Publications by authors named "Vincent Jongkind"

31 Publications

Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature.

Eur J Vasc Endovasc Surg 2021 Sep 6. Epub 2021 Sep 6.

Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.

Objective: To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients.

Methods: Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines.

Results: Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation.

Conclusion: Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.
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http://dx.doi.org/10.1016/j.ejvs.2021.08.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8418912PMC
September 2021

Dataset of the vascular -earning during the -19 pandemic (EL-COVID) survey.

Data Brief 2021 Oct 1;38:107442. Epub 2021 Oct 1.

University of Bologna, Italy.

This dataset supports the findings of the vascular e-Learning during the COVID-19 pandemic survey (the EL-COVID survey). The General Data Protection Regulation (GDPR) of the European Union was taken into consideration in all steps of data handling. The survey was approved by the institutional ethics committee of the Primary Investigator and an online English survey consisting of 18 questions was developed ad-hoc. A bilingual English-Mandarin version of the questionnaire was developed according to the instructions of the Chinese Medical Association in order to be used in mainland People's Republic of China. Differences between the two questionnaires were minor and did affect the process of data collection. Both questionnaires were hosted online. The EL-COVID survey was advertised through major social media. All national and regional contributors contacted their respective colleagues through direct messaging on social media or by email. Eight national societies or groups supported the dissemination of the EL-COVID survey. The data provided demographics information of the EL-COVID participants and an insight on the level of difficulty in accessing or citing previously attended online activities and whether participants were keen on citing these activities in their Curricula Vitae. A categorization of additional comments made by the participants are also based on the data. The survey responses were filtered, anonymized and submitted to descriptive analysis of percentage.
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http://dx.doi.org/10.1016/j.dib.2021.107442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8484229PMC
October 2021

ACTION-1: study protocol for a randomised controlled trial on ACT-guided heparinization during open abdominal aortic aneurysm repair.

Trials 2021 Sep 19;22(1):639. Epub 2021 Sep 19.

Department of Vascular Surgery, Dijklander ziekenhuis, Maelsonstraat 3, 1624, NP, Hoorn, The Netherlands.

Background: Heparin is used worldwide for 70 years during all non-cardiac arterial procedures (NCAP) to reduce thrombo-embolic complications (TEC). But heparin also increases blood loss causing possible harm for the patient. Heparin has an unpredictable effect in the individual patient. The activated clotting time (ACT) can measure the effect of heparin. Currently, this ACT is not measured during NCAP as the standard of care, contrary to during cardiac interventions, open and endovascular. A RCT will evaluate if ACT-guided heparinization results in less TEC than the current standard: a single bolus of 5000 IU of heparin and no measurements at all. A goal ACT of 200-220 s should be reached during ACT-guided heparinization and this should decrease (mortality caused by) TEC, while not increasing major bleeding complications. This RCT will be executed during open abdominal aortic aneurysm (AAA) surgery, as this is a standardized procedure throughout Europe.

Methods: Seven hundred fifty patients, who will undergo open AAA repair of an aneurysm originating below the superior mesenteric artery, will be randomised in 2 treatment arms: 5000 IU of heparin and no ACT measurements and no additional doses of heparin, or a protocol of 100 IU/kg bolus of heparin and ACT measurements after 5 min, and then every 30 min. The goal ACT is 200-220 s. If the ACT after 5 min is < 180 s, 60 IU/kg will be administered; if the ACT is between 180 and 200 s, 30 IU/kg. If the ACT is > 220 s, no extra heparin is given, and the ACT is measured after 30 min and then the same protocol is applied. The expected incidence for the combined endpoint of TEC and mortality is 19% for the 5000 IU group and 11% for the ACT-guided group.

Discussion: The ACTION-1 trial is an international RCT during open AAA surgery, designed to show superiority of ACT-guided heparinization compared to the current standard of a single bolus of 5000 IU of heparin. A significant reduction in TEC and mortality, without more major bleeding complications, must be proven with a relevant economic benefit. TRIAL REGISTRATION {2A}: NTR NL8421 ClinicalTrials.gov NCT04061798 . Registered on 20 August 2019 EudraCT 2018-003393-27 TRIAL REGISTRATION: DATA SET {2B}: Data category Information Primary registry and trial identifying number ClinicalTrials.gov : NCT04061798 Date of registration in primary registry 20-08-2019 Secondary identifying numbers NTR: NL8421 EudraCT: 2018-003393-27 Source(s) of monetary or material support ZonMw: The Netherlands Organisation for Health Research and Development Dijklander Ziekenhuis Amsterdam UMC Primary sponsor Dijklander Ziekenhuis Secondary sponsor(s) N/A Contact for public queries A.M. Wiersema, MD, PhD [email protected] 0031-229 208 206 Contact for scientific queries A.M. Wiersema, MD, PhD [email protected] 0031-229 208 206 Public title ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair (ACTION-1) Scientific title ACTION-1: ACT Guided Heparinization During Open Abdominal Aortic Aneurysm Repair, a Randomised Trial Countries of recruitment The Netherlands. Soon the recruitment will start in Germany Health condition(s) or problem(s) studied Abdominal aortic aneurysm, arterial disease, surgery Intervention(s) ACT-guided heparinization 5000 IU of heparin Key inclusion and exclusion criteria Ages eligible for the study: ≥18 years Sexes eligible for the study: both Accepts healthy volunteers: no Inclusion criteria: Study type Interventional Allocation: randomized Intervention model: parallel assignment Masking: single blind (patient) Primary purpose: treatment Phase IV Date of first enrolment March 2020 Target sample size 750 Recruitment status Recruiting Primary outcome(s) The primary efficacy endpoint is 30-day mortality and in-hospital mortality during the same admission. The primary safety endpoint is the incidence of bleeding complications according to E-CABG classification, grade 1 and higher. Key secondary outcomes Serious complications as depicted in the Suggested Standards for Reports on Aneurysmal disease: all complications requiring re-operation, longer hospital stay, all complications.
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http://dx.doi.org/10.1186/s13063-021-05552-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8449992PMC
September 2021

Vascular e-Learning During the COVID-19 Pandemic: The EL-COVID Survey.

Ann Vasc Surg 2021 Sep 1. Epub 2021 Sep 1.

University of Bologna, Italy.

Background: The corona virus disease (COVID-19) pandemic has radically changed the possibilities for vascular surgeons and trainees to exchange knowledge and experience. The aim of the present survey is to inventorize the e-learning needs of vascular surgeons and trainees as well as the strengths and weaknesses of vascular e-Learning.

Methods: An online survey consisting of 18 questions was created in English, with a separate bilingual English-Mandarin version. The survey was dispersed to vascular surgeons and trainees worldwide through social media and via direct messaging from June 15, 2020 to October 15, 2020.

Results: Eight hundred and fifty-six records from 84 different countries could be included. Most participants attended several online activities (>4: n = 461, 54%; 2-4: n = 300, 35%; 1: n = 95, 11%) and evaluated online activities as positive or very positive (84.7%). In deciding upon participation, the topic of the activity was most important (n = 440, 51.4%), followed by the reputation of the presenter or the panel (n = 178, 20.8%), but not necessarily receiving accreditation or certification (n = 52, 6.1%). The survey identified several shortcomings in vascular e-Learning during the pandemic: limited possibility to attend due to lack of time and increased workload (n = 432, 50.5%), no protected/allocated time (n = 488, 57%) and no accreditation or certification, while technical shortcomings were only a minor problem (n = 25, 2.9%).

Conclusions: During the COVID-19 pandemic vascular e-Learning has been used frequently and was appreciated by vascular professionals from around the globe. The survey identified strengths and weaknesses in current e-Learning that can be used to further improve online learning in vascular surgery.
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http://dx.doi.org/10.1016/j.avsg.2021.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8407942PMC
September 2021

Microbubbles and Ultrasound Accelerated Thrombolysis for Peripheral Arterial Occlusions: The Outcomes of a Single Arm Phase II Trial.

Eur J Vasc Endovasc Surg 2021 09 22;62(3):463-468. Epub 2021 Jul 22.

Department of Vascular Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands; Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands. Electronic address:

Objective: Acute peripheral arterial occlusions can be treated by catheter directed thrombolysis (CDT). However, CDT is time consuming and accompanied by the risk of bleeding complications. The addition of contrast enhanced ultrasound and microbubbles could improve thrombus susceptibility to thrombolytic agents and potentially shorten treatment time with a lowered risk of bleeding complications. This article reports the outcomes of the safety and feasibility of this novel technique.

Methods: In this single arm phase II trial, 20 patients with acute lower limb ischaemia received CDT combined with an intravenous infusion of microbubbles and locally applied ultrasound during the first hour of standard intra-arterial thrombolytic therapy. The primary endpoint was safety, i.e., occurrence of serious adverse events (haemorrhagic complications and/or amputation) and death within one year. Secondary endpoints included angiographic and clinical success, thrombolysis duration, additional interventions, conversion, and quality of life.

Results: The study included 20 patients (16 men; median age 68.0 years; range, 50.0 - 83.0; and 40% native artery and 60% bypass graft). In all patients, the use of microbubble contrast enhanced sonothrombolysis could be applied successfully. There were no serious adverse events related to the experimental treatment. Duplex examination showed flow distal from the occlusion after 23.1 hours (range 3.1 - 46.5) with a median thrombolysis time of 47.5 hours (range 6.0 - 81.0). The short term ABI and pain scores significantly improved; however, no changes were observed before or after thrombolysis in the microcirculation. Overall mortality and amputation rates were both 2% within one year. The one year patency rate was 55%.

Conclusion: Treatment of patients with acute peripheral arterial occlusions with contrast enhanced sonothrombolysis is feasible and safe to perform in patients. Further research is necessary to investigate the superiority of this new treatment over standard treatment.
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http://dx.doi.org/10.1016/j.ejvs.2021.05.030DOI Listing
September 2021

More Effective Anticoagulation During Non-Cardiac Arterial Procedures Using Activated Clotting Time Guided Heparin Administration.

Ann Vasc Surg 2021 Oct 3;76:378-388. Epub 2021 May 3.

Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam University Medical Centers (Amsterdam UMC) location VU Medical Center, Amsterdam, the Netherlands.

Objectives: Arterial thrombo-embolic complications (ATEC) are still common during and after non-cardiac arterial procedures (NCAP) despite the administration of (a fixed bolus of) heparin. These ATEC could be due to existing individual differences in heparin sensitivity. The purpose of this study was to evaluate the feasibility and safety of an ACT guided heparin dose protocol and to evaluate if a more effective target ACT can be achieved during NCAP.

Methods: In this multi-center prospective study, 194 patients undergoing elective and non-elective NCAP were enrolled and received heparin according to a heparin dose protocol which aimed to obtain a target ACT of 250 seconds (s.), measured by the Medtronic HMS Plus. Patients received a standardized bolus of 5 000 IU followed by additional boluses depending on the actual ACT. Primary outcome was the ACT value reached. Secondary outcomes were incidence of all ATEC and haemorrhagic complications.

Results: The mean baseline ACT was 138 ± 17 s. The mean ACT five minutes after the initial heparin bolus of 5 000 IU was 197 ± 31 s. 48% of patients reached an ACT of 200 s. and six per cent of patients reached an ACT of 250 s. Additional dosages of heparin were administered in 72% of patients. With this ACT guided heparin protocol 86% of patients reached an ACT of 200 s. and 26% of patients reached an ACT of 250 s. A negative correlation was found between body weight and the ACT at T1 (P ˂ 0.001). ATEC and haemorrhagic complications occurred in 11.3% and 16.5% of patients. The lowest incidence of ATEC was found in patients with peak ACT between 200 and 250 s, namely 6.3%.

Conclusion: This ACT guided heparin protocol proved to be feasible, safe and more patients reached an ACT > of 200 s. compared to a standardized heparin bolus of 5 000 IU. Further research is needed to investigate if ACT guided heparin administration could be preferable over not monitoring the anticoagulant effect of peri-procedural heparin and results in a lower incidence of ATEC, without an increase in haemorrhagic complications.
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http://dx.doi.org/10.1016/j.avsg.2021.04.023DOI Listing
October 2021

Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome.

Vascular 2021 Apr 9:1708538121997332. Epub 2021 Apr 9.

Cardiovascular Sciences, Department of Vascular Surgery, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, Netherlands.

Background: Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars.

Methods: We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire.

Results: Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population.

Conclusion: Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.
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http://dx.doi.org/10.1177/1708538121997332DOI Listing
April 2021

Survival and Living Situation After Ruptured Abdominal Aneurysm Repair in Octogenarians.

Eur J Vasc Endovasc Surg 2021 03 6;61(3):375-381. Epub 2021 Jan 6.

Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, The Netherlands; Department of Vascular Surgery, Amsterdam UMC, Amsterdam, The Netherlands.

Objective: To determine the 30 day and one year mortality and post-operative living situation in octogenarians treated for ruptured abdominal aortic aneurysm (rAAA).

Methods: A retrospective study was performed at four centres in the Netherlands. All consecutive patients aged ≥80 years, presenting with a rAAA between January 2013 and October 2018, were included. The primary outcomes were post-operative living situation and one year mortality.

Results: In total, 157 patients were included. Forty-seven received palliative care and 110 patients had surgery. After endovascular or open repair, the one year mortality rate was 50.0%. The 30 day mortality rate was 40.8% (95% confidence interval [CI] 27-55) and 31.7% (95% CI 20-44), for endovascular and open repair, respectively (p = .32). Sixty-five per cent of survivors were discharged home, while 34.8% went to a nursing home for rehabilitation. Of the surviving patients, 82.6% went back to living in their pre-rupture home situation. Of the investigated variables, only a high body mass index proved a significant predictor of death at 30 days and one year. Compared with operated patients, patients turned down for surgery were older (mean age 87.5 ± 3.8 vs. 84.0 ± 3.5; p < .001), lived significantly more often in a nursing home (odds ratio 1.02, 95% CI 1.00-1.03; p < .001), were more often dependent (odds ratio 3.69, 95% CI 2.31-5.88; p < .001) and had a lower Glasgow Coma Scale score on arrival (odds ratio 0.42, 95% CI 0.25-0.69; p = .002). All palliative patients died within three days.

Conclusion: Overall treatment outcomes showed that octogenarians should not be denied surgery based on age alone, as half of the octogenarians that undergo surgical treatment are still alive one year after rAAA repair. In addition, > 80% returned to their own home after rehabilitation.
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http://dx.doi.org/10.1016/j.ejvs.2020.11.023DOI Listing
March 2021

A Standardized Bolus of 5 000 IU of Heparin Does not Lead to Adequate Heparinization during Non-cardiac Arterial Procedures.

Ann Vasc Surg 2021 Feb 6;71:280-287. Epub 2020 Aug 6.

Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam University Medical Centers location VU Medical Center, Amsterdam, the Netherlands.

Background: In non-cardiac arterial procedures (NCAP), heparin is administered to prevent arterial thromboembolic complications (ATEC). Heparin has a nonpredictable effect in the individual patient, also known as variation in heparin sensitivity. Various dosing protocols are in use, but the optimal dose is currently still unknown. A standardized bolus of 5 000 IU heparin is most frequently used by vascular surgeons and interventional radiologists. The activated clotting time (ACT) is an established method to measure the level of anticoagulation, but has, until now, not gained widespread use in NCAP. The purpose of this study was to evaluate the anticoagulant effect during NCAP of a standardized bolus of 5 000 IU heparin by measuring the ACT.

Methods: In this prospective study, 190 patients undergoing NCAP were enrolled between December 2016 and September 2018. The ACT was measured during open and endovascular/hybrid procedures. All patients received a standardized bolus of 5 000 IU heparin. The ACT was measured by the Hemostasis Management System Plus (HMS Plus, Medtronic®), before, 5 minutes after administration of heparin, and every 30 minutes thereafter. The primary outcome was periprocedural ACT values measured. Secondary outcomes were ATEC and hemorrhagic complications.

Results: A large individual patient variability in the response to heparin was found. The mean baseline ACT in all patients was 129 ± 18 s., and the mean ACT 5 minutes after the initial bolus of heparin was 191 ± 36 s. After the initial dose of 5 000 IU heparin 60 (33%) and 10 (6%) patients reached an ACT of 200 and 250 s., respectively. Despite the use of heparin, ATEC occurred in 17 patients (9%). The lowest number of ATEC occurred in the group of patients with an ACT between 200 and 250 s.

Conclusions: A standardized bolus of 5 000 IU heparin does not lead to adequate and safe heparinization in non-cardiac arterial procedures. Patient response to heparin shows a large individual variability. Therefore, routine ACT measurements are necessary to ascertain adequate anticoagulation. Further research is needed to investigate if heparin dosing based on the ACT could result in less arterial thromboembolic complications, without increasing hemorrhagic complications.
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http://dx.doi.org/10.1016/j.avsg.2020.07.035DOI Listing
February 2021

Focus on Patient Safety: European Patient Safety Policy Summit.

Eur J Vasc Endovasc Surg 2020 Sep 3;60(3):337-338. Epub 2020 Aug 3.

Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.

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http://dx.doi.org/10.1016/j.ejvs.2020.07.006DOI Listing
September 2020

Outcome of Ruptured Abdominal Aortic Aneurysm Repair in Octogenarians: A Systematic Review and Meta-Analysis.

Eur J Vasc Endovasc Surg 2020 Jan 4;59(1):16-22. Epub 2019 Dec 4.

Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam UMC, Amsterdam, the Netherlands. Electronic address:

Objective: This meta-analysis sought to identify the mortality and ambulatory state 30 days and one year post-operatively in octogenarians treated for ruptured abdominal aortic aneurysm (rAAA) by endovascular aneurysm repair (EVAR) or open repair (OR). rAAA is a life threatening emergency occurring increasingly in octogenarians. Surgical treatment, open or endovascular, offers the only chance of survival albeit with significant mortality and morbidity rates and a high burden to society. In order to make an informed decision on management, contemporary treatment outcomes should be known. The aim of this study was to perform a systematic review and meta-analysis on rAAA repair in octogenarians.

Methods: The Pubmed, Embase and Cochrane databases were searched for articles published between 2013 and October 2018 on octogenarians treated for a rAAA. Meta-analysis was performed using the random effects model to calculate the 30 day and one year mortality.

Results: The search resulted in a total of 1569 articles, of which eight retrospective studies could be included, reporting on 7526 patients. All studies reported 30 day mortality in octogenarians, and the one year mortality was addressed in four studies. Ambulatory state was not reported. Meta-analysis showed a 30 day mortality of 43% (95% confidence interval (CI) 33-53) and a one year mortality of 47% (95% CI 32-62). Patients after EVAR had a significant lower mortality at 30 days (risk ratio (RR) 0.50, 95% CI 0.38-0.67) and at one year (RR 0.65, 95% CI 0.44-0.96).

Conclusion: The 30 day and one year mortality rates for rAAA repair in octogenarians are similar to the outcome at all ages, with a significant survival advantage of EVAR over OR. Patients should therefore not be denied treatment of a rAAA based on age alone.
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http://dx.doi.org/10.1016/j.ejvs.2019.07.014DOI Listing
January 2020

Cold Renal Perfusion During Simulation of Juxtarenal Aortic Aneurysm Repair Reduces Systemic Oxidative Stress and Sigmoid Damage in Rats.

Eur J Vasc Endovasc Surg 2019 Dec;58(6):891-901

Amsterdam University Medical Centres, Location VUmc, Department of Surgery, Amsterdam, the Netherlands; Amsterdam University Medical Centres, Location VUmc, Department of Physiology, Amsterdam, the Netherlands. Electronic address:

Objectives: Juxtarenal aortic surgery induces renal ischaemia reperfusion, which contributes to systemic inflammatory tissue injury and remote organ damage. Renal cooling during suprarenal cross clamping has been shown to reduce renal damage. It is hypothesised that renal cooling during suprarenal cross clamping also has systemic effects and could decrease damage to other organs, like the sigmoid colon.

Methods: Open juxtarenal aortic aneurysm repair was simulated in 28 male Wistar rats with suprarenal cross clamping for 45 min, followed by 20 min of infrarenal aortic clamping. Four groups were created: sham, no, warm (37 °C saline), and cold (4 °C saline) renal perfusion during suprarenal cross clamping. Primary outcomes were renal damage and sigmoid damage. To assess renal damage, procedure completion serum creatinine rises were measured. Peri-operative microcirculatory flow ratios were determined in the sigmoid using laser Doppler flux. Semi-quantitative immunofluorescence microscopy was used to measure alterations in systemic inflammation parameters, including reactive oxygen species (ROS) production in circulating leukocytes and leukocyte infiltration in the sigmoid. Sigmoid damage was assessed using digestive enzyme (intestinal fatty acid binding protein - I-FABP) leakage, a marker of intestinal integrity.

Results: Suprarenal cross clamping caused deterioration of all systemic parameters. Only cold renal perfusion protected against serum creatinine rise: 0.45 mg/dL without renal perfusion, 0.33 mg/dL, and 0.14 mg/dL (p = .009) with warm and cold perfusion, respectively. Microcirculation in the sigmoid was attenuated with warm (p = .002) and cold renal perfusion (p = .002). A smaller increase of ROS production (p = .034) was seen only after cold perfusion, while leukocyte infiltration in the sigmoid colon decreased after warm (p = .006) and cold perfusion (p = .018). Finally, digestive enzyme leakage increased more without (1.5AU) than with warm (1.3AU; p = .007) and cold renal perfusion (1.2AU; p = .002).

Conclusions: Renal ischaemia/reperfusion injury after suprarenal cross clamping decreased microcirculatory flow, increased systemic ROS production, leukocyte infiltration, and I-FABP leakage in the sigmoid colon. Cold renal perfusion was superior to warm perfusion and reduced renal damage and had beneficial systemic effects, reducing sigmoid damage in this experimental study.
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http://dx.doi.org/10.1016/j.ejvs.2019.05.021DOI Listing
December 2019

No Concluding Evidence on Optimal Activated Clotting Time for Non-cardiac Arterial Procedures.

Eur J Vasc Endovasc Surg 2020 01 4;59(1):137-147. Epub 2019 Nov 4.

Department of Vascular Surgery, Dijklander Ziekenhuis, Hoorn, the Netherlands; Department of Vascular Surgery, Amsterdam University Medical Centres (Amsterdam UMC) Location VU Medical Centre (VUMC), Amsterdam, the Netherlands.

Objectives: Heparin has a non-predictable effect in the individual patient. The activated clotting time (ACT) is used to measure the level of anticoagulation after administration of heparin. To date, appropriate heparin dose protocols and corresponding therapeutic ACT values have not been established in non-cardiac arterial procedures (NCAP). The aim of this review was to study the use of ACT monitoring during NCAP, and whether an optimal ACT could be determined based on the fewest arterial thrombo-embolic complications (ATEC) and bleeding complications.

Methods: This systematic review was performed in accordance with the PRISMA Guidelines. A systematic search was conducted in MEDLINE, EMBASE, and the Cochrane database. Any associations were evaluated between peri-procedural ACT levels and ATEC and bleeding complications detected during the same admission as the primary procedure or during 30 day follow up. Also, heparin dose protocols, peri-procedural target ACTs, different ACT devices, protamine use and pre-, peri-, and post-procedural anticoagulation therapy were evaluated.

Results: In total, 21 studies with 3982 patients were included, on both open and endovascular NCAP. Four studies were primarily designed to correlate peak peri-procedural ACT with clinical outcomes; however, the definitions of the results and the clinical outcomes were too heterogeneous for analysis. There was major variability in all studied aspects of ACT measurement, heparin and protamine use, and in the type of procedures in the included studies. Overall methodological quality of the included studies was poor. No randomised controlled trials were found. Studies were at a high risk of bias.

Conclusions: This systematic review demonstrates a lack of data and no consensus in the literature concerning the optimal ACT, and the possible association with haemorrhagic complications and ATEC during NCAP.
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http://dx.doi.org/10.1016/j.ejvs.2019.08.007DOI Listing
January 2020

Coming of Age of European Vascular Surgeons in Training: Celebrating 25 Years.

Eur J Vasc Endovasc Surg 2019 Oct 1;58(4):475-476. Epub 2019 Jun 1.

Division of Vascular Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, USA.

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http://dx.doi.org/10.1016/j.ejvs.2019.04.030DOI Listing
October 2019

Prediction of Survival after 48 Hours of Intensive Unit Care following Repair of Ruptured Abdominal Aortic Aneurysm-Multicentric Study for External Validation of a New Prediction Score for 30-Day Mortality.

Ann Vasc Surg 2019 Oct 8;60:95-102. Epub 2019 May 8.

Department of Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal; Department of Vascular Surgery, Faculdade de Medicina Universidade Porto, Porto, Portugal.

Background: Ruptured abdominal aortic aneurysm (rAAA) remains a critical life-threatening condition. We aimed to evaluate rAAA management in our center focusing on predictors of mortality at 48 hr of intensive care unit (ICU) and to develop a new mortality prediction score considering data at 48 hr postprocedure. External validation of the modified score with patient data from independent vascular surgery centers was subsequently pursued.

Methods: Clinical data of all patients admitted in our center from January 2010 to December 2017 with the diagnosis of rAAA were retrospectively reviewed for the development of the mortality prediction score. Subsequently, clinical data from patients admitted at independent centers from January 2010 to December 2017 were reviewed for external validation of the score. Statistical analysis was performed with SPSS Version 25.

Results: A total of 78 patients were included in the first part of the study: 21 endovascular aneurysm repairs (EVARs), 56 open repairs (ORs), and 1 case of conservative management. Intraoperative mortality in EVAR and OR groups was 0% vs. 24.6%, respectively (P = 0.012). Thirty-day mortality reached 50% and 33% in the OR and EVAR groups. For patients alive at 48 hr, 30-day mortality diminished to 27.6%. Several preoperative predictors of outcome were identified: smoking (P = 0.004), hemodynamic instability(P = 0.004), and elevated international normalized ratio (P < 0.0001). Dutch Aneurysm Score and Vascular Study Group of New England Score (VSGNE) were also significant predictors of outcome (area under the receiver operating characteristic curve [ROC AUC] 0.89 and 0.79, respectively; P < 0.0001). At 48 hr of ICU stay, high lactate level, high Sequential Organ Failure Assessment score, need for hemodyalitic technique, and hemodynamic instability were significant risk predictors for 30-day mortality (P < 0.05). VSGNE score was modified with the inclusion of 2 variables: hemodynamic instability and lactate level at 48 hr and a new score was attained-Postoperative Aneurysm Score (PAS). Comparing AUC for VSGNE and PAS for patients alive at 48 hr, the latter was significantly better (AUC 0.775 vs. 0.852, P = 0.039). The PAS was applied and validated in 3 independent vascular surgery centers (AUC VSGNE 0.782 vs. AUC PAS 0.820, P = 0.027).

Conclusions: Despite recent evidence on preoperative predictors of survival in an era when both EVAR and OR are available, emergent decision to withhold life-saving treatment will always be extremely difficult. Therefore, the policy in our department is to try surgical repair in all cases. It remains important, however, to identify whether late deaths can be predicted, so that unnecessary prolonged treatment can be avoided. A PAS was delineated predicting 30-day mortality significantly better in patients alive at 48 hr. The score was externally applied and validated in independent centers, corroborating the score's usefulness.
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http://dx.doi.org/10.1016/j.avsg.2019.02.026DOI Listing
October 2019

Catheter Directed Thrombolysis Protocols for Peripheral Arterial Occlusions: a Systematic Review.

Eur J Vasc Endovasc Surg 2019 05 17;57(5):667-675. Epub 2019 Apr 17.

Department of Vascular Surgery, Amsterdam UMC, Amsterdam, the Netherlands. Electronic address:

Objective: Catheter directed thrombolysis (CDT) for peripheral arterial occlusions is a well established alternative to thrombo-embolectomy in patients with (sub)acute limb ischaemia. However, protocols are heterogeneous and need optimisation to improve results and lower bleeding risks. The objective was to review the results and outcomes of different CDT protocols for patients with peripheral arterial occlusions.

Data Sources: Electronic information sources (MEDLINE, Embase, Cochrane) and reference lists were searched to identify studies reporting results of CDT of peripheral arterial occlusions.

Methods: Two independent observers performed study selection, quality assessment and data extraction. Primary outcomes were treatment duration, success rates, and bleeding complications. Secondary outcomes were mortality and amputation rates.

Results: One hundred and six studies were included: 19 randomised controlled trials (RCTs), 38 prospective studies, 48 retrospective studies, and one mixed cohort study. The studies comprised a total number of 10,643 cases of which 9877 received CDT for lower extremity arterial occlusion, with a mean treatment duration of 21.4 h (95% confidence interval [CI] 21.0-21.8), an angiographic patency of 75% (95% CI 74.6-75.1), and freedom from amputation rate of 91% (95% CI 90.3-90.7). Pooled results showed a thrombolysis duration with high dose protocols of 21.9 h (95% CI 21.4-22.5) and 32.7 h with low dose protocols, with bleeding rates of 16.7% (95% CI 16.3-17.1) and 13.4% (95% CI 12.8-14.0), respectively. Weighted mean results for all RCTs and prospective cohorts of >100 cases analysed separately, showed comparable results to all observational cohorts pooled. Bleeding complications occurred in 18% (95% CI 17.8-18.3) of patients and remain an important risk of CDT.

Conclusion: CDT is an effective treatment for peripheral arterial occlusions, the main concern is bleeding complications. Although no formal meta-analysis could be performed, the pooled results suggest that lower doses of fibrinolytics lead to similar success rates at a cost of longer treatment duration but with less bleeding. There is large variation in treatment protocols and the available literature suffers from absence of reporting standards and high heterogeneity.
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http://dx.doi.org/10.1016/j.ejvs.2018.11.018DOI Listing
May 2019

Secondary Fill Minimizes Gutter Size in Chimney EVAS Configurations In Vitro.

J Endovasc Ther 2019 02 21;26(1):62-71. Epub 2018 Dec 21.

1 Department of Vascular Surgery, VU University Medical Center, Amsterdam, the Netherlands.

Purpose: To investigate in an in vitro model if secondary endobag filling can reduce gutter size during chimney endovascular aneurysm sealing (chEVAS).

Materials And Methods: Nellix EVAS systems were deployed in 2 silicone juxtarenal aneurysm models with suprarenal aortic diameters of 19 and 24 mm. Four configurations were tested: EVAS with 6-mm balloon-expandable (BE) or self-expanding (SE) chimney grafts (CGs) in the renal branches of both models. Balloons were inflated simultaneously in the CGs and main endografts during primary and secondary endobag filling and polymer curing. Computed tomography (CT) was performed immediately after the primary and secondary fills. Cross-sectional lumen areas were measured on the CT images to calculate gutter volumes and percent change. CG compression was calculated as the reduction in lumen surface area measured perpendicular to the central lumen line. The largest gutter volume and highest compression were presented per CG configuration per model.

Results: Secondary endobag filling reduced the largest gutter volumes from 99.4 to 73.1 mm (13.2% change) and 84.2 to 72.0 mm (27.6% change) in the BECG configurations and from 67.2 to 44.0 mm (34.5% change) and 92.7 to 82.3 mm (11.2% change) in the SECG configurations in the 19- and 24-mm models, respectively. Secondary endobag filling increased CG compression in 6 of 8 configurations. BECG compression changed by -0.2% and 5.4% and by -1.0% and 0.4% in the 19- and 24-mm models, respectively. SECG compression changed by 10.2% and 16.0% and by 7.2% and 7.3% in the 19- and 24-mm models, respectively.

Conclusion: Secondary endobag filling reduced paragraft gutters; however, this technique did not obliterate them. Increased CG compression and prolonged renal ischemia time should be considered if secondary endobag filling is used.
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http://dx.doi.org/10.1177/1526602818819494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330694PMC
February 2019

Efficacy versus Complications in Arterial Thrombolysis.

Ann Vasc Surg 2018 Apr 6;48:111-118. Epub 2017 Dec 6.

Department of Surgery, Westfriesgasthuis, Hoorn, The Netherlands; Department of Vascular Surgery, VU University Medical Center, Amsterdam, The Netherlands. Electronic address:

Background: Acute peripheral arterial occlusions threaten life and limb. Thrombolysis is an established, minimally invasive alternative treatment for surgical thromboembolectomy. Yet, there is no consensus regarding an optimal thrombolysis protocol, and current knowledge is largely based on studies from the 1990s. This study reviews a contemporary cohort of patients treated with thrombolysis and aims to evaluate the treatment results and to identify possible predictors for outcome and (bleeding) complications.

Methods: The electronic health record data of all consecutive patients who underwent thrombolysis for acute limb ischemia due to thromboembolic lower extremity arterial occlusions between April 2006 and June 2012 were analyzed. End points were change in clinical stage of ischemia, incidence of bleeding complications, duration of thrombolysis, predictors of outcome and complications, and mortality and amputation-free rates after 30-day and 6-months follow-up.

Results: In total, 109 cases were included. Clinical improvement was observed in 79%. Amputation-free rates at 30 days and 6 months were 94% and 90%, respectively. The incidence of major bleeding complications was 13%. Median duration of thrombolysis was 27 (4-68) hr. Mortality rates at 30 days and 6 months were 7% and 16%, respectively; none bleeding related. In addition to age, popliteal artery occlusions and a progressed chronic vascular stage are predictive for a worse outcome. Age, female sex, and cardiac history were risk factors for bleeding.

Conclusions: Treatment of peripheral arterial occlusions with high-dose thrombolysis on an intensive-care unit yields high clinical success rates, but major bleeding complications are often observed. Strict clinical observation remains essential since intensive monitoring of hemostatic parameters during thrombolysis does not predict bleeding complications.
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http://dx.doi.org/10.1016/j.avsg.2017.10.012DOI Listing
April 2018

Organ protection during aortic cross-clamping.

Best Pract Res Clin Anaesthesiol 2016 Sep 20;30(3):305-15. Epub 2016 Aug 20.

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

Open surgical repair of an aortic aneurysm requires aortic cross-clamping, resulting in temporary ischemia of all organs and tissues supplied by the aorta distal to the clamp. Major complications of open aneurysm repair due to aortic cross-clamping include renal ischemia-reperfusion injury and postoperative colonic ischemia in case of supra- and infrarenal aortic aneurysm repair. Ischemia-reperfusion injury results in excessive production of reactive oxygen species and in oxidative stress, which can lead to multiple organ failure. Several perioperative protective strategies have been suggested to preserve renal function during aortic cross-clamping, such as pharmacotherapy and therapeutic hypothermia of the kidneys. In this chapter, we will briefly discuss the pathophysiology of ischemia-reperfusion injury and the preventative measures that can be taken to avoid abdominal organ injury. Finally, techniques to minimize the risk of complications during and after open aneurysm repair will be presented.
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http://dx.doi.org/10.1016/j.bpa.2016.07.005DOI Listing
September 2016

Thoracic sympathectomy for upper extremity ischemia.

Minerva Cardioangiol 2016 Dec 13;64(6):676-85. Epub 2016 May 13.

Department of Vascular Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands -

Introduction: Thoracic sympathectomy is performed in the management of a variety of disorders of the upper extremity. To evaluate the contemporary results of thoracic sympathectomy for upper extremity ischemia a systematic review of the literature was conducted.

Evidence Aquisition: We performed a PubMed, EMBASE and Cochrane search of the literature written in the English language from January 1975 to December 2015. All articles presenting original patient data regarding the effect of treatment on symptoms or on the healing of ulcers were eligible for inclusion. Individual analyses for Primary Raynaud's Disease (PRD) and Secondary Raynaud's Phenomenon (SRP) were performed.

Evidence Synthesis: We included 6 prospective and 23 retrospective series with a total of 753 patients and 1026 affected limbs. Early beneficial effects of thoracic sympathectomy were noticed in 63-100% (median 94%) of all patients, in 73-100% (median 98%) of PRD patients and in 63-100% (median 94%) of SRP patients. The beneficial effect was noted to lessen over time. Long-term beneficial effects were reported in 13-100% (median 75%) of all patients, in 22-100% (median 58%) of PRD patients, and in 13-100% (median 79%) of SRD patients. Complete or improved ulcer healing was achieved in 33-100% and 25-67% respectively, of all patients.

Conclusions: Thoracic sympathectomy can be beneficial in the treatment of upper extremity ischemia in select patients. Although the effect in patients with PRD will lessen over time, it may still reduce the severity of symptoms. In SRD, effects are more often long-lasting. In addition, thoracic sympathectomy may maximize tissue preservation or prevent amputation in cases of digital ulceration.
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December 2016

Recovery of Renal Function after Prolonged Anuria in Acute Suprarenal Aortic Occlusion.

Ann Vasc Surg 2016 Jan 28;30:307.e11-4. Epub 2015 Oct 28.

Department of Surgery, Westfriesgasthuis, Hoorn, The Netherlands.

Acute suprarenal aortic occlusion is a rare but often catastrophic event. Despite immediate treatment, mortality and morbidity are high. We present a case of acute suprarenal aortic occlusion presenting with renal failure and dyspnea but without lower limb ischemia. Diagnosis was initially not taken in consideration. The patient required hemodialysis and temporary mechanical ventilation. After 13 days, an abdominal ultrasound was performed which revealed thrombosis of the suprarenal abdominal aorta. Suprarenal aortic thrombectomy was performed followed by aortobi-iliac bypass grafting. Diuresis returned 4 hr after surgery, and the patient fully recovered. Thorough review of the literature revealed only 8 cases of acute suprarenal aortic occlusion. Only 3 patients survived. To our knowledge, this is the first reported case of acute suprarenal occlusion, in which renal function could be restored after a 14-day period of anuria. The case illustrates that in select cases with prolonged acute renal failure aortorenal revascularization can be performed successfully.
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http://dx.doi.org/10.1016/j.avsg.2015.07.024DOI Listing
January 2016

Pararenal aortic aneurysm repair using fenestrated endografts.

J Vasc Surg 2012 Jul 21;56(1):238-46. Epub 2012 Jan 21.

Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.

Objective: We performed a systematic review of the current literature to analyze the immediate and follow-up results of fenestrated endovascular aortic aneurysm repair (F-EVAR) in patients with pararenal abdominal aortic aneurysms (AAAs).

Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting F-EVAR of pararenal AAAs published between January 2000 and May 2011. Two independent observers selected studies for inclusion, assessed the quality of the included studies, and performed the data extraction. Studies were selected based on specific predefined criteria. Outcomes were technical success (successfully completed procedure with endograft patency, preservation of target vessels, and no evidence of type I or III endoleak at postprocedural imaging), 30-day mortality, all-cause mortality, branch vessel patency, renal impairment, and secondary interventions. Between-study heterogeneity was calculated using I(2) statistics. Pooled estimates were calculated using a fixed-effects (I(2) <25%) or a random-effects (I(2) >25% to <50%) model.

Results: Nine studies were included reporting 629 patients who underwent F-EVAR for a pararenal AAA, of which 1622 target vessels were incorporated in an endograft design. Between-study heterogeneity was ≤ 41% for all outcomes. The pooled estimate (95% confidence interval [CI] was 90.4% (87.7%-92.5%) for technical success, 2.1% (1.2%-3.7%) for 30-day mortality, and 16% (12.5%-20.4%) for all-cause mortality. Follow-up was 15 to 25 months. The pooled estimate (95% CI) during follow-up was 93.2% (90.4%-95.3%) for branch vessel patency, 22.2% (16%-30.1%) for renal impairment, and 17.8% (13.5%-22.6%) for secondary interventions.

Conclusions: Promising immediate and midterm results (up to 2 years) support F-EVAR as a feasible, safe, and effective treatment in a relatively high-risk cohort of patients with pararenal AAAs.
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http://dx.doi.org/10.1016/j.jvs.2011.10.092DOI Listing
July 2012

Mid-term results of robot-assisted laparoscopic surgery for aortoiliac occlusive disease.

Vascular 2011 Feb;19(1):1-7

Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.

The aim of this study was to evaluate middle-term clinical results of robot-assisted laparoscopic surgery (RALS) to treat aortoiliac occlusive disease (AIOD). Between 2002 and 2007, 28 consecutive patients received robot-assisted laparoscopic aortobifemoral bypass grafting (n = 24) or aortoiliac endarterectomy (n = 4). Patients were followed prospectively. RALS could be completed successfully in 24 patients; conversion to open surgery was necessary in four patients (14%). Median operative time was 350 min. Median aortic clamping time was 70 min. Median hospital stay was five days. One patient died within 30 days. Non-lethal complications occurred in four patients (14%). Clinical symptoms improved in all patients. Primary and secondary limb-based patencies at 36 months were 89% and 91%, respectively. In conclusion, RALS is a feasible and durable technique for patients with AIOD. Although operative times are long, RALS allows rapid postoperative recovery.
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http://dx.doi.org/10.1258/vasc.2010.oa0249DOI Listing
February 2011

A systematic review of endovascular treatment of extensive aortoiliac occlusive disease.

J Vasc Surg 2010 Nov;52(5):1376-83

Department of Surgery, Spaarne Hospital, Hoofddorp, The Netherlands.

Objectives: Current multidisciplinary guidelines recommend to treat extensive aortoiliac occlusive disease (AIOD) by surgical revascularization. Surgery provides good long-term patency, but at the cost of substantial perioperative morbidity. Development of new technologies and techniques has led to increased use of endovascular therapy for extensive AIOD. We performed a systematic review of the literature to determine contemporary short- and long-term results of endovascular therapy for extensive AIOD.

Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting endovascular treatment of extensive AIOD (TransAtlantic Inter-Society Consensus (TASC) type C and D) from January 2000 to June 2009. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Outcomes were technical success, clinical success, mortality, complications, long-term primary, and secondary patency rates.

Results: Nineteen nonrandomized cohort studies reporting on 1711 patients were included. There was substantial clinical heterogeneity between the studies considering study population and interventional techniques. Technical success was achieved in 86% to 100% of the patients. Clinical symptoms improved in 83% to 100%. Mortality was described in seven studies and ranged from 1.2% to 6.7%. Complications were reported in 3% to 45% of the patients. Most common complications were distal embolization, access site hematomas, pseudoaneurysms, arterial ruptures, and arterial dissections. The majority of complications could be treated using percutaneous or noninvasive techniques. Four- or 5-year primary and secondary patency rates ranged from 60% to 86% and 80% to 98%, respectively.

Conclusions: Endovascular treatment of extensive AIOD can be performed successfully by experienced interventionists in selected patients. Although primary patency rates are lower than those reported for surgical revascularization, reinterventions can often be performed percutaneously, with secondary patency comparable to surgical repair.
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http://dx.doi.org/10.1016/j.jvs.2010.04.080DOI Listing
November 2010

Juxtarenal aortic aneurysm repair.

J Vasc Surg 2010 Sep 10;52(3):760-7. Epub 2010 Apr 10.

Department of Surgery, Spaarne Hospital, Hoofddorp, The Netherlands.

Objectives: Juxtarenal aortic aneurysms (JAA) account for approximately 15% of abdominal aortic aneurysms. Despite advances in endovascular aneurysm repair, open repair requiring suprarenal aortic cross-clamping is still the treatment of choice for JAA. We performed a systematic review of the literature to determine perioperative mortality and postoperative renal dysfunction after open repair for non-ruptured JAA.

Methods: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting non-ruptured JAA repair published between January 1966 and December 2008. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Study heterogeneity was assessed using forest plots and by calculating the between-study variance. Outcomes were perioperative mortality, postoperative renal dysfunction, and new onset of dialysis. Summary estimates with 95% confidence interval (95% CI) were calculated using a random effects model based on the binomial distribution.

Results: Twenty-one non-randomized cohort studies from 1986 to 2008, reporting on 1256 patients, were included. Heterogeneity between the studies was low. The mean perioperative mortality was 2.9% (95% CI, 1.8 to 4.6). The mean incidence of new onset of dialysis was 3.3% (95% CI, 2.4 to 4.5). Incidence of postoperative renal dysfunction could be derived from 13 studies and ranged from 0% to 39% (median, 18%). In seven studies, cold renal perfusion during suprarenal clamping was performed in order to preserve renal function; however, based upon the included data, definitive conclusions regarding its efficacy could not be drawn.

Conclusions: Open repair of non-ruptured JAA using suprarenal cross-clamping can be performed with acceptable perioperative mortality; however, postoperative deterioration of renal function is a common complication. Preservation of renal function after JAA repair requires further investigation.
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http://dx.doi.org/10.1016/j.jvs.2010.01.049DOI Listing
September 2010

Direct videoscopic approach to the thoracic aorta for aortic endograft delivery: evaluation in a human cadaver circulation model.

J Endovasc Ther 2010 Feb;17(1):12-8

Department of Surgery, VU University Medical Center, Amsterdam 1007 MB, The Netherlands.

Purpose: To examine the feasibility of a direct videoscopic approach to the descending thoracic aorta for branched endograft delivery to the aortic arch and abdominal aorta.

Methods: Aneurysms were created in the aortic arch and pararenal aorta of 3 human cadavers, and pulsatile flow was established using a roller pump. Thoracoscopically, 2 double-felted purse-string sutures were placed on the thoracic aorta. Via the most distal trocar, an endoscopic needle was used to insert a stiff guidewire into the aorta through the center of the purse-string suture. Under direct videoscopic control, a 20-F sheath was advanced over the wire into the aorta. Switching to fluoroscopic control, a fenestrated endograft was deployed in the aortic arch followed by placement of a branch graft into the left subclavian artery. The delivery sheath was withdrawn from the aorta while simultaneously tightening the purse-string sutures. A similar procedure was performed in the same cadaver for antegrade branched endograft delivery to the pararenal aorta. Correct deployment of the branched endografts was evaluated by post implant angiography and autopsy.

Results: The procedure was successfully completed in all cadavers. "Hemostasis" was obtained in all cadavers without aortic cross clamping. Median fluid loss was 165 mL. Autopsy proved all purse-string sutures to be adequately placed and all branched endografts to be deployed in the correct position.

Conclusion: A direct videoscopic approach to the descending thoracic aorta proved a feasible technique for branched endograft delivery to the aortic arch and abdominal aorta in a human cadaver model.
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http://dx.doi.org/10.1583/09-2877.1DOI Listing
February 2010

Aortoiliac reconstruction for abdominal aortic rupture after blunt trauma.

J Trauma 2009 Apr;66(4):1248-50

Department of Surgery, Vrije Universiteit Medical Center, Amsterdam, The Netherlands.

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http://dx.doi.org/10.1097/01.ta.0000236010.41841.7aDOI Listing
April 2009

Direct videoscopic approach to the descending thoracic aorta for aortic arch endograft delivery: evaluation in a porcine model.

J Endovasc Ther 2007 Feb;14(1):39-43

Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.

Purpose: To examine the feasibility of a direct videoscopic approach to the descending thoracic aorta for endograft delivery to the aortic arch.

Methods: A double purse-string suture was placed on the aorta of 3 pigs via a thoracoscopic approach. Subsequently, the aorta was cannulated in the center of the purse-string. A 22-F delivery catheter was advanced under fluoroscopic control over a guidewire via a trocar into the proximal aorta. After deployment of a tubular endograft, the catheter was withdrawn from the aorta while simultaneously tightening the purse-string suture, without aortic cross clamping. The outcome was evaluated by post implant angiography and autopsy results.

Results: The procedure was successfully completed in all animals, with a mean total procedure time of 126 minutes (range 118-137). Mean endograft implantation time from needle puncture to catheter extraction was 27 minutes (range 21-37). Hemostasis was obtained in all animals after withdrawal of the delivery catheter and tightening the purse-string suture. The mean blood loss was 143 mL (range 80-220). Autopsy proved all purse-string sutures to be adequately placed and all endografts deployed in the correct position.

Conclusion: A direct videoscopic approach to the descending thoracic aorta proved a feasible technique for endograft delivery to the aortic arch in a porcine model.
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http://dx.doi.org/10.1583/06-1906.1DOI Listing
February 2007
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