Abdominal Aortic Surgery Research Articles

The role of Tranexamic acid in the Reduction of Bleeding in Abdominal Aortic Aneurysm Surgery

Objective: To determine the effects of Tranexamic acid on intraoperative blood loss. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Jun to Oct 2021. Methodology: A total of 96 patients from both genders undergoing elective open abdominal aortic aneurysm surgery under general anaesthesia enrolled in the study after random distribution to Drug and Control Groups. The primary determinant was intraoperative blood loss. Additionally, determining variables were intraoperative and postoperative blood transfusions, thromboembolic episodes, and postoperative mortality rate. Results: A total of 96 patients enrolled in the study, out of which 90(93%) were males, whereas 6(7%) were females, with a mean age of 65.37±7.01 (55–75 years). Of 96 participants, 52(54%) patients were from ASA Class II and 44(46%) were from ASA Class III. There was no significant correlation between surgical time (p-value 0.45), clamping time (p-value 0.34), and intraoperative and postoperative transfusions (p-value 0.56 and 0.28, respectively). However, a statistically significant reduction in intraoperative and postoperative blood loss was recorded (p-value <0.001). Conclusion: Tranexamic acid significantly impacts the reduction of intraoperative and postoperative bleeding in elective open abdominal aortic aneurysm surgeries under general anaesthesia.

Ruptured abdominal aortic aneurysms early recognition, hemodynamic stabilization, and emergency vascular surgery

Ruptured abdominal aortic aneurysms (rAAAs) are extremely dangerous. Require attention. This thorough review explores the management of rAAA, focusing on the detection stabilizing blood flow and emergency vascular surgery. Recognizing symptoms such as intense abdominal pain, low blood pressure, a pulsating mass in the abdomen, signs of reduced blood flow to the lower limbs, and back pain is crucial for quick identification. Diagnostic imaging techniques like ultrasound and computed tomography angiography (CTA) play a role in confirming the diagnosis and assessing the risk involved. Properly managing hemodynamics by balancing resuscitation efforts with approaches is essential to control ongoing bleeding. Emergency vascular surgery options include aneurysm repair (EVAR) and open repair; the choice depends on factors like anatomy, stability of blood flow, and surgical expertise. Prioritizing optimization to address any health conditions and closely monitoring patients after surgery greatly contribute to overall success rates. A collaborative approach among healthcare professionals ensures a multidisciplinary strategy during the period emphasizing effective communication. This comprehensive approach aims for outcomes in dealing with challenging rAAAs while considering advancements in research and clinical practices.

Enhancing predictive accuracy of the cardiac risk score in open abdominal aortic surgery: the role of left ventricular wall motion abnormalities.

Open abdominal aortic surgery carries many potential complications, with cardiac adverse events being the most significant concern. The Vascular Study Group Cardiac Risk Index (VSG-CRI) is a commonly used tool for predicting severe cardiac complications and guiding clinical decision-making. However, despite the potential prognostic significance of left ventricular wall motion abnormalities (LVWMAs) and reduced LV ejection fraction (LVEF) for adverse outcomes, the VSG-CRI model has not accounted for them. Hence, the main objective of this study was to analyze the added value of LV wall motion on the discriminatory power of the modified VSG-CRI in predicting major postoperative cardiac complications. A prospective study was conducted involving 271 patients who underwent elective abdominal aortic surgery between 2019 and 2021. VSG-CRI scores were calculated, and preoperative transthoracic echocardiography was conducted for all patients. Subsequently, a modified version of the VSG-CRI, accounting for reduced LVEF and LVWMAs, was developed and incorporated into the dataset. The postoperative incidence of the composite endpoint of major adverse cardiac events (MACEs), including myocardial infarction, clinically relevant arrhythmias treated with medicaments or by cardioversion, or congestive heart failure, was assessed at discharge from the index hospitalization, with adjudicators blinded to events. The predictive accuracy of both the original and modified VSG-CRI was assessed using C-Statistics. In total, 61 patients (22.5%) experienced MACEs. Among these patients, a significantly higher proportion had preoperative LVWMAs compared to those without (62.3% vs. 32.9%, p < 0.001). Multivariable regression analysis revealed the VSG-CRI [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.21-1.77; p < 0.001] and LVWMA (OR 2.76; 95% CI 1.46-5.23; p = 0.002) as independent predictors of MACEs. Additionally, the modified VSG-CRI model demonstrated superior predictability compared to the baseline VSG-CRI model, suggesting an improved predictive performance for anticipating MACEs following abdominal aortic surgery [area under the curve (AUC) 0.74; 95% CI 0.68-0.81 vs. AUC 0.70; 95% CI 0.63-0.77; respectively]. The findings of this study suggest that incorporating preoperative echocardiography can enhance the predictive accuracy of the VSG-CRI for predicting MACEs after open abdominal aortic surgery. Before its implementation in clinical settings, external validation is necessary to confirm the generalizability of this newly developed predictive model across different populations.

Postoperative Myocardial Injury and Inflammatory Biomarkers in Patients Undergoing Vascular Surgery: A Subanalysis of the Platelet Reactivity and Postoperative Myocardial Injury after Major Vascular Surgery (PROMISE) Study

BackgroundPostoperative myocardial injury (PMI) is associated with morbidity and mortality, but the aetiology remains unclear. We studied whether PMI is associated with perioperative systemic inflammation. ObjectiveTo examine the relationship between inflammatory biomarkers (Interleukin 6[IL-6], C-reactive protein [CRP]) and PMI, detected by elevated cardiac troponin (cTn), in patients undergoing elective open abdominal aortic surgery. MethodsThis prospective, single-centre, observational, cohort study included 54 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. IL-6 and CRP were measured pre-operatively, directly after surgery, 24h and 48h post-operative. The primary outcome was cTn release assessed by a fifth generation high-sensitive cTn assay. Multivariable generalized linear regression models were used to evaluate the association between inflammatory biomarkers and cTn concentrations. ResultsFifteen patients (27.8%) developed PMI. IL-6 directly and 24h post-operatively was associated with elevated cTn concentrations (1.28 [1.07-1.54], p=0.009)) and 1.75 [1.18-2.59], p=0.006, respectively). Also, CRP directly and 24h post-operatively was associated with elevated cTn concentrations (1.25 [1.06-1.47], p=0.009)) and 1.61 [1.1-2.33], p=0.013, respectively). No association was found between IL-6 or CRP and cTn concentrations when measured at 48h post-surgery. ConclusionBiomarkers of inflammation are associated with elevated post-operative cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery.

Major vascular surgery is associated with ahigh perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment. The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of adedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of astepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30days. The secondary endpoint was acute renal failure and severe bleeding. In total, 77patients (mean age 68.1 ± 8.1years, 70% male) were included: 39underwent standard and 38underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups. Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

The incidence of cardiovascular and other major complications after open abdominal aortic surgery.

Abdominal aortic aneurysms (AAAs) and peripheral artery disease significantly increase the risk of perioperative complications. The study aimed to determine the incidence of myocardial injury after noncardiac surgery (MINS), its association with 30-day mortality, as well as predictors of postoperative acute kidney injury (pAKI) and bleeding independently associated with mortality (BIMS) in patients undergoing open vascular surgeries involving the abdominal aorta. We performed a retrospective cohort study using a sample of consecutive patients who underwent open abdominal aortic surgery due to infrarenal AAA and/or aortoiliac occlusive disease in a single tertiary center. In each patient, at least two postoperative troponin measurements were performed (on the first and second postoperative day). Creatinine and hemoglobin levels were measured preoperatively and at least twice postoperatively. The outcomes included MINS (primary outcome), pAKI, and BIMS (secondary outcomes). We assessed the associations between them and 30-day mortality and performed multivariable analysis to identify risk factors for these outcomes. The study group comprised 553 patients. The mean age was 67.6 years, and 82.5% of patients were male. The incidence of MINS, pAKI, and BIMS was 43.8%, 17.2%, and 45.8%, respectively. The 30-day mortality rate was higher in patients who developed MINS (12.0% vs. 2.3%; P <0.001), pAKI (32.6% vs. 1.1%; P <0.001), or BIMS (12.3% vs. 1.7%; P <0.001) compared to patients who did not develop these complications. This study demonstrated that MINS, pAKI, and BIMS are common complications after open aortic surgeries, and they are related to a substantial increase in the 30-day mortality rate.

Abdominal aortic aneurysm surgery with a modern method - is there anything to fear?

Background: Endovascular surgery for abdominal aortic aneurysms using a stent graft is the modern method of supplying these life-threatening lesions in large arterial vessels. In recent years, there have been significant improvements in the technique of performing these procedures, despite which complications are still common. In order to make progress in dealing with this problem, it is important to understand in which areas of the treatment strategy appropriate changes have not yet been implemented. Various clinical cases that describe post-operative complications of stent-graft surgery, types of post-operative complications and methods of dealing with the complication that has occurred should be analysed. And also other research papers relating to this topic. The first step is to deepen the knowledge of existing post-operative complications and the types of complications that can occur after stent-graft implantation into the abdominal aorta, as well as contemporary methods of treating complications that have already arisen.&#x0D; Aim of the study: The aim of this study is to present the incidence of complications after endovascular surgery for abdominal aortic aneurysms using a stent graft, the repair methods used when a complication occurs, the types of complications and their different kinds based on a review of the literature.&#x0D; Material and methods: A literature review was conducted in English-language databases, based on original articles and case reports, on post-operative complications of abdominal aortic stent-graft surgery, together with treatment methods and different types of complications arising from this procedure published between 2022 and 2023. Using the keywords: "abdominal aortic stent-graft" and "complications".

Debranching abdominal aortic hybrid surgery for aortic diseases involving the visceral arteries.

Aortic diseases involving branches of the visceral arteries mainly include thoracoabdominal aortic aneurysm (TAAA), aortic dissection (AD) and abdominal aortic aneurysm (AAA). The focus of treatment is to reconstruct the splanchnic arteries and restore blood supply to the organs. Commonly used methods include thoracoabdominal aortic replacement, thoracic endovascular aortic repair and hybrid approaches. Hybrid surgery for aortic disease involving the visceral arteries, consisting of visceral aortic debranching with retrograde revascularization of the celiac trunk and renal arteries and using stent grafts, has been previously described and may be considered particularly appealing in high-risk patients. This study retrospectively analyzed recorded data of patients and contrasted the outcomes with those of a similar group of patients who underwent conventional open repair surgery. Between 2019 and 2022, 72 patients (52 men) with an average age of 61.57 ± 8.66 years (range, 36-79 years) underwent one-stage debranching abdominal aortic hybrid surgery. These patients, the hybrid group, underwent preoperative Computed Tomographic Angiography (CTA) and had been diagnosed with aortic disease (aneurysm or dissection) involving the visceral arteries and were at high risk for open repair. The criteria used to define these patients as high-risk group who are in the need of hybrid treatment were American Society of Anesthesiologists (ASA) class 3 or 4. In all cases, we accomplished total visceral aortic debranching through a previous visceral artery retrograde revascularization with synthetic grafts (customized Y or four-bifurcated grafts), and aortic endovascular repair with one of two different commercially produced stent grafts (Medtronic® and Lifetech®). In some cases, we chose to connect the renal artery to the artificial vessel with a stent graft (Viabahn) and partly or totally anastomosed. We analyzed the results and compared the outcomes of the hybrid group with those of a similar group of 46 patients (36 men) with an average age 54.15 ± 12.12 years (range, 32-76). These 46 patients, the conventional open group, were selected for having had thoracoabdominal aortic replacement between 2019 and 2022. In the hybrid group, 72 visceral bypasses were completed, and endovascular repair was successful in all cases. No intraoperative deaths occurred. Perioperative mortality was 2.78%, and perioperative morbidity was 9.72% (renal insufficiency in 1, unilateral renal infarction in 5, Intestinal ischemia in 1). At 1-month postoperative CTA showed 2 endoleaks, one of which was intervened. At follow-up, there were unplanned reoperation rate of 4.29% and 5 (7.14%) deaths. The remaining patients' grafts were patent at postoperative CTA and no endoleak or stent graft migration had occurred. In the conventional open group, 1 died intraoperatively, 4 died perioperatively, perioperative mortality was 10.87% and complications were respiratory failure in 5, intestinal paralysis/necrosis in 4, renal insufficiency in 17, and paraplegia in 2. At follow-up, 5 (12.20%) patients presented with synthetic grafts hematoma 4 (9.76%) patient died, and 6 (14.63%) patients required unplanned reoperation intervention. Hybrid surgery is technically feasible in selected cases. For aortic diseases involving the visceral arteries, the application of hybrid abdominal aorta debranching can simplify the operation process, decrease the risks of mortality and morbidity in high-risk and high-age populations and decrease the incidence of various complications while achieving ideal early clinical efficacy. However, a larger series is required for valid statistical comparisons, and longer follow-ups are necessary to evaluate the long-term efficacy of hybrid surgery.

Effect of Remote Ischemic Preconditioning on Patient Survival and End Organ Injury During Elective Open Abdominal Aortic Surgery Repair: A Randomized Controlled Trial

Effect of Remote Ischemic Preconditioning on Patient Survival and End Organ Injury During Elective Open Abdominal Aortic Surgery Repair: A Randomized Controlled Trial

저강도 인터벌훈련이 복대동맥 치환술 후 발생한 전신쇠약 환자에게 미치는 영향

Purpose: This study aimed to examine the effects of low-intensity interval training on a patient unable to walk due to generalized weakness after surgery. Methods: A patient who underwent abdominal aortic replacement surgery was included in this study. Low-intensity interval training was performed with little difficulty for 24 days using an S-bar standing frame and a walking aid. Results: With low-intensity training, the patient’s muscle strength (lower extremity) increased from F− to F+. Aerobic ability improved, and the patient was able to walk more than 90 m using a walking aid in a state where walking was not possible. Furthermore, pulmonary edema and effusion improved. Conclusion: Low-intensity interval training is useful for patients with general weakness after abdominal aortic replacement surgery.

Identification of Perioperative Procedural and Hemodynamic Risk Factors for Developing Colonic Ischemia after Ruptured Infrarenal Abdominal Aortic Aneurysm Surgery: A Single-Centre Retrospective Cohort Study.

(1) Background: This retrospective study evaluated perioperative and intensive care unit (ICU) variables to predict colonic ischemia (CI) after infrarenal ruptured abdominal aortic aneurysm (RAAA) surgery. (2) Materials and Methods: We retrospectively analyzed the data of the patients treated for infrarenal RAAA from January 2011 to December 2020 in our hospital. (3) Results: A total of 135 (82% male) patients were admitted to ICU after treatment of infrarenal RAAA. The median age of all patients was 75 years (IQR 68-81 years). Of those, 24 (18%) patients developed CI, including 22 (92%) cases within the first three postoperative days. CI was found more often after open repair compared to endovascular treatment (22% vs. 5%, p = 0.021). Laboratory findings in the first seven PODs revealed statistically significant differences between CI and non-CI patients for serum lactate, minimum pH, serum bicarbonate, and platelet count. Norepinephrine (NE) was used in 92 (68%) patients during ICU stay. The highest daily dose of norepinephrine was administered to CI patients at POD1. Multivariable analysis revealed that NE > 64 µg/kg (RD 0.40, 95% CI: 0.25-0.55, p < 0.001), operating time ≥ 200 min (RD 0.18, 95% CI: 0.05-0.31, p = 0.042), and pH < 7.3 (RD 0.21, 95% CI: 0.07-0.35, p = 0.019), significantly predicted the development of CI. A total of 23 (17%) patients died during the hospital stay, including 8 (33%) patients from the CI group and 15 (7%) from the non-CI group (p = 0.032). (4) Conclusions: CI after RAAA is a sever complication occurring most frequently within the first 3 postoperative days. Our study identified many surrogate markers associated with colonic ischemia after aortic RAAA, including norepinephrine dose > 64 µg/kg, operating time ≥ 200 min, and PH < 7.3. Future studies are needed to support these results.

Low-volume surgeons can have better outcomes at certain hospital settings for open abdominal aortic repairs

ObjectiveThe volume-outcomes relationship is cross-cutting among open abdominal aortic operations, where higher-volume surgeons have better perioperative outcomes. However, there has been minimal focus on low-volume surgeons and how to improve their outcomes. This study sought to identify if there are any differences in outcomes among low-volume surgeons for open abdominal aortic surgeries by different hospital settings. MethodsWe used the 2012-2019 Vascular Quality Initiative registry to identify all patients who underwent open abdominal aortic surgery for aneurysmal or aorto-iliac occlusive disease by a low-volume surgeon (<7 operations annually). We categorized high-volume hospitals using three distinct definitions: those that performed ≥10 operations annually, those with at least one high-volume surgeon, and by the number of surgeons (1-2 surgeons, 3-4 surgeons, 5-7 surgeons, and 8+ surgeons). Outcomes included 30-day perioperative mortality, overall complications, and failure-to-rescue. We compared outcomes among low-volume surgeons using univariable and multivariable logistic regressions across each of these three hospital categorizations. ResultsAmong 14,110 patients who underwent open abdominal aortic surgery, 10,252 (7 3%) were performed by 1155 low-volume surgeons. Two-thirds of these patients (66%) underwent their surgery at a high-volume hospital, fewer than one-third (30%) at a hospital that had at least one high-volume surgeon, and one-half (49%) at hospitals with at least five surgeons. Among all patients operated on by low-volume surgeons, rates of 30-day mortality were 3.8%, perioperative complications were 35.3%, and failure-to-rescue were 9.9%. Low-volume surgeons operating at high-volume hospitals for aneurysmal disease had lower rates of perioperative death (adjusted odds ratio [aOR], 0.66; 95% confidence interval [CI], 0.48-0.90) and failure-to-rescue (aOR, 0.70; 95% CI, 0.50-0.98), but similar rates of complications (aOR, 1.06; 95% CI, 0.89-1.27). Similarly, patients undergoing their operation at hospitals that had at least one high-volume surgeon had lower rates of death (aOR, 0.71; 95% CI, 0.50-0.99) for aneurysmal disease. Patient outcomes among low-volume surgeons for aorto-iliac occlusive disease did not vary by hospital setting. ConclusionsThe majority of patients undergoing open abdominal aortic surgery have a low-volume surgeon, where outcomes are slightly better for those taking place at a high-volume hospital. Focused and incentivized interventions may be needed to improve outcomes among low-volume surgeons across all practice settings.

Time of the day negatively impacts immune cell myocardial recruitment and cardiac remodeling induced by abdominal aortic constriction in mice

Consequences of myocardial infarction are more severe when it occurred in the middle of the day (active phase) rather than in the resting phase; and patients operated in the afternoon displayed fewer cardiovascular events after cardiac surgery than patients operated in the morning, suggesting that circadian rhythm may affect cardiovascular events or cardiac remodeling. Interestingly, the immune system plays a critical role in the myocardial remodeling process, and the heart is submitted to circadian variations of immune cells amount. Our objective is to determine the impact of abdominal aortic constriction surgery (AAC) time of day on the severity of cardiac remodeling and the myocardial immune profile induced by the pressure overload in mice. We compared hearts of AAC (ligation 27G) mice operated in their resting phase, at Zeitgeber time 5 (ZT5 n = 6) and early active phase (ZT13 n = 8) with SHAM mice (ZT5 n = 7; ZT13 n = 7). Animal survival, heart weights, and cardiac immunophenotyping analyzed by flow cytometry were studied one week after AAC. Heart weights of AAC mice were increased 7 days after surgery (+20% at ZT5 and +40% at ZT13; P < 0.05 and P < 0.01 compared to SHAM groups respectively). Immune cell analysis showed a 1.7-fold increase in myocardial leukocyte infiltration in ZT13 vs. ZT5 AAC group (P < 0.05) with increased numbers of total, resident, and monocyte-derived macrophages. Myocardial infiltration of dendritic cells and granulocytes was also greater in AAC ZT13 mice compared with AAC ZT5 mice and SHAM groups. Finally, we showed higher mortality in AAC mice operated at ZT13 (vs. ZT5). Time of day when sustained cardiac pressure overload occurs affected cardiac remodeling one week after the onset of AAC; with more pronounced innate immune cells infiltration and hypertrophy of the myocardium at ZT13 (vs. ZT5). Further explorations are needed to determine the link between the increased number of immune cells and the more severe phenotype observed in the ZT13 group.

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block. Adult patients undergoing open abdominal aortic aneurysm repair and aortobifemoral or aortoiliac bypass for occlusive disease were identified and stratified by use of general anesthesia alone (GA) versus adjunctive use of a rectus sheath block (GA+RB). A small number of patients with GA and concomitant epidural analgesia, along with patients that had retroperitoneal repairs, were not included in further analysis. Outcomes included time to extubation, intraoperative and postoperative morphine milligram equivalents (MME) utilization, length of stay, discharge MME, and postoperative complications. Categorial data were compared with Person Chi-Square tests or Fisher's exact tests. Continuous data were tested with independent t-tests or Mann-Whitney U-tests. From January 2017 to April 2022, there were 106 patients who underwent open aortic surgery, 55 patients with GA alone, 39 with GA+RB, and 12 patients who had a GA with concomitant epidural analgesia. Between GA and GA+RB, patients were comparable in both groups in terms of age, BMI (body mass index), smoking history, hypertension, diabetes, CAD (coronary artery disease), COPD (chronic obstructive pulmonary disease), and ASA (American Society of Anesthesiologists) class and prior opioid use. Patients with GA+RB were more likely to have scheduled elective procedures (80% GA cohort vs. 94.9% RB, P=0.040), and a lower incidence of retroperitoneal exposure (14.5% GA cohort vs. 0% RB, P=0.019). Patients with GA+RB had shorter time to extubation than GA (84.6%<12hr vs. 44.4%, P<0.001), greater rate of procedural ketamine usage (GA+RB: 61.5% vs. GA: 40.0%, P=0.049), lower MME at first postoperative day (median MME GA+RB: 25.0 vs. GA: 67.5, P=0.002), lower discharge MME (median MME GA+RB: 142.5 vs. GA: 225.0, P=0.036), and overall shorter length of stay (median stay GA+RB: 5 vs. GA: 6days, P=0.006). Postoperative complications were similar between groups. Similar findings were found in the comparison between elective-only GA and GA+RB patients and after exclusion of patients who only had a single shot of regional anesthesia. Patients that receive adjunctive rectus sheath blocks for pain control following OAS utilize fewer opioid medications during hospital stay and at discharge. Rectus sheath blocks represent an alternative option to other periprocedural analgesia following open aortic surgery.

Impact of General Anaesthesia Versus Combined Epidural and General Anesthesia on Postoperative Complications and Mortality in Elective Abdominal Aortic Aneurysm Surgeries

Objective: To determine the impact of general anaesthesia versus combined epidural and general anaesthesia on postoperative complications in elective abdominal aortic aneurysm surgeries.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Jun 2018 to Sep 2020.&#x0D; Methodology: A total of 100 patients from both genders undergoing elective open abdominal aortic aneurysm surgery under general anaesthesia enrolled in the study after random distribution to drug and control groups in equal proportions. The primary determinants were postoperative complications. Additionally, it determined the impact on postoperative mortality rate. &#x0D; Results: Of 100 participants, 54% of patients were from ASA status II, and 46% were from ASA status III. Among postoperative complications, bowel ischemia was recorded in 16% and 2% among Group-A and Group-B, respectively (pvalue 0.01). Postoperative dialysis was required in 18% of patients in Group-A, whereas among Group-B, only 4%went through it (p-value 0.02). Pulmonary complications variation was not statistically different between the two groups, with 54% and 46% (p-value 0.42) frequencies in Group-A and Group-B, respectively. However, surgical reintervention within 30 days was notable, 36% in Group-A and 14% in Group-B (p-value 0.01).&#x0D; Conclusion: Combined general and epidural anaesthesia, when compared with general anaesthesia alone, significantly impacts the reduction of postoperative complications after elective open abdominal aortic aneurysm surgeries without increasing morbidity and mortality.

Pseudo-aneurysm of Distal Aortic Stump – A Manifestation of Aortoenteric Fistula

Background: Secondary aortoenteric fistula (AEF) is rare but devastating complication of abdominal aortic reconstruction surgery for aortic aneurysm. Most patients presented with acute upper gastrointestinal bleeding. CTA abdomen is usually performed to attain the diagnosis. However, AEF has invariable appearances on CT where mostly are non-specific and similar to perigraft infection (PGI). A case of secondary AEF following multiple series of aortic surgery, with CT manifestation of recurrent pseudo-aneurysm of aortic stump, is presented. Case Presentation: 65 years old man who had undergone series of aortic reconstructive surgery for infra-renal abdominal aortic aneurysm presented acutely for hematemesis and per rectal bleeding. Initial CTA abdomen revealed pseudoaneurysm of the distal aortic stump, which was successfully embolized with coils. However, the symptoms recurred and repeated CTA showed new pseudo-aneurysm but no typical findings of AEF. Emergency laparotomy confirmed AEF at duodenojejunal junction that was repaired with primary closure. Unfortunately, patient died 3 days later due to multiple post-operative complications. Conclusion: Presence of pseudo-aneurysm with background of perigraft infection should raise the suspicion of AEF, especially in patients with history of aortic intervention that presented with gastro-intestinal bleeding. CTA abdomen is invaluable in providing the diagnosis of AEF despite its variable manifestations.

25, 50 and 75 years ago

25, 50 and 75 years ago

Red blood cell transfusion-related eicosanoid profiles in intensive care patients-A prospective, observational feasibility study.

Introduction: Eicosanoids are bioactive lipids present in packed red blood cells (PRBCs), and might play a role in transfusion-related immunomodulation (TRIM). We tested the feasibility of analyzing eicosanoid profiles in PRBC supernatant and in plasma samples of postoperative intensive care unit (ICU) patients transfused with one unit of PRBCs. Methods: We conducted a prospective, observational feasibility study enrolling postoperative ICU patients: 1) patients treated with acetylsalicylic acid following abdominal aortic surgery (Aorta); 2) patients on immunosuppressants after bilateral lung transplantation (LuTx); and 3) patients undergoing other types of major surgery (Comparison). Abundances of arachidonic acid (AA) and seven pre-defined eicosanoids were assessed by liquid chromatography and tandem mass spectrometry. PRBC supernatant was sampled directly from the unit immediately prior to transfusion. Spearman's correlations between eicosanoid abundance in PRBCs and storage duration were assessed. Patient plasma was collected at 30-min intervals: Three times each before and after transfusion. To investigate temporal changes in eicosanoid abundances, we fitted linear mixed models. Results: Of 128 patients screened, 21 were included in the final analysis (Aorta n = 4, LuTx n = 8, Comparison n = 9). In total, 21 PRBC and 125 plasma samples were analyzed. Except for 20-hydroxyeicosatetraenoic acid (HETE), all analyzed eicosanoids were detectable in PRBCs, and their abundance positively correlated with storage duration of PRBCs. While 5-HETE, 12-HETE/8-HETE, 15-HETE, 20-HETE, and AA were detectable in virtually all plasma samples, 9-HETE and 11-HETE were detectable in only 57% and 23% of plasma samples, respectively. Conclusions: Recruitment of ICU patients into this transfusion study was challenging but feasible. Eicosanoid abundances increased in PRBC supernatants during storage. In plasma of ICU patients, eicosanoid abundances were ubiquitously detectable and showed limited fluctuations over time prior to transfusion. Taken together, larger clinical studies seem warranted and feasible to further investigate the role of PRBC-derived eicosanoids in TRIM.

Population pharmacokinetic-pharmacodynamic model of dexmedetomidine in elderly patients undergoing sedation after abdominal aortic surgery

Background. Dexmedetomidine (DEX) is a widely used sedative agent for treating post-surgery patients. It also acts on hemodynamic parameters like heart rate or cardiac output. This study aimed to develop a pharmacokinetic-pharmacodynamic (PK/PD) model of DEX using bispectral index (BIS) and cardiac output (CO) as a response. Methodology and results. 21 mechanically ventilated elderly cardiac patients undergoing abdominal aortic surgery were enrolled in the study. DEX was given to maintain moderate or deep sedation. Genotypes of ADR2A*55 were identified using real-time PCR-HRM. Data were analyzed using nonlinear mixed-effect modelling. A two-compartment model described DEX pharmacokinetics. The sigmoid Emax and linear models were used to describe BIS and CO measurements. The typical value of EC50 for DEX effects on BIS was 3.62 ng/ml, and the slope between CO and DEX concentrations was 0.819 (L/min)/(ng/ml). We were unable to show the effects of considered covariates on DEX pharmacodynamics. Conclusions. WE proposed the PK/PD model of DEX to understand better the BIS and CO changes observed after surgery. The measured CI values were in the reference range showing that the used doses of DEX ensured stable cardiac function in the studied patients.

Rectus Sheath Block Improves Patient Recovery Following Open Aortic Surgery

Postoperative pain management remains a barrier to recovery following aortic surgery. Although epidural catheters help in adjunctive pain management, less is known about the use of rectus sheath blocks. We compared patient recovery following open abdominal aortic surgery (OAS) with and without adjunctive rectus block.