92.6% vs 92.5%, 85.2% vs 85.0% and 62.9% vs 72.5%, p = 0.287). After PSM no differences in mortality, myocardial infarction, pacemaker implantation, stroke or acute renal insufficiency were found. Transcatheter procedure was associated with shorter hospital stay, lower rate of blood products transfusions and higher incidence of mild paravalvular leaks. Our study supports the opinion that transcatheter approach for treatment of patients with degenerated aortic bioprostheses is a safe alternative to Redo-AVR procedures particularly for those at high-risk. • Self-expanding TAVI-VIV ensures comparable early and long-term outcomes to Redo-AVR. • Femoral TAVI-VIV implantation is less invasive than conventional chest reopening. • Femoral TAVI-VIV leads to a short hospital stay. • Mild paravalvular leak after TAVI-VIV occurs more often than after Redo-AVR. • FemTAVI-VIV is an excellent solution for high risk patient with failed bioprosthesis. [ABSTRACT FROM AUTHOR]

Although endovascular aneurysm repair (EVAR) has been widely adopted, long-term data remain limited. This study analyses the long-term outcome (16 years) after EVAR with the Zenith stent graft in a single academic centre. From 2000 to 2010, 282 patients with an abdominal aortic aneurysm (AAA) were treated electively and monitored annually. Primary outcomes were overall and AAA rupture free survival; the secondary outcomes were complication and re-intervention free survival. Kaplan–Meier analysis was used to examine survival. The median patient age was 76 years (range 49–92 years) and mean aneurysm diameter 61 mm (range 40–110 mm). Patients were followed for a median of 76 months (range 0–201 months). Overall survival was 93% (SE 0.02), 61% (SE 0.08), 25% (SE 0.16), and 9% (0.19) at 1, 2, 5, 10, and 16 years, respectively. Ten (3.5%) AAA ruptures occurred, and the cumulative AAA rupture free survival was 100%, 98% (SE 0.01), 96% (SE0.02), and 79% (SE 0.12) at 1, 5, 10, and 16 years, respectively. The mean annual AAA rupture rate was 0.5%. Freedom from any stent graft related complications was 68% (SE 0.03), 58% (SE 0.09), 54% (SE 0.17), and 52% (SE 0.21), respectively; freedom from graft related re-interventions was 95% (SE 0.01), 80% (SE 0.08), 73% (SE 0.11), 70% (SE 0.16), at 1, 5, 10, and 16 years, respectively. Five (1.8%) late conversions were required during follow up. The variables that significantly and independently correlated with ruptured AAA were pre-operative aneurysm size and primary type II endoleak. The latter was the only independent significant factor to increase the risk of re-intervention. The number of graft related complications is high after EVAR, and new complications keep appearing years after the initial procedure. Even though fatal AAA rupture after EVAR is rare, it cannot be totally avoided despite systematic follow up. [ABSTRACT FROM AUTHOR]

Objectives The efficacy and need for secondary interventions for type II endoleaks following endovascular abdominal aortic aneurysm repair (EVAR) remain controversial. This systematic review aimed at investigating the clinical outcomes of different type II endoleak treatments in patients with a persistent type II endoleak after EVAR. Data sources Embase, Medline via Ovid, Web of Science Core Collection, the Cochrane CENTRAL, and Google Scholar. Review methods This systematic review was performed in accordance with the PRISMA Statement. Outcomes of interest were technical and clinical success, change in sac diameter, complications, need for additional interventions, abdominal aortic aneurysm (AAA) rupture, and (AAA related) mortality. Meta-analyses were performed with random effects models. Results A total of 59 studies were included, with a cumulative cohort of 1073 patients with persistent type II endoleak. Peri-operative complications following treatment of type II endoleaks occurred in 3.8% of patients (95% CI 2.7–5.2%), and AAA related mortality was 1.8% (95% CI 1.1–2.7%). Overall technical success was 87.9% (95% CI 83.1–92.1%), while clinical success was 68.4% (95% CI 61.2–75.1%). Among studies detailing sac dynamics, decrease or stable sac, with or without resolution, was achieved in 78.4% (95% CI 70.2–85.6%). Changes in sac diameter following type II endoleak treatment were documented in 157 patients to at least 24 months. Within this group an actual decrease in sac diameter was reported in only 27 of 40 patients. Conclusion There is little evidence supporting the efficacy of secondary intervention for type II endoleaks after EVAR. Although generally safe, the lack of evidence supporting the efficacy of type II endoleak treatment leads to difficulty in assessing its merits. [ABSTRACT FROM AUTHOR]

Objective/Background The aim was to describe the re-interventions after endovascular and open repair of rupture, and investigate whether these were associated with aortic morphology. Methods In total, 502 patients from the IMPROVE randomised trial (ISRCTN48334791) with repair of rupture were followed-up for re-interventions for at least 3 years. Pre-operative aortic morphology was assessed in a core laboratory. Re-interventions were described by time (0–90 days, 3 months–3 years) as arterial or laparotomy related, respectively, and ranked for severity by surgeons and patients separately. Rare re-interventions to 1 year, were summarised across three ruptured abdominal aortic aneurysm trials (IMPROVE, AJAX, and ECAR) and odds ratios (OR) describing differences were pooled via meta-analysis. Results Re-interventions were most common in the first 90 days. Overall rates were 186 and 226 per 100 person years for the endovascular strategy and open repair groups, respectively ( p = .20) but between 3 months and 3 years (mid-term) the rates had slowed to 9.5 and 6.0 re-interventions per 100 person years, respectively ( p = .090) and about one third of these were for a life threatening condition. In this latter, mid-term period, 42 of 313 remaining patients (13%) required at least one re-intervention, most commonly for endoleak or other endograft complication after treatment by endovascular aneurysm repair (EVAR) (21 of 38 re-interventions), whereas distal aneurysms were the commonest reason (four of 23) for re-interventions after treatment by open repair. Arterial re-interventions within 3 years were associated with increasing common iliac artery diameter (OR 1.48, 95% confidence interval [CI] 0.13–0.93; p = .004). Amputation, rare but ranked as the worst re-intervention by patients, was less common in the first year after treatment with EVAR (OR 0.2, 95% CI 0.05–0.88) from meta-analysis of three trials. Conclusion The rate of mid-term re-interventions after rupture is high, more than double that after elective EVAR and open repair, suggesting the need for bespoke surveillance protocols. Amputations are much less common in patients treated by EVAR than in those treated by open repair. [ABSTRACT FROM AUTHOR]

The field of critical care medicine is confronted every day with cases of surgical interventions. When Data Mining is properly applied in this field, it is possible through predictive models to identify if a patient, should or should not have surgery again upon the same problem. The goal of this work is to apply clustering techniques in collected data in order to categorize re-interventions in intensive care. By knowing the common characteristics of the re-intervention patients it will be possible to help the physician to predict a future resurgery. For this study various attributes were used related to the patient's health problems like heart problems or organ failure. For this study it was also considered important aspects such as age and what type of surgery the patient was submitted. Classes were created with the patients’ age and the number of days after the first surgery. Another class was created where the type of surgery that the patient was operated upon was identified. This study comprised Davies Bouldin values between -0.977 and -0.416. The used variables, in addition to being provided by Hospital de Santo António in Porto, they are provided from the electronic medical record. [ABSTRACT FROM AUTHOR]

Objective Total arch transposition (TAT) during hybrid endovascular repair for aortic arch disease is believed to allow a better landing zone, but also to be associated with higher peri-operative mortality than partial arch transposition (PAT). Information on this issue is limited. Method This study was a retrospective analysis. All 53 consecutive patients with aortic arch disease (41 males, mean age 65.0 years) who underwent hybrid endovascular repair with TAT (zone 0, n =20) or PAT (zone 1 or 2, n =33) from 2008 to 2014 were analyzed retrospectively. The peri-operative and late outcomes of these two groups were compared. Results Baseline characteristics, including EuroSCORE II results, were similar in the two groups. After procedures, peri-operative mortalities and stroke rates were similar in the two groups (5.0% vs. 9.1%, p =1.000, and 10.0% vs. 6.1%, p =.627). Interestingly, all four strokes occurred in patients with a type III aortic arch irrespective of transposition type. Primary success rates (80.0% vs. 69.7%, p =.527) and type I endoleak incidences (20.0% vs. 27.3%, p =.744) were not significantly different. During follow up (mean duration 36.9 months), overall survival (89.7% vs. 87.4% at 1 year and 89.7% vs. 79.3% at 3 years; p =.375) and re-intervention free survival rates (78.6% vs. 92.0% at 1 year; 72.0% vs. 62.2% at 3 years, p =.872) were similar in the two groups. Conclusion Morbidity and mortality were high within the first year of hybrid endovascular therapy for aortic arch disease, implying that candidates for hybrid procedures need to be selected carefully. Hybrid endovascular repair with TAT was found to have peri-operative mortality, stroke, and long-term survival rates comparable with PAT, so hybrid endovascular repair may be considered, irrespective of type of arch reconstruction, when clinically indicated. [ABSTRACT FROM AUTHOR]

Background: Surgical intervention has traditionally been reserved as the last management option for pain in chronic pancreatitis. Recently, there has been a call for surgery to be offered earlier in the disease process. The objectives of this review were to evaluate the effect of early surgery on postoperative pain, pancreatic function, and re-intervention rates in chronic pancreatitis. Methods: A systematic literature search through EMBASE, Cochrane Review, and PubMed from January 1950 to January 2014 was conducted. Citations found in relevant papers are hand-searched. Data which could be pooled were analyzed using Revman (v5.2). Risk of bias analysis was conducted. Results: Of the 2,886 potentially eligible studies identified, 11 studies met the inclusion criteria. There was large heterogeneity in the study designs, and studies were conducted over a lengthy time span. Seven studies examined pain, three studies examined pancreatic function, and three studies examined rates of re-intervention. Meta-analysis of the three studies with comparative raw data regarding complete pain relief showed that early surgery was associated with an increased likelihood of complete postoperative pain relief (RR = 1.67, 95 % CI 1.09-2.56, p = 0.02). Early surgery was also associated with reduced risk of pancreatic insufficiency and low re-intervention rates. Conclusions: Data from this study supports considering early surgery for pain management in patients with chronic pancreatitis, with the potential of a reduced risk of pancreatic insufficiency and the need for further intervention. Further prospective randomized studies are warranted comparing early surgery against conservative step-up approaches. [ABSTRACT FROM AUTHOR]

Background Data comparing long-term results after percutaneous intervention with drug-eluting stents (DES/PCI) and coronary artery grafting (CABG) in diabetic patients (pts) with multi-vessel disease is conflicting. We have conducted a systematic review and meta-analysis to help answer this issue. Methods MEDLINE, WoS, and Scopus were systematically analysed to yield observational studies (OBS) or randomised controlled trials (RCT) fulfilling search criteria. Odds ratio (OR) for studied end-points were obtained with inverse variance random effects analysis. Results are presented with 95% confidence intervals with significance at p<0.05. Results A total of 14 studies (5 RCT; 9 OBS) including more than 5000 pts were selected for review. Early/30-day was lower in the DES/PCI cohort [OR 0.49(0.27, 0.88); p=0.02; I2=0%]. Post-procedural stroke was higher in the CABG (1.8%) cohort compared to DES/PCI (0.17%; p<0.01). A pooled analysis of RCT demonstrated that stroke rate was similar in both cohorts at the end of one year [OR 0.84(0.19, 3.74); p=0.82; I2 =67%].During a follow-up of three to five years, repeat intervention was much higher in the DES/PCI cohort [OR 3.02(2.13, 4.28; p<0.01]. The odds of suffering an adverse cardiovascular /cerebrovascular event were 1.71 (1.27, 2.3) times higher in the DES/PCI cohort compared to CABG. Conclusion In diabetic patients with multivessel disease, early mortality is lower in the DES/PCI cohort. While peri-procedural stroke rates are lower with PCI, they are, however, comparable at the end of one year. Use of drug-eluting stents leads to a higher rate of re-intervention and major cardiovascular/cerebrovascular events at three to five years. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To report our experience regarding the use of partially absorbable mesh, evaluating the nature and rate of re-intervention after transvaginal pelvic organ prolapse repair. Materials and methods: We retrospectively collected data on 269 consecutive patients who underwent partially absorbable mesh repair between January 2009 and January 2011. Data were obtained from our hospital medical records and we phoned patients to check if they had surgery in another hospital since then. Results: 250 patients were included, with a median follow-up duration of 20 months (range 8–34 months). The global rate of re-interventions was 8%. The main indications were mesh exposure (2%), prolapse recurrence (1.2%), and urinary complications such as de novo stress urinary incontinence (4.8%). Afterwards, we compared these data with those previously obtained in our centre with non-absorbable mesh. Conclusion: Our study shows that the use of a partially absorbable mesh is efficient and reliable with relatively low rates of re-intervention. According to the available literature data, a partially absorbable mesh does not seem to give advantages in comparison with classic non-absorbable mesh regarding rates of re-intervention. [Copyright &y& Elsevier]

Summary: Aim of the study: The use of free flaps in head and neck reconstructive surgery requires postoperative monitoring, usually by conventional clinical tests. Nevertheless, clinical testing is not applicable to buried free flaps that are more frequently used in the head and neck area. The purpose of this study was to describe the use and to evaluate the implantable doppler system in this setting. Patients and method: Among 162 patients who underwent free flap reconstruction in our department, between June 2008 and October 2012, 23 patients had postoperative monitoring using implantable doppler system. Probe placement, monitoring parameters and postoperative course was analyzed. Results: Our series included 15 forearm free flaps, seven fibular flaps and one scapular flap. Indications for reconstruction were following the removal of a malignant tumor in 18 cases, a benign tumor in two cases and an osteoradionecrosis in three cases. Free flap monitoring by conventional clinical tests was not possible in 19 patients. Doppler signal was detected continuously during seven days in 82% of cases. A loss of signal was observed in three cases. Surgical exploration was required in one patient. Conclusion: Implantable doppler for free flap monitoring is a safe, reliable and efficient technique and cost is reasonable. The use of implantable doppler system seems particularly useful in head and neck reconstruction for buried free flaps, which are not accessible to conventional clinical tests. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The study aimed to investigate early and long-term outcome of thoracic endovascular aortic repair (TEVAR) for acute complicated type B dissection. Design: This was a retrospective, single-centre, consecutive case series. Materials and Methods: During the period 1999–2009, TEVAR was carried out in 50 patients with non-traumatic acute complicated type B dissection, and in another 10 patients with acute complications, including rupture, end-organ ischaemia and acute dilatation during the primary hospitalisation, but >14 days after onset of symptoms. Thus, in total, 60 patients were included; 22 with a DeBakey type IIIa dissection and 38 with a type IIIb; median age was 67 years. Early (30-day) and long-term (5-year) survival, re-intervention rate and complications were recorded until 1 July 2010. Results: Within 30 days, two (3%) deaths, one (2%) paraplegia and three (5%) strokes were observed. Five-year survival was 87% and freedom from re-intervention at 5 years was 65%. Conclusions: In patients with acute complicated type B aortic dissection, TEVAR can be performed with excellent early and long-term survival, whereas morbidity and long-term durability must be further elucidated. [Copyright &y& Elsevier]

Summary: Background: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the ‘failing’ free flap, and practice is often guided by anecdote. Material and methods: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. Results: Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. Conclusion: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates. [Copyright &y& Elsevier]

Abstract: Aim: To determine whether administrative data can be used to determine metrics to inform the quality agenda. To determine the relationship between these metrics and the method of abdominal aortic aneurysm (AAA) repair undertaken. Methods: The Hospital Episode Statistics (HES) data were taken for a 5-year period (01.04.2003–31.03.2008). Cases of elective AAA repair were identified. Outcomes were determined in terms of mortality, discharge destination, re-intervention rates and emergency readmission rates. The results were interpreted in light of whether AAA repair was open or endovascular and whether patients were octogenarians or younger patients. Results: There were 18,060 elective AAA repairs with a mean in-hospital mortality rate of 5.9%. Of these 14,141 were open repairs with a mean mortality of 6.5% and 3919 EVAR (22%) with a mean mortality of 3.8%. EVAR patients were less likely to be discharged to ongoing care (p < 0.001) but were associated with a higher rate of re-intervention (p = 0.001) than open repairs. No differences were seen in one-year readmission rates. Octogenarians were more likely to undergo EVAR (p = 0.001), to be readmitted within 30-days (p = 0.009), to require further interventions on their index admission (p < 0.001) and less likely to be discharged home (p < 0.001) than younger patients. Conclusion: Administrative data can be used to identify metrics other than mortality and length of stay. These metrics might be used to inform service provision. In particular for AAA repair, differences in these outcomes were identified between open repair and EVAR and between octogenarians and younger patients. [Copyright &y& Elsevier]

Abstract: Aim: The aim of this study is to report the subsequent treatment provided, over the 11 years’ data available, when a re-intervention was considered clinically necessary on a glass ionomer (GI) restoration. Methods: A detailed sample of treatment records of patients has been established at the Dental Practice Division of the NHS Business Services Authority, consisting of records containing directly placed restorations for adult patients from January 1991. This database contains the records of over half a million restorations. For each direct restoration placed, the subsequent history of that tooth was consulted, for the period up to December 2001, and the restorations divided into three groups: amalgam, composite and GI, the latter being subdivided into anterior teeth, premolars, and molars. Results: Data on 164,036 directly placed restorations were analyzed. Results indicated that, for amalgam and composite restorations, the subsequent treatment was likely to be another restoration in the same material. For GI (24,947 restorations), only one third of restorations, overall, were followed by another GI. In anterior teeth, GI restorations were more often followed by composite than by GI, this trend increasing with increasing time interval since restoration. For premolar teeth, the GI restoration was most likely to be followed by another GI within 4 years, with an increasing trend towards re-intervention by an amalgam or composite in older restorations. For molar teeth, GI restorations were more likely to be followed by an amalgam restoration. Conclusion: For GI restorations, on re-intervention, there is variation in the next restoration material used according to tooth position and time interval to re-intervention. GI restorations in anterior and molar teeth are not likely to be followed by another GI restoration. [Copyright &y& Elsevier]

Abstract: Aim: It is the aim of this paper to consider the treatment instituted when re-intervention is deemed necessary on a tooth which has previously been crowned. Methods: A detailed sample of treatment records of patients has been established at the NHS Business Services Authority (Dental Services Division), consisting of records containing indirectly placed restorations for patients of age 18 years or older from January 1991. For each tooth treated with a crown, the subsequent history of intervention on that tooth was recorded. Results: There were data on 47,474 crowns available for analysis, with metal-ceramic (bonded) crowns dominating the data (overall, 80% of crowns being these). There were 10,426 crowned teeth with re-interventions in the study period, with 36% of the re-interventions involving recementing, 17% being replacement crowns, 13% direct restorations, 12% root treatment, and 19% of crowned teeth being extracted and/or replaced by a denture. The longer the interval since crown placement, the higher the proportion of extractions or direct restoration and the lower the proportion of recementing. Conclusions: Recementation is the most frequently recorded re-intervention, with the incidence of this decreasing with increasing age of the crown. In 17% of re-interventions, the next intervention was a replacement crown. [Copyright &y& Elsevier]

Abstract: The incidence of congenital heart disease is 6–8 per 1000 live births and has remained unchanged for many years. Congenital heart defects occur with similar frequency throughout all ethnic groups and regions of the world. It is estimated that 1600 patients requiring long-term care will enter adulthood every year in the UK – many of whom have complex disease. The majority have survived as a consequence of innovative cardiac surgery. Their management offers an insight into the surgical, medical, social and psychosocial therapies that have been introduced in recent years. [Copyright &y& Elsevier]

Purpose: Complete surgical excision is the main factor for successful breast-conserving surgery in patients with ductal carcinoma in situ (DCIS) of the breast. Preoperative magnetic resonance imaging (MRI) may allow surgery optimization in this indication. From an economic standpoint, systematic preoperative MRI is associated with an extra cost, which may be offset by a decrease in the number of re-interventions. We performed an economic evaluation alongside IRCIS randomised controlled trial (NCT01112254) to determine whether systematic preoperative MRI in DCIS is a cost-effective strategy.Methods: 360 patients were included in IRCIS trial. Costs were assessed from the French national health insurance perspective. Resource use was prospectively collected during a 6-month period after randomisation. We estimated the mean cost per averted re-intervention.Results: Despite extra costs due to MRI and additional biopsies, difference in total costs between arms was not statistically significant (mean cost of €9980 in MRI arm and €9682 in no MRI arm, cost difference: €298 [CI95% : -470; 1063]). There was a non-significant decrease in the rate of re-hospitalisations for positive or close margins (20% in MRI arm versus 27% in No MRI arm, difference -7% [CI95% : -17; 3]). At a willingness to pay of €500 to avert a re-intervention, the probability that MRI strategy is cost-effective was 93%.Conclusion: Systematic preoperative MRI in patients with DCIS of the breast may be a cost-effective strategy. However, the modest clinical benefit associated with such a strategy limits the interest for this procedure in routine practice given the current MRI techniques. [ABSTRACT FROM AUTHOR]