Publications by authors named "Jan van Schaik"

36 Publications

Towards Patient Centred Outcomes for Elective Abdominal Aortic Aneurysm Repair: A Scoping Review of Quality of Life Scales.

Eur J Vasc Endovasc Surg 2021 Aug 31. Epub 2021 Aug 31.

Department of Vascular Surgery, Leiden University Medical Centre, Leiden, the Netherlands. Electronic address:

Objective: In order to better incorporate the patient's perspective in medical decision making, core outcome sets (COS) are being defined. In the field of abdominal aortic aneurysm (AAA), efforts to capture the patient's perspective focus on generic quantitative quality of life (QoL) scales. The question arises whether these quantitative scales adequately reflect the patient's perspective on QoL, and whether they can be included in the QoL aspect of COS. A scoping review of QoL assessment in the context of elective AAA repair was undertaken.

Data Sources: PubMed, Embase, Web of Science, and the Cochrane Library.

Review Methods: A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Articles reporting QoL assessment in the context of elective AAA repair were identified. Quantitative studies (i.e., traditional QoL scales) were aligned (triangulation approach) with qualitative studies (i.e., patient perspective) to identify parallels and discrepancies. Mean Short Form 36 item survey (SF-36) scores were pooled using a random effects model to evaluate sensitivity to change.

Results: Thirty-three studies were identified, of which 29 (88%) were quantitative and four (12%) qualitative. The 33 studies reported a total of 54 quantitative QoL scales; the most frequently used were the generic SF-36 (16 studies) and five dimension EuroQol (EQ-5D; eight studies). Aneurysm specific scales were reported by one study. The generic quantitative scales showed poor alignment with the patient's perspective. The aneurysm specific scales better aligned but missed "concerns regarding symptoms" and "the impact of possible outcomes/complications". "Self control and decision making", which was brought forward by patients in qualitative studies, was not captured in any of the current scales.

Conclusion: There is no established tool that fully captures all aspects of the patient's perspective appropriate for a COS for elective AAA repair. In order to fulfil the need for a COS for the management of AAA disease, a more comprehensive overview of the patient's perspective is required.
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http://dx.doi.org/10.1016/j.ejvs.2021.06.026DOI Listing
August 2021

Ruptured Aneurysm of the Common Iliac Artery Caused by : A Case Report.

EJVES Vasc Forum 2021 14;52:26-29. Epub 2021 Jul 14.

Department of Surgery, Haaglanden Medical Centre, The Hague, The Netherlands.

Introduction: is a genus of aerobic Gram negative bacteria that causes the disease brucellosis. It is considered a zoonotic infection transmitted to humans by ingestion of unpasteurised dairy products. Although aortic involvement is rarely seen, it can be a life threatening complication of this disease. This case report describes a ruptured aneurysm of the common iliac artery (CIA) due to secondary infection by

Report: A 79 year old man with a known isolated aneurysm of the CIA presented with acute abdominal pain. Contrast enhanced computed tomography (CT) revealed rupture of the aneurysm. The patient underwent prompt endovascular repair. Several weeks after an uneventful recovery, the patient presented with spiking fever and abdominal discomfort. CT revealed an abscess anterior to the CIA. Blood and pus cultures grew . In recurrent re-admissions, conservative antibiotic therapy proved to be insufficient. Eventually, neo-aorto-iliac system (NAIS) reconstruction using bilateral femoral veins was performed to provide definitive treatment four months after initial presentation.

Conclusion: Although infected aneurysms are rare, they are associated with life threatening disease. Diagnosing this type of brucellar infection can be challenging owing to the long incubation time needed for blood and tissue cultures. Definitive treatment of these aneurysms often needs open surgery and antibiotics for complete treatment. Vigilant surveillance is required to monitor for post-operative complications such as graft infection, recurrent (false) aneurysm, and abscess formation.
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http://dx.doi.org/10.1016/j.ejvsvf.2021.06.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339252PMC
July 2021

Near-infrared fluorescence imaging with indocyanine green for quantification of changes in tissue perfusion following revascularization.

Vascular 2021 Jul 28:17085381211032826. Epub 2021 Jul 28.

Department of Vascular Surgery, 4501Leiden University Medical Center, Leiden, The Netherlands.

Objectives: Current diagnostic modalities for patients with peripheral artery disease (PAD) mainly focus on the macrovascular level. For assessment of tissue perfusion, near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) seems promising. In this prospective cohort study, ICG NIR fluorescence imaging was performed pre- and post-revascularization to assess changes in foot perfusion.

Methods: ICG NIR fluorescence imaging was performed in 36 patients with PAD pre- and post-intervention. After intravenous bolus injection of 0.1 mg/kg ICG, the camera registered the NIR fluorescence intensity over time on the dorsum of the feet for 15 min using the Quest Spectrum Platform®. Time-intensity curves were plotted for three regions of interest (ROI): (1) the dorsum of the foot, (2) the forefoot, and (3) the hallux. Time-intensity curves were normalized for maximum fluorescence intensity. Extracted parameters were the maximum slope, area under the curve (AUC) for the ingress, and the AUC for the egress. The non-treated contralateral leg was used as a control group.

Results: Successful revascularization was performed in 32 patients. There was a significant increase for the maximum slope and AUC egress in all three ROIs. The most significant difference was seen for the maximum slope in ROI 3 (3.7%/s to 6.6%/s, < 0.001). In the control group, no significant differences were seen for the maximum slope and AUC egress in all ROIs.

Conclusions: This study shows the potential of ICG NIR fluorescence imaging in assessing the effect of revascularization procedures on foot perfusion. Future studies should focus on the use of this technique in predicting favorable outcome of revascularization procedures.
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http://dx.doi.org/10.1177/17085381211032826DOI Listing
July 2021

Functional Performance After Complex Endovascular Aortic Repair: A Single-Center Retrospective Cohort Study.

J Endovasc Ther 2021 Jun 30:15266028211028222. Epub 2021 Jun 30.

Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.

Purpose: Complex endovascular aortic repair (EVAR) procedures provide a treatment option for patients with aortic aneurysms involving visceral branches. Good technical results and short-term outcomes have been reported. Whether complex EVAR provides acceptable outcomes is not clear. The current study aims to describe postoperative functional outcomes in complex EVAR patients-an older and relatively frail patient group.

Materials And Methods: A single-center retrospective cohort study was performed, using data from a computerized database of consecutive patients who underwent complex EVAR in the Leiden University Medical Center (LUMC, The Netherlands) between July 2013 and September 2020. As of May 2017, patients scheduled for complex EVAR were referred to a geriatric care pathway to determine (Instrumental) Activities of Daily Living ((I)ADL) scores at baseline and, if informed consent was given, after 12 months. For the total patient group, adverse functional performance outcomes were: discharge to a nursing home and 12-month mortality. For the patients included in geriatric follow-up, the additional outcome was the incidence of functional decline (defined by a ≥2 point increase in (I)ADL-score) at 12-month follow-up.

Results: Eighty-two patients underwent complex EVAR, of which 68 (82.9%) were male. Mean age was 73.3 years (SD=6.3). Within 30 days postsurgery, 6 patients (7.3%) died. Mortality within 12 months for the total patient group was 14.6% (n=12). After surgery, no patients had to be discharged to a nursing home. Fifteen patients (18.3%) were discharged to a rehabilitation center. Twenty-three patients gave informed consent and were included in geriatric follow-up. Five patients (21.7%) presented functional decline 12 months postsurgery and 4 patients had died (17.4%) by that time. This means that 39.1% of the patients in the care pathway suffered an adverse outcome.

Conclusion: To our knowledge, this is the only study that examined functional performance after complex EVAR, using a prospectively maintained database. No patients were newly discharged to a nursing home and functional performance results at 12 months are promising. Future multidisciplinary research should focus on determining which patients are most prone to deterioration of function, so that efforts can be directed toward preventing postoperative functional decline.
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http://dx.doi.org/10.1177/15266028211028222DOI Listing
June 2021

Assessment of Tissue Viability Following Amputation Surgery Using Near-Infrared Fluorescence Imaging With Indocyanine Green.

Ann Vasc Surg 2021 Jun 25. Epub 2021 Jun 25.

Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands. Electronic address:

Background: Patients with chronic limb threatening ischemia have a risk of undergoing a major amputation within 1 year of nearly 30% with a substantial risk of re-amputation since wound healing is often impaired. Quantitative assessment of regional tissue viability following amputation surgery can identify patients at risk for impaired wound healing. In quantification of regional tissue perfusion, near-infrared (NIR) fluorescence imaging using Indocyanine Green (ICG) seems promising.

Methods: This pilot study included adult patients undergoing lower extremity amputation surgery due to peripheral artery disease or diabetes mellitus. ICG NIR fluorescence imaging was performed within 5 days following amputation surgery using the Quest Spectrum Platform. Following intravenous administration of ICG, the NIR fluorescence intensity of the amputation wound was recorded for 10 minutes. The NIR fluorescence intensity videos were analyzed and if a fluorescence deficit was observed, this region was marked as "low fluorescence." All other regions were marked as "normal fluorescence."

Results: Successful ICG NIR fluorescence imaging was performed in 10 patients undergoing a total of 15 amputations. No "low fluorescence" regions were observed in 11 out of 15 amputation wounds. In 10 out of these 11 amputations, no wound healing problems occurred during follow-up. Regions with "low fluorescence" were observed in 4 amputation wounds. Impaired wound healing corresponding to these regions was observed in all wounds and a re-amputation was necessary in 3 out of 4. When observing time-related parameters, regions with low fluorescence had a significantly longer time to maximum intensity (113 seconds vs. 32 seconds, P = 0.003) and a significantly lesser decline in outflow after five minutes (80.3% vs. 57.0%, P = 0.003).

Conclusions: ICG NIR fluorescence imaging was able to predict postoperative skin necrosis in all four cases. Quantitative assessment of regional perfusion remains challenging due toinfluencing factors on the NIR fluorescence intensity signal, including camera angle, camera distance and ICG dosage. This was also observed in this study, contributing to a large variety in fluorescence intensity parameters among patients. To provide surgeons with reliable NIR fluorescence cut-off values for prediction of wound healing, prospective studies on the intra-operative use of this technique are required. The potential prediction of wound healing using ICG NIR fluorescence imaging will have a huge impact on patient mortality, morbidity as well as the burden of amputation surgery on health care.
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http://dx.doi.org/10.1016/j.avsg.2021.04.030DOI Listing
June 2021

Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature.

Life (Basel) 2021 May 11;11(5). Epub 2021 May 11.

Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands.

(1) Background: Near-infrared fluorescence imaging is a technique capable of assessing tissue perfusion and has been adopted in various fields including plastic surgery, vascular surgery, coronary arterial disease, and gastrointestinal surgery. While the usefulness of this technique has been broadly explored, there is a large variety in the calculation of perfusion parameters. In this systematic review, we aim to provide a detailed overview of current perfusion parameters, and determine the perfusion parameters with the most potential for application in near-infrared fluorescence imaging. (2) Methods: A comprehensive search of the literature was performed in Pubmed, Embase, Medline, and Cochrane Review. We included all clinical studies referencing near-infrared perfusion parameters. (3) Results: A total of 1511 articles were found, of which, 113 were suitable for review, with a final selection of 59 articles. Near-infrared fluorescence imaging parameters are heterogeneous in their correlation to perfusion. Time-related parameters appear superior to absolute intensity parameters in a clinical setting. (4) Conclusions: This literature review demonstrates the variety of parameters selected for the quantification of perfusion in near-infrared fluorescence imaging.
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http://dx.doi.org/10.3390/life11050433DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8151115PMC
May 2021

Risk assessment in aortic aneurysm repair by medical specialists versus the American College of Surgeons National Surgical Quality Improvement Program risk calculator outcomes.

JRSM Cardiovasc Dis 2021 Jan-Dec;10:20480040211006582. Epub 2021 Apr 8.

Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands.

Objective: The aim of this online clinical vignette-based survey study was to compare risk assessments by vascular surgeons, anaesthesiologists and interventional radiologists involved in treating patients with aortic aneurysms in the Netherlands with the NSQIP risk calculator outcomes.

Methods: Participants, recruited using purposive sampling, provided their estimation of the likelihood of postoperative complications and events following aortic surgery in five fictional cases. These cases were subsequently scored using the NSQIP calculator. The risk assessments were statistically analysed using the ANOVA and student t-test.

Results: All participating specialists i.e. twelve vascular surgeons, ten interventional radiologists and ten anaesthesiologists completed the survey. In the vast majority of outcomes and vignettes, no significant differences were found between various specialists, whereas significant differences were found between the NSQIP risk calculator outcomes and the combined risk assessments of the specialists. Overall, specialist risk assessments differ from the NSQIP, but neither particularly higher nor lower compared to the risk calculator.

Conclusions: Risk assessment by vascular surgeons, anaesthesiologists and interventional radiologists differs significantly with NSQIP risk calculator outcomes, within the framework of both endovascular and open aortic aneurysm repair. Based on these results, implementing the NSQIP risk calculator in preoperative workup could be of added value in both patient planning as well as adequately informing patients for obtaining consent.
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http://dx.doi.org/10.1177/20480040211006582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8040563PMC
April 2021

Mirror, Mirror on the Wall'?

EJVES Vasc Forum 2021 13;50:27. Epub 2020 Dec 13.

Department of Vascular Surgery, Leiden University Medical Centre, Leiden, The Netherlands.

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http://dx.doi.org/10.1016/j.ejvsvf.2020.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873629PMC
December 2020

Measuring CMAPs in addition to MEPs can distinguish peripheral ischemia from spinal cord ischemia during endovascular aortic repair.

Clin Neurophysiol Pract 2021 11;6:16-21. Epub 2020 Dec 11.

Department of Neurology, Leiden University Medical Center, the Netherlands.

Objective: Spinal cord injury is a devastating complication after endovascular thoracic and thoracoabdominal aneurysm repair (EVAR). Motor evoked potentials (MEPs) can be monitored to detect spinal cord injury, but may also be affected by peripheral ischemia caused by femoral artery sheaths. We aimed to determine the incidence of peripheral ischemia during EVAR, and whether central and peripheral ischemia can be distinguished using compound muscle action potentials (CMAPs).

Methods: We retrospectively analyzed all EVAR procedures between March 1st 2015 and January 1st 2020 during which MEPs were monitored. Peripheral ischemia was defined as both a reduction in MEP amplitudes reversed by removing the femoral sheaths and no clinical signs of immediate post-procedural paraparesis. All other MEP decreases were defined as central ischemia.

Results: A significant MEP decrease occurred in 14/27 (52%) of all procedures. Simultaneous CMAP amplitude reduction was observed in 7/8 (88%) of procedures where peripheral ischemia occurred, and never in procedures with central ischemia.

Conclusions: MEP reductions due to peripheral ischemia are common during EVAR. A MEP-reduction without a CMAP decrease indicates central ischemia.

Significance: CMAP measurements can help to distinguish central from peripheral ischemia, potentially reducing the chance of misinterpreting of MEP amplitude declines as centrally mediated, without affecting sensitivity.
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http://dx.doi.org/10.1016/j.cnp.2020.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7804348PMC
December 2020

Giant true hepatic aneurysm mimicking Mirizzi syndrome.

J Vasc Surg Cases Innov Tech 2020 Dec 25;6(4):633-636. Epub 2020 Sep 25.

Department of Surgery, Leiden University Medical Center, Leiden.

Giant true aneurysms of the hepatic arteries are rare. Pseudoaneurysms of the hepatic arteries are more common and are mostly caused by intra-abdominal infection, iatrogenic injury, or trauma. Hepatic or cystic pseudoaneurysms are often successfully treated by embolization owing to their saccular nature as opposed to true aneurysms. We present a case of a patient with a giant true aneurysm of the proper hepatic artery, mimicking Mirizzi syndrome. Open reconstruction was successfully preformed, and the patient made a full recovery.
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http://dx.doi.org/10.1016/j.jvscit.2020.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599373PMC
December 2020

Rupture of a Median Sacral Artery Aneurysm in a Patient with Vascular Ehlers Danlos Syndrome.

EJVES Vasc Forum 2020 11;47:87-89. Epub 2020 Jan 11.

Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands.

Introduction: Vascular Ehlers Danlos syndrome is a rare connective tissue disease that is associated with various arterial complications.

Report: A 25 year old man with vascular Ehlers Danlos syndrome presented with acute lower back pain as a result of a ruptured aneurysm of the median sacral artery (MSA). Prior medical history included several vascular events resulting in a right iliac occlusion. The unusual location of aneurysmal disease of the MSA might be explained by extensive collateral flow recruitment due to this occlusion.

Conclusion: Previous vascular events inducing collateral recruitment might justify a more frequent follow up in patients with connective tissue disorders.
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http://dx.doi.org/10.1016/j.ejvssr.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320209PMC
January 2020

Antegrade common femoral artery access site closure using the MANTA vascular closure device.

Radiol Case Rep 2020 Nov 7;15(11):2205-2207. Epub 2020 Sep 7.

Department of Radiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands.

In antegrade peripheral endovascular procedures, the use of covered stents may require a large sheath size, which precludes the use of regular closure devices. The MANTA vascular closure device is a collagen plug-based vascular closure device for large bore percutaneous arterial interventions, which is normally used to close retrograde vascular access sites. We describe successful antegrade common femoral access site closure with the MANTA vascular closure device in 2 patients, a 68-year-old male and an 89-year-old male, both with a popliteal artery aneurysm which was treated by percutaneous endovascular stentgraft placement. Use of the MANTA vascular closure device simplifies large-bore antegrade common femoral artery access and avoids the need for surgical artery cutdown.
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http://dx.doi.org/10.1016/j.radcr.2020.08.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7486571PMC
November 2020

Stent Graft Sizing for Endovascular Abdominal Aneurysm Repair Using Open Source Image Processing Software.

Ann Vasc Surg 2021 Feb 3;71:411-418. Epub 2020 Sep 3.

Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands. Electronic address:

Introduction: An important step to reach a favorable outcome of abdominal endovascular aneurysm repair (EVAR) is preoperative sizing of the stent graft using computed tomography angiography (CTA) images of the abdominal aorta. A variety of costly image processing software options is available to obtain the necessary aortic measurements. A package that can be used for EVAR sizing is OsiriX Lite®-an open source, freely downloadable image processing option. This study assesses the concurrent validity of OsiriX Lite® when compared with commercially available 3Mensio Vascular® and Siemens Syngo.via®.

Methods: CTA scans of 20 patients that underwent EVAR for abdominal aneurysm were selected, 10 elective and 10 ruptured. For each scan, 6 observers determined 20 parameters needed for proper stent graft sizing, 2 using Osirix Lite®, 3 using 3Mensio Vascular®, and 1 using Siemens Syngo.via®. For each parameter, an intraclass correlation coefficient (ICC) and a P-value were calculated. Interrater agreement was interpreted using the Koo and Li Guidelines. Time needed to perform EVAR planning was compared.

Results: Overall interrater agreement between the 3 sizing options was found to be either "good" or "moderate" for 16 out of 20 parameters (80%). Time needed to perform EVAR planning was not significantly different for Osirix Lite® (568 sec) when compared with 3Mensio Vascular® (603 sec) or Siemens Syngo.via® (659 sec) with a P-value of 0.88.

Conclusions: The authors conclude that Osirix Lite® is an accurate and time-effective image processing option for preoperative sizing of an EVAR stent graft when matched to 3Mensio Vascular® and Siemens Syngo.via®.
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http://dx.doi.org/10.1016/j.avsg.2020.08.126DOI Listing
February 2021

Teamwork and Safety Attitudes in Complex Aortic Surgery at a Dutch Hospital: Cross-Sectional Survey Study.

JMIR Hum Factors 2020 Apr 8;7(2):e17131. Epub 2020 Apr 8.

Department of Vascular Surgery, Leiden University Medical Center, Leiden, Netherlands.

Background: Improving teamwork in surgery is a complex goal and difficult to achieve. Human factors questionnaires, such as the Safety Attitudes Questionnaire (SAQ), can help us understand medical teamwork and may assist in achieving this goal.

Objective: This paper aimed to assess local team and safety culture in a cardiovascular surgery setting to understand how purposeful teamwork improvements can be reached.

Methods: Two cardiovascular surgical teams performing complex aortic treatments were assessed: an endovascular-treatment team (ETT) and an open-treatment team (OTT). Both teams answered an online version of the SAQ Dutch Edition (SAQ-NL) consisting of 30 questions related to six different domains of safety: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. In addition, one open-ended question was posed to gain more insight into the completed questionnaires.

Results: The SAQ-NL was completed by all 23 ETT members and all 13 OTT members. Team composition was comparable for both teams: 57% and 62% males, respectively, and 48% and 54% physicians, respectively. All participants worked for 10 years or more in health care. SAQ-NL mean scores were comparable between both teams, with important differences found between the physicians and nonphysicians of the ETT. Nonphysicians were less positive about the safety climate, job satisfaction, and working climate domains than were the physicians (P<.05). Additional education on performed procedures, more conjoined team training, as well as a hybrid operating room were suggested by participants as important areas of improvement.

Conclusions: Nonphysicians of a local team performing complex endovascular aortic aneurysm surgery perceived safety climate, job satisfaction, and working conditions less positively than did physicians from the same team. Open-ended questions suggested that this is related to a lack of adequate conjoined training, lack of adequate education, and lack of an adequate operating room. With added open-ended questions, the SAQ-NL appears to be an assessment tool that allows for developing strategies that are instrumental in improving quality of care.
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http://dx.doi.org/10.2196/17131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177441PMC
April 2020

Vascular Surgeons' Views on Ejaculation Disorders After Abdominal Aortic Surgery: Results of a Dutch Survey.

Ann Vasc Surg 2020 Aug 1;67:346-353. Epub 2020 Apr 1.

Department of Urology, Leiden University Medical Centre, Leiden, the Netherlands.

Background: The aim of this study is to evaluate vascular surgeons' knowledge and appreciation of ejaculatory dysfunction after open aortic aneurysm repair and the knowledge of possible nerve-preserving techniques.

Methods: A Dutch national survey was conducted on sexual counseling in the case of open aortic surgery. For this purpose, a designed questionnaire based on a review of the literature in the field and on other surveys aiming to analyze care for sexual health by medical specialists was used.

Results: The response rate was almost 60%. All responders were familiar with the occurrence of postoperative neurogenic complications. Sixty percent preoperatively informs their patients, but only one-third inquires whether such complications have occurred postoperatively. Most respondents estimated the incidence of postoperative neurogenic complications due to dissection of the periaortic tissues between 5% and 25%. Almost 75% take nerve anatomy into consideration when exposing the abdominal aorta, but only 29% mention the correct structures, and only 37% mention possible correct nerve-sparing techniques.

Conclusions: Dutch vascular surgeons are well aware of the occurrence of postoperative sexual disorders after infrarenal aortic reconstruction. A gap in knowledge of pathophysiology and anatomy exists. Furthermore, a significant part of vascular surgeons seems to lack skills in sexual counseling. Therefore, more education should be offered during vascular surgical training.

What This Article Adds: This article addresses iatrogenic neurogenic complications affecting sexual health following open aortic surgery. It opens the discussion on possible gaps in modern training of vascular surgeons and on sexual health in relation to postoperative quality of life and shared decision-making.
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http://dx.doi.org/10.1016/j.avsg.2020.02.021DOI Listing
August 2020

Magnetic Resonance Direct Thrombus Imaging (MRDTI) Can Distinguish Between Old and New Thrombosis in the Abdominal Aorta: a Case Report.

Eur J Case Rep Intern Med 2020 9;7(1):001351. Epub 2020 Jan 9.

Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.

A 43-year-old man complaining of abdominal angina for several months showed a large suprarenal aneurysm of the abdominal aorta with extensive circumferential wall thrombosis, complete occlusion of the right renal artery and a critically stenosed left renal artery on CT angiography. He suffered from severe hypertension and renal failure. A percutaneous transluminal angioplasty (PTA) was planned. After the PTA procedure, which was complicated by the development of left renal artery occlusion, successful rescue revascularization surgery was performed. Since we were hesitant to start anticoagulant treatment because of a high bleeding risk, magnetic resonance direct thrombus imaging was performed to assess the age of the extensive arterial thrombosis. The aortic thrombus showed a low signal intensity, which is indicative of chronic rather than acute thrombosis. Therefore, oral anticoagulant treatment was not started. The patient recovered without major complications.

Learning Points: Accurate diagnosis and treatment of aortic intraluminal thrombosis are of the utmost importance to prevent serious complications such as (peripheral) arterial embolic occlusion with resultant ischemia.Current imaging modalities do not allow for accurate distinction between acute and chronic thrombosis in the abdominal aorta. Hence, differentiating between stable and unstable thrombosis is challenging.The non-invasive magnetic resonance direct thrombus imaging technique may be a valuable additional imaging test to establish a definitive diagnosis and treatment plan in patients with abdominal aortic thrombosis.
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http://dx.doi.org/10.12890/2020_001351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993914PMC
January 2020

A systematic review of the use of near-infrared fluorescence imaging in patients with peripheral artery disease.

J Vasc Surg 2019 Jul;70(1):286-297.e1

Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands. Electronic address:

Objective: In the diagnosis of peripheral artery disease (PAD), the ankle-brachial index plays an important role. However, results of the ankle-brachial index are unreliable in patients with severe media sclerosis. Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) can provide information about tissue perfusion and has already been studied in oncologic, reconstructive, and cardiac surgery. For patients with PAD, this technique might give insight into skin perfusion and thereby guide treatment. We performed a systematic review of the literature on the use of NIR fluorescence imaging in patients with PAD.

Methods: PubMed, MEDLINE, Embase, and Cochrane were searched for articles and abstracts on the application of NIR fluorescence imaging using ICG as fluorescent dye in patients with PAD. Our search strategy combined the terms "fluorescence," "ICG," or synonyms and "peripheral artery disease" or synonyms. The extracted data included fluorescence parameters and test characteristics for diagnosis of PAD.

Results: Twenty-three articles were found eligible for this review using 18 different parameters for evaluation of the fluorescence signal intensity. NIR fluorescence imaging was used for four main indications: diagnosis, quality control in revascularization, guidance in amputation surgery, and visualization of vascular structures. For the diagnosis of PAD, NIR fluorescence imaging yields a sensitivity ranging from 67% to 100% and a specificity varying between 72% and 100%. Significant increases in multiple fluorescence parameters were found in comparing patients before and after revascularization.

Conclusions: NIR fluorescence imaging can be used for several indications in patients with PAD. NIR fluorescence imaging seems promising in diagnosis of PAD and guidance of surgeons in treatment, especially in patients in whom current diagnostic methods are not applicable. Further standardization is needed to reliably use this modality in patients with PAD.
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http://dx.doi.org/10.1016/j.jvs.2018.11.023DOI Listing
July 2019

Minimally invasive treatment of vascular complications after neoaortoiliac system reconstruction using autologous vein grafts.

J Vasc Surg Cases Innov Tech 2018 Dec 4;4(4):283-286. Epub 2018 Dec 4.

Department of Vascular Surgery, Leiden University Medical Center, Leiden, the Netherlands.

Treatment of complications after neoaortoiliac system vein reconstruction is a complex clinical problem with poor results. Endovascular treatment might offer an acceptable outcome in selected cases. We report two rare complications after neoaortoiliac system vein reconstruction for an infected aortic graft. These complications were treated with minimally invasive endovascular techniques. A 54-year-old man presented with an arterioureteral fistula located between the right ureter and the right branch of the venous reconstruction. The second case describes a 71-year-old man who developed a large dilation proximally in the venous reconstruction.
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http://dx.doi.org/10.1016/j.jvscit.2018.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282657PMC
December 2018

Identifying error types in visual diagnostic skill assessment.

Diagnosis (Berl) 2017 06;4(2):93-99

Radiology Department, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: Misinterpretation of medical images is an important source of diagnostic error. Errors can occur in different phases of the diagnostic process. Insight in the error types made by learners is crucial for training and giving effective feedback. Most diagnostic skill tests however penalize diagnostic mistakes without an eye for the diagnostic process and the type of error. A radiology test with stepwise reasoning questions was used to distinguish error types in the visual diagnostic process. We evaluated the additional value of a stepwise question-format, in comparison with only diagnostic questions in radiology tests.

Methods: Medical students in a radiology elective (n=109) took a radiology test including 11-13 cases in stepwise question-format: marking an abnormality, describing the abnormality and giving a diagnosis. Errors were coded by two independent researchers as perception, analysis, diagnosis, or undefined. Erroneous cases were further evaluated for the presence of latent errors or partial knowledge. Inter-rater reliabilities and percentages of cases with latent errors and partial knowledge were calculated.

Results: The stepwise question-format procedure applied to 1351 cases completed by 109 medical students revealed 828 errors. Mean inter-rater reliability of error type coding was Cohen's κ=0.79. Six hundred and fifty errors (79%) could be coded as perception, analysis or diagnosis errors. The stepwise question-format revealed latent errors in 9% and partial knowledge in 18% of cases.

Conclusions: A stepwise question-format can reliably distinguish error types in the visual diagnostic process, and reveals latent errors and partial knowledge.
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http://dx.doi.org/10.1515/dx-2016-0033DOI Listing
June 2017

Increasing Authenticity of Simulation-Based Assessment in Diagnostic Radiology.

Simul Healthc 2017 Dec;12(6):377-384

From the Department of Radiology (A.V.D.G., C.J.R., D.R.R., I.C.V.D.S., C.P.M., K.L.V., J.P.J.V.S.), University Medical Center, Utrecht; Department of Radiology (C.A.T., K.D.C., M.M.), Academic Medical Center, Amsterdam; Examination Committee (D.R.R.), Radiological Society of the Netherlands; Department of Education (M.F.V.D.S.), Utrecht University; and Center for Research and Development of Education (O.T.J.T.C), University Medical Center, Utrecht, the Netherlands.

Introduction: Clinical reasoning in diagnostic imaging professions is a complex skill that requires processing of visual information and image manipulation skills. We developed a digital simulation-based test method to increase authenticity of image interpretation skill assessment.

Methods: A digital application, allowing volumetric image viewing and manipulation, was used for three test administrations of the national Dutch Radiology Progress Test for residents. This study describes the development and implementation process in three phases. To assess authenticity of the digital tests, perceived image quality and correspondence to clinical practice were evaluated and compared with previous paper-based tests (PTs). Quantitative and qualitative evaluation results were used to improve subsequent tests.

Results: Authenticity of the first digital test was not rated higher than the PTs. Test characteristics and environmental conditions, such as image manipulation options and ambient lighting, were optimized based on participants' comments. After adjustments in the third digital test, participants favored the image quality and clinical correspondence of the digital image questions over paper-based image questions.

Conclusions: Digital simulations can increase authenticity of diagnostic radiology assessments compared with paper-based testing. However, authenticity does not necessarily increase with higher fidelity. It can be challenging to simulate the image interpretation task of clinical practice in a large-scale assessment setting, because of technological limitations. Optimizing image manipulation options, the level of ambient light, time limits, and question types can help improve authenticity of simulation-based radiology assessments.
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http://dx.doi.org/10.1097/SIH.0000000000000278DOI Listing
December 2017

Arteriovenous Fistula Maturation Failure in a Large Cohort of Hemodialysis Patients in the Netherlands.

World J Surg 2018 06;42(6):1895-1903

Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.

Objectives: Radiocephalic arteriovenous fistulas (RCAVF) are the preferred vascular access (VA) for hemodialysis (HD). Cohort studies from North America revealed that nonmaturation is a significant disadvantage of RCAVFs compared to other VAs.

Design: This present retrospective study describes the incidence of nonmaturation of AVFs and functional failure of arteriovenous grafts (AVG) in a multicentre cohort in the Netherlands and attempts to create a prediction model for nonmaturation of RCAVFs. Furthermore, the efficacy of interventions to promote maturation as well as the variability between hemodialysis centers was evaluated.

Materials: Medical records from 8 hospitals from 1997 to 2016 were retrospectively evaluated for VA type, maturation/primary success and demographics and comorbidities.

Methods: A prediction model was created for RCAVF nonmaturation using multivariate logistic regression analysis, selecting significant predictors using backward selection. Discrimination and calibration of the model were assessed.

Results: 1383 AVFs and 273 AVGs were included in 1221 patients. Overall nonmaturation was 24% for RCAVFs, and 11% for upper arm AVFs. The functional failure rate for AVGs was 6%. The nonmaturation rate of contralateral RCAVFs after failure of an RCAVF was 22%. Procedures to improve RCAVF maturation were successful in 98/142 cases (69%). Predictors for nonmaturation were female gender, peripheral vascular disease, cerebrovascular disease and a cephalic vein diameter <2.5 mm, but the prediction model lacked sensitivity and specificity predicting individual RCAVF nonmaturation (C-statistic 0.629).

Conclusion: Nonmaturation rates are highest for RCAVFs, but nonmaturation could not be predicted with demographic parameters.
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http://dx.doi.org/10.1007/s00268-017-4382-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5934452PMC
June 2018

Integrated Residency in Radiology and Nuclear Medicine in The Netherlands.

J Nucl Med 2017 07;58(7):9N-11N

Academic Medical Center Amsterdam, The Netherlands.

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July 2017

Predictors of Knowledge and Image Interpretation Skill Development in Radiology Residents.

Radiology 2017 09 11;284(3):758-765. Epub 2017 Apr 11.

From the Department of Radiology (C.J.R., A.v.d.G., D.R.R., C.H., J.P.J.v.S.), Julius Center (C.L.J.J.K.) and Center for Research and Education Development (O.t.C.), University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands; and Department of Education, University Utrecht, Utrecht, the Netherlands (M.F.v.d.S.).

Purpose To investigate knowledge and image interpretation skill development in residency by studying scores on knowledge and image questions on radiology tests, mediated by the training environment. Materials and Methods Ethical approval for the study was obtained from the ethical review board of the Netherlands Association for Medical Education. Longitudinal test data of 577 of 2884 radiology residents who took semiannual progress tests during 5 years were retrospectively analyzed by using a nonlinear mixed-effects model taking training length as input variable. Tests included nonimage and image questions that assessed knowledge and image interpretation skill. Hypothesized predictors were hospital type (academic or nonacademic), training hospital, enrollment age, sex, and test date. Results Scores showed a curvilinear growth during residency. Image scores increased faster during the first 3 years of residency and reached a higher maximum than knowledge scores (55.8% vs 45.1%). The slope of image score development versus knowledge question scores of 1st-year residents was 16.8% versus 12.4%, respectively. Training hospital environment appeared to be an important predictor in both knowledge and image interpretation skill development (maximum score difference between training hospitals was 23.2%; P < .001). Conclusion Expertise developed rapidly in the initial years of radiology residency and leveled off in the 3rd and 4th training year. The shape of the curve was mainly influenced by the specific training hospital. RSNA, 2017 Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2017152648DOI Listing
September 2017

Alpha-1 Antitrypsin Deficiency Presenting with MPO-ANCA Associated Vasculitis and Aortic Dissection.

Case Rep Med 2017 6;2017:8140641. Epub 2017 Mar 6.

Department of Nephrology, Leiden University Medical Center, Leiden, Netherlands.

The combination of alpha-1 antitrypsin (AAT) deficiency, ANCA-vasculitis, and aortic aneurysm has been rarely described in literature. We report an eventually fatal case in a 70-year-old patient who initially presented with giant cell arteritis and ANCA associated glomerulonephritis. Several years later, he presented with aortic dissection due to large vessel vasculitis, raising the suspicion of AAT deficiency, as two first-line relatives had chronic obstructive pulmonary disease, while they never smoked. This diagnosis was confirmed by AAT electrophoresis and immunohistochemistry on a temporal artery biopsy. Considering AAT deficiency in these cases might lead to a more timely diagnosis.
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http://dx.doi.org/10.1155/2017/8140641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5358468PMC
March 2017

Improvement of radiocephalic fistula maturation: rationale and design of the Liposomal Prednisolone to Improve Hemodialysis Fistula Maturation (LIPMAT) study - a randomized controlled trial.

J Vasc Access 2017 Mar 5;18(Suppl. 1):114-117. Epub 2017 Mar 5.

Departments of Internal Medicine and Vascular Surgery, Leiden University Medical Center, Leiden - The Netherlands.

Background: Non-maturation is a frequent complication of radiocephalic arteriovenous fistulas (RCAVF). In an animal model, liposomal prednisolone improved maturation of experimental fistulas. The Liposomal Prednisolone to Improve Hemodialysis Fistula Maturation (LIPMAT) study investigates if liposomal prednisolone improves RCAVF maturation.

Methods And Results: The LIPMAT study is an investigator-initiated, multicenter, double-blinded, placebo-controlled randomized controlled trial with 1:1 randomization to liposomal prednisolone or placebo. Eighty patients receiving an RCAVF will be included. The primary outcome is the cephalic vein diameter six weeks after surgery, measured by ultrasound. The LIPMAT study started in May 2016. Enrollment is expected to be completed by the end of 2017.

Conclusions: The LIPMAT study is the first to evaluate the efficacy of liposomal prednisolone to enhance RCAVF maturation.
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http://dx.doi.org/10.5301/jva.5000673DOI Listing
March 2017

Tests, Quizzes, and Self-Assessments: How to Construct a High-Quality Examination.

AJR Am J Roentgenol 2016 Aug 1;207(2):339-43. Epub 2016 Jun 1.

1 Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Ave, M-391, San Francisco, CA 94143-0628.

Objective: The purposes of this article are to highlight aspects of tests that increase or decrease their effectiveness and to provide guidelines for constructing high-quality tests in radiology.

Conclusion: Many radiologists help construct tests for a variety of purposes. Only well-constructed tests can provide reliable and valuable information about the test taker.
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http://dx.doi.org/10.2214/AJR.15.15944DOI Listing
August 2016

The pros and cons of preserving a functioning arteriovenous fistula after kidney transplantation.

J Vasc Access 2016 Mar 6;17 Suppl 1:S16-22. Epub 2016 Mar 6.

Department of Nephrology, Leiden University Medical Center, Leiden - The Netherlands.

The autologous arteriovenous fistula (AVF) for hemodialysis burdens the cardiovascular system with increased cardiac output and pulmonary artery pressure, increasing cardiovascular risk. This article reviews literature on the benefits and drawbacks of a functioning AVF after kidney transplantation and discusses the cardiovascular effects of AVF closure. Several cohort studies demonstrate a significant cardiac burden of an AVF and improvement of cardiac dimensions after AVF ligation. However, no randomized trials have been conducted on routine AVF closure after successful kidney transplantation. Therefore, clinical trials are warranted to evaluate whether the cardiovascular benefits of routine AVF closure outweigh the potential harm for patients after successful kidney transplantation.
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http://dx.doi.org/10.5301/jva.5000525DOI Listing
March 2016

Volumetric and two-dimensional image interpretation show different cognitive processes in learners.

Acad Radiol 2015 May 20;22(5):632-9. Epub 2015 Feb 20.

Department of Radiology, UMC Utrecht, E01.132, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.

Rationale And Objectives: In current practice, radiologists interpret digital images, including a substantial amount of volumetric images. We hypothesized that interpretation of a stack of a volumetric data set demands different skills than interpretation of two-dimensional (2D) cross-sectional images. This study aimed to investigate and compare knowledge and skills used for interpretation of volumetric versus 2D images.

Materials And Methods: Twenty radiology clerks were asked to think out loud while reading four or five volumetric computed tomography (CT) images in stack mode and four or five 2D CT images. Cases were presented in a digital testing program allowing stack viewing of volumetric data sets and changing views and window settings. Thoughts verbalized by the participants were registered and coded by a framework of knowledge and skills concerning three components: perception, analysis, and synthesis. The components were subdivided into 16 discrete knowledge and skill elements. A within-subject analysis was performed to compare cognitive processes during volumetric image readings versus 2D cross-sectional image readings.

Results: Most utterances contained knowledge and skills concerning perception (46%). A smaller part involved synthesis (31%) and analysis (23%). More utterances regarded perception in volumetric image interpretation than in 2D image interpretation (Median 48% vs 35%; z = -3.9; P < .001). Synthesis was less prominent in volumetric than in 2D image interpretation (Median 28% vs 42%; z = -3.9; P < .001). No differences were found in analysis utterances.

Conclusions: Cognitive processes in volumetric and 2D cross-sectional image interpretation differ substantially. Volumetric image interpretation draws predominantly on perceptual processes, whereas 2D image interpretation is mainly characterized by synthesis. The results encourage the use of volumetric images for teaching and testing perceptual skills.
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http://dx.doi.org/10.1016/j.acra.2015.01.001DOI Listing
May 2015

New insights in the neuroanatomy of the human adult superior hypogastric plexus and hypogastric nerves.

Auton Neurosci 2015 May 14;189:60-7. Epub 2015 Feb 14.

Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address:

Background: The superior hypogastric plexus (SHP) is an autonomic plexus, located ventrally to the abdominal aorta and its bifurcation, innervating pelvic viscera. It is classically described as being composed of merely sympathetic fibres. However, post-operative complications after surgery damaging the peri-aortic retroperitoneal compartment suggest the existence of parasympathetic fibres. This immunohistochemical study describes the neuroanatomical composition of the human mature SHP.

Material And Methods: Eight pre-determined retroperitoneal localizations including the lumbar splanchnic nerves, the SHP and the HN were studied in four human cadavers. Control tissues (white rami, grey rami, vagus nerve, splanchnic nerves, sympathetic ganglia, sympathetic chain and spinal nerve) were collected to verify the results. All tissues were stained with haematoxylin and eosin and antibodies S100, tyrosine hydroxylase (TH), vasoactive intestinal peptide (VIP) and myelin basic protein (MBP) to identify pre- and postganglionic parasympathetic and sympathetic nerve fibres.

Results: All tissues comprising the SHP and hypogastric nerves (HN) showed isolated expression of TH, VIP and MBP, revealing the presence of three types of fibres: postganglionic adrenergic sympathetic fibres marked by TH, unmyelinated VIP-positive fibres and myelinated preganglionic fibres marked by MBP. Analysis of control tissues confirmed that TH, VIP and MBP were well usable to interpret the neurochemical composition of the SHP and HN.

Conclusion: The human SHP and HN contain sympathetic and most likely postganglionic parasympathetic fibres. The origin of these fibres is still to be elucidated, however surgical damage in the peri-aortic retroperitoneal compartment may cause pelvic organ dysfunction related to both parasympathetic and sympathetic denervation.
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http://dx.doi.org/10.1016/j.autneu.2015.02.001DOI Listing
May 2015
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