Ionizing radiation absorption of vascular surgeons during endovascular procedures

OBJECTIVE: Endovascular procedures have become an integral part of a vascular surgeon's practice. The exposure of surgeons to ionizing radiation and other safety issues have not been well studied. We investigated the radiation exposure of a team of vascular surgeons in an active endovascular unit and compared yearly dosages absorbed by various body parts among different surgeons. Patients' radiation exposure was also assessed. METHODS: The radiation absorption of a team of vascular surgeons was prospectively monitored in a 12-month period. During each endovascular procedure, the effective body, eye, and hand radiation doses of all participating surgeons were measured by mini-thermoluminescent dosimeters (TLD) attached at the chest level under a lead apron, at the forehead at eye level, and at the hand. The type of procedure, fluoroscopy machine, fluoroscopy time, and personal and operating theatre radiation protection devices used in each procedure were also recorded. One TLD was attached to the patient's body near the operative site to measure the patient's dose. The yearly effective body, eye, and hand dose were compared with the safety limits of radiation for occupational exposure recommended by the International Commission on Radiation Protection (ICRP). The radiation absorption of various body parts per minute of fluoroscopy was compared among different surgeons. RESULTS: A total of 149 consecutive endovascular procedures were performed, including 30 endovascular aortic repairs (EVAR), 58 arteriograms with and without embolization (AGM), and 61 percutaneous transluminal angioplasty and stent (PTA/S) procedures. The cumulative fluoroscopy time was 1132 minutes. The median yearly effective body, eye, and hand dose for the surgeons were 0.20 mSv (range, 0.13 to 0.27 mSv), 0.19 mSv (range, 0.10 to 0.33 mSv) and 0.99 mSv (0.29 to 1.84 mSv) respectively, which were well below the safety limits of the ICRP. The mean body, eye, and hand dose of the chief surgeon per procedure were highest for EVAR. A significant discrepancy was observed for the average hand dose per minute of fluoroscopy among different surgeons. The mean radiation absorption of patients who underwent EVAR, AGM, and PTA/S was 12.7 mSv, 13.6 mSv, and 3.4 mSv, respectively. CONCLUSION: With current radiation protection practice, the radiation absorbed by vascular surgeons with a high endovascular workload did not exceed the safety limits recommended by ICRP. Variations in practice, however, can result in significant discrepancy of radiation absorption between surgeons.     

Fast-track rehabilitation after open aorto-iliac vascular procedures

BACKGROUND: Fast-track rehabilitation programs have resulted in a decrease in mortality and morbidity after major surgical procedures, e. g., in colorectal surgery. It is not known whether fast-track rehabilitation can safely be applied in major vascular surgery. METHOD: 35 patients (mainly ASA III) who underwent open aorto-iliac reconstruction (21 for abdominal aneurysm, 14 for aorto iliac occlusive disease) between May 2005 and June 2006 were treated with a fast-track protocol including PDA, early postoperative oral fluid and food supply, early postoperative mobilisation, all starting on the day of operation. The average daily oral fluid amount, duration of mobilisation, step of oral nutrition, day of first defecation, PONV, pain levels while resting, under effort and mobilisation, and fatigue were monitored. RESULTS: The 30-day mortality was 0%, overall morbidity was 14.8% with 9% pulmonary, 2.9% cardiac and 2.9% renal complications. Mobility was safely achieved. The oral fluid consumption was 329 mL on the day of operation and 1160 mL on the second day after operation. 33 patients (94%) achieved total oral nutrition on day four after operation. The average pain level in all categories and the fatigue were below 4 on the VAS. CONCLUSION: Fast-track rehabilitation can safely be applied to patients undergoing conventional aorto-iliac reconstruction. Early onset of oral nutrition and mobilisation influence the fatigue in a positive way. Thoracal PDA leads to acceptable pain levels.     

腹主动脉瘤开腹手术与腔内修复术的对照研究

目的对比分析腹主动脉瘤病人开放手术与腔内修复术的治疗效果。方法收集新疆维吾尔自治区人民医院血管外科2012年7月至2017年6月收治的腹主动脉瘤病人,对比开放手术与腔内治疗病人的一般情况、住院情况、术后及随访期间并发症情况。结果 176例接受手术的腹主动脉瘤病人均获成功,其中腔内修复术(endovascular aneurysm repair,EVAR)156例,开放手术(open surgery,OS)20例,平均年龄(68.8±9.9)岁,平均随访时间(25.9±16.2)个月。OS组住院期间输注红细胞量、输注血浆量、术后重症监护室治疗时间、住院时间明显多于EVAR组(P0.05)。EVAR术后髂支闭塞、支架感染等问题值得重视。结论尽管腔内治疗效果优于开放手术的循证资料十分有限,EVAR仍然是一个令血管外科医生及病人容易接受的手术方式。     

Use of thrombolytics in vascular and endovascular surgery

Until recently, acute arterial or venous thromboses were routinely managed with surgical intervention. With the development of effective thrombolytic pharmacologic agents and improved modes of delivery of these agents to the target site, surgery is no longer the only option. Greater understanding and knowledge about the finely orchestrated, counterbalanced processes of coagulation and fibrinolysis/thrombolysis have enabled development of agents and strategies for pharmacologic restoration of vascular patency while reducing or eliminating the need for surgery. An evidence-based rationale now exists for the use of thrombolysis in acute limb ischemia, deep venous thrombosis, stroke, and arteriovenous vascular access thromboses. Thrombolytic agents are valuable ancillary agents that allow a less invasive solution to a variety of thrombotic vascular conditions. Strategies that combine thrombolytic agents with endovascular techniques provide precise delivery of these drugs to the target thrombus. A more widespread adoption of this strategy has been limited primarily owing to problems with the currently available pharmacologic agents. The future of thrombolysis therapy is discussed in terms of data obtained from ongoing and recently completed clinical trials. Efforts to develop and study new thrombolytic agents that act directly on the thrombus without activation of intermediary biochemical steps will provide the next major step forward, as well as the rational basis for expansion of currently accepted indications for the treatment of acute arterial and venous thromboses.     

Open vascular surgery as a starting point for endovascular surgery

What distinguishes vascular surgeons from other specialists who treat patients with vascular disease is their ability to combine skills in both open and endovascular treatments. Open vascular surgery should be considered the "starting point" for endovascular surgery, since training and practice in vascular surgery require extensive knowledge of the basic science and a thorough education in general surgical techniques. In addition, surgeons must possess detailed specialized knowledge of the anatomy and physiology of arteries, veins and lymphatics and of the pathological processes which may affect them. This scientific and technical background is also imperative for endovascular surgery. Open vascular surgery can also be considered as a potential finishing point of endovascular surgery. In fact, open surgery is still often the only solution for complex cases considered unsuitable for an endovascular approach, or for different types of complications following endovascular treatments. As endovascular surgery is increasingly considered as the initial treatment option for many patients with vascular disease, it is crucial that vascular surgery training programs develop methods to maintain the open surgical skills of their trainees. The only way for vascular surgeons to remain the premier specialists to care for patients with vascular disease is for them to combine skills in both open and endovascular treatments.     

Carotid blowout with infection: management with endovascular and open vascular approaches--a case report

The management of patients with head and neck cancer can be complicated by massive carotid artery hemorrhage, often requiring ligation owing to the emergent conditions and scarring from previous surgery and radiation. A case of emergent endovascular management of carotid artery hemorrhage in a patient treated for pharyngeal carcinoma is described. Hemorrhage was controlled, but on follow-up the patient developed a carotid-cutaneous fistula with exposure of the coils. Further management required the use of autogenous vein to replace the involved vessels. This case demonstrates that endovascular control of carotid hemorrhage can be successful, but close follow-up is necessary to identify potential subsequent complications.     

血管外科进展和趋势

近二十年来,血管外科的诊治技术得到了迅速发展.随着腔内治疗材料和设备的不断更新,微创治疗适应证逐渐扩大,腔内血管外科技术的禁区逐渐缩小.例如杂交治疗以及带分支的腔内移植物出现,已经能够治疗累及主动脉弓的胸主动脉和升主动脉病变.从TASC Ⅱ分级和ACC/AHA指南的改变,可以明显看到这种趋势[1-2].     

The endovascular approach to the open arterial duct surgery

There are different ways of the open arterial duct treatment, based on its anatomical form. Endovascular occlusion is considered to be the safest. The morphometric protocol was developed for the adequate choice of the occluder. The first-stand results of the endovascular occlusion of the open arterial duct with the use of two types of guided occluders (Flipper and Amplatzer ductus occluder) are presented in the article.     

高风险患者腹主动脉瘤手术与腔内治疗效果的比较

目的 比较高风险患者腹主动脉瘤(abdominal aortic aneurysm,AAA)手术治疗(opensurgical repair,OSR)与腔内治疗(endovascular aneurysm repair,EVAR)的效果,探讨高风险患者AAA治疗方式的选择.方法 利用(customized probability index,CPI)危险评分方法[1]筛选出我院1998年至2008年高风险患者55例,比较OSR组(20例)与EVAR组(35例)围手术期及术后近期结果.结果 OSR组随访率100%,平均随访6年3个月.EVAR组随访率94%,平均随访5年10个月.(1)手术时间高风险患者EVAR组(3.1±0.6)h短于OSR组[(4.9±0.9)h(P<0.05)];(2)EVAR组术中出血、ICU时间和住院时间均短于OSR组(P<0.01);(3)围手术期死亡率EVAR组(2.86%)明显低于OSR组(15.00%);(4)术后并发症发生率EVAR组(17%)明显低于OSR组(40%);(5)EVAR组术后并发症主要为内漏(8.57%);(6)OSR组并发症主要为心脏相关性疾病(25%).结论 EVAR对于高风险患者AAA的治疗可以更少的导致围手术期心血管事件的发生,降低围手术期的死亡率和并发症发生率.CPI可以相对准确评估血管手术围手术期死亡率和并发症的发生率,可用于指导围手术期的治疗策略.     

One hundred twenty-five concomitant endovascular and open procedures for lower extremity arterial disease

OBJECTIVE: Although the results of staged endovascular and open surgical reconstructions have been well documented, the safety and efficacy of concomitant procedures in the operating room are less well defined. Suboptimal performance of endovascular procedures in an operative setting, or inappropriate reliance on endovascular techniques, might theoretically compromise graft patency. We questioned whether late graft thrombosis is frequently attributable to failure at the endovascularly treated site in this setting. Materials and Methods: Between May 1, 1993, and June 30, 2001, we performed 125 concomitant endovascular and open arterial reconstructions (73 primary reconstructions, 52 graft revisions) in 106 patients. Endovascular techniques were used to treat inflow lesions in 72 cases, outflow lesions in 14 cases, both in four cases, and the graft itself in 35 cases. Fifty-five iliac, 18 femoral, 13 popliteal, six tibial, and 35 graft lesions were treated. For primary bypasses, 33 were to the popliteal level (21 prosthetic, 12 autogenous), 19 were to the tibial or pedal arteries (16 autogenous, three prosthetic or composite), and 12 were to the femoral arteries (one autogenous, 11 prosthetic). Nine patch angioplasties (eight femoral, one popliteal) were performed. For graft revisions, endovascular intervention was for inflow in 13 cases, outflow in three cases, both in one case, and of the graft itself in 35 cases. Surgical revisions involved segmental grafts in 33 cases, patch angioplasty in 18 cases, and both in one case. RESULTS: In the primary group, the initial technical success rate of the endovascular procedure was 93% (68/73), with five patients needing open conversion. The 30-day mortality rate was 1.4%, and the morbidity rate was 11.0%. Of the 19 grafts in the primary group that occluded during the follow-up period (mean, 11.9 months), five thromboses could possibly be attributed to failure at the endovascular site. In the revision group, the initial technical success rate of the endovascular procedure was 88% (46/52), with six patients undergoing conversion to open procedure. The 30-day mortality rate was 0%, and the morbidity rate was 15.4%. Of 22 late graft occlusions in the revision group, only three were attributed to failure at the endovascular site. CONCLUSION: This largest report to date of concomitant lower extremity endovascular and open revascularization procedures shows the approach to be safe. Few late graft occlusions were attributable to failure at the endovascularly treated site. The concomitant approach offers the efficiency and convenience of single stage therapy and allows immediate treatment for inadequate endovascular results or their complications and potential cost savings.