Abdominal Aortic Surgery Research Articles

Procena kardijalnog rizika u elektivnoj otvorenoj reparaciji aneurizme abdominalne aorte

When indicated, patients with abdominal aortic aneurysm are referred for elective abdominal aortic surgery. Abdominal aortic aneurysm open repair is associated with a high risk for the development of cardiovascular morbidity and mortality. Cardiac risk assessment in abdominal aortic surgery includes evaluation of the likelihood of adverse cardiac events during surgery and/or in the postoperative period. Overall cardiac risk is assessed individually for the patient, taking into account the patient's general condition, cardiac function, patient functional capacity, comorbidity status, and vascular surgery risk. Cardiac morbidity and mortality are several times higher in emergency procedures than in elective abdominal aortic procedures, as well as in surgical procedures compared to endovascular procedures, especially in cases with suprarenal clamping of the aorta. Patients with ischemic heart disease and heart failure are at high risk for adverse cardiac events. Pathophysiologic mechanisms activated intraoperatively by aortic clamping and unclamping, hemodynamic fluctuations, blood loss, coagulopathy, and ischemia-reperfusion injury influence the potential development of perioperative infarction, heart failure, and cardiac arrest in high-risk patients. Assessment of perioperative cardiac function and cardiac risk using leading recommendations and scoring systems before surgery may change the approach to management of high-risk patients with multiple comorbidities and significantly reduce the incidence of perioperative morbidity and mortality.

Salivary cortisol as a biomarker of stress in surgical patients.

Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients. A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI - morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA - morphine patient-controlled analgesia) included patients who received morphine via the PCA system - intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes.

Endovascular surgery for complications after open surgery of abdominal aorta

Endovascular surgery for complications after open surgery of abdominal aorta

Myocardial and renal protective effects of Dexmedetomidine vs Magnesium sulphate in patients undergoing elective open abdominal aortic surgery

Myocardial and renal protective effects of Dexmedetomidine vs Magnesium sulphate in patients undergoing elective open abdominal aortic surgery

Racial disparities in presentation and outcomes for endovascular abdominal aortic aneurysm repair.

In the present study, we used a national database to identify racial differences in the presentation and outcomes for patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (EVAR) and identified areas for improving their care. We queried the EVAR-targeted National Surgical Quality Improvement Program database (2016-2019) to identify patients who had undergone EVAR for both ruptured and nonruptured AAAs. The patients were categorized according to race (White, Black, and Asian). Patients with a history of abdominal aortic surgery or an indication other than AAAs were excluded. The data was analyzed using the χ2 and Kruskal-Wallis tests, presented as frequencies and percentages or median and interquartile range (IQR) for categorical and continuous variables, respectively. We identified 3629 patients (16.6% female), including 3312 White (91.3%), 248 Black (6.8%), and 69 Asian (1.9%) patients. Black patients were more frequently women (27.0%) compared with White patients (15.9%) and were younger (median age, 71years; IQR, 64-77years) than White (median age, 73years; IQR, 67-79years) and Asian (median age, 76years; IQR, 67-81years) patients (P< .001 for both). The incidence of smoking, congestive heart failure, and dialysis dependency was highest for Black patients, and the incidence of obesity was lowest for Asian patients. The AAAs in Black patients extended more frequently beyond the aortic bifurcation (P= .047). In Asian patients, the internal iliac arteries were more involved (P= .040). For Black patients, 29.8% of the EVARs were performed in a nonelective setting compared with 20.2% for the White and 15.9% for the Asian patients (P< .001). The aneurysm diameter, nonruptured symptomatic rate, and rupture rate were similar across the groups (P= .807). The operative time was prolonged for Black (median, 128minutes; IQR, 96-177minutes) compared with White (median, 114minutes; IQR, 84-162minutes) patients (P< .001). Postoperatively, Black patients were more likely to require blood transfusion (16.5%) and had prolonged length of hospital stay (median, 2days; IQR, 1-4days) compared with White (10.0%; median, 1day; IQR, 1-3days) and Asian (4.3%; median, 1day; IQR, 1-3days) patients (P= .001 and P< .001, respectively). Black patients also had a higher 30-day readmission rate (P= .038). On multivariate analysis, Black race was an independent factor for length of stay >1day after both elective and nonelective EVAR and 30-day readmission for elective EVAR, but not 30-day mortality after elective and nonelective EVAR. In the present nationwide sample of EVAR cases, Black patients were more often women and younger. Despite similar rates of symptomatic and ruptured AAAs at presentation and 30-day mortality, Black patients more often presented and were treated during the same nonelective admission; they also had associated increased length of hospital stay and readmission. These findings signal a missed opportunity to diagnose, optimize, and treat this particular group of patients in an elective setting.

The effect of adding magnesium sulphate versus dexmedetomidine as an adjuvant to bupivacaine in ultrasound rectus sheath block on postoperative analgesia in patients undergoing abdominal aortic surgery

The effect of adding magnesium sulphate versus dexmedetomidine as an adjuvant to bupivacaine in ultrasound rectus sheath block on postoperative analgesia in patients undergoing abdominal aortic surgery

The effects of different doses of amantadine on lung tissue in lower extremity ischemia reperfusion injury in rats

Aim: Ischemia/reperfusion (I/R) injury is a common complication after abdominal aortic surgery. N-Methyl D-Aspartate (NMDA) antagonists protect many organs against to I/R injury. Therefore, in this study, we aimed to investigate the effects of 135 mg/kg and 90 mg/kg of amantadine, on lung tissue after lower extremity I/R injury in rats.&#x0D; Material and Methods: 36 wistar rats were randomly divided into 6 groups each containing six rats as follows; Sham group (Group S), Amantadine 90 group (Group A-90), Amantadine 135 group (Group A-135), Ischemia/Reperfusion group (Group I/R), Ischemia/Reperfusion + Amantadine 90 group (Group I/R-A 90), Ischemia/Reperfusion + Amantadine 135 group (Group I/R-A 135). At the end of procedure, all rats were sacrificed, and their lung tissues were obtained. Lung tissues were examined biochemical and histopathologically.&#x0D; Results: The lung tissue catalase, superoxide dismutase activities and malondialdehide levels were similar between the groups. Lung tissue neutrophil/lymphocyte infiltration score levels were higher in Group I/R than Group S, Group A-90 and Group A-135. Alveolar wall thickening score levels were higher in Group I/R than Group S, Group A-90, Group A-135 and Group I/R-A 135. &#x0D; Conclusion: Although we could not find a statistically significant difference between lung tissue biochemical values, we observed that lung tissue was histopathologically affected by I/R damage and the damage was less with amantadine use. In the reduction of I/R damage, 135 mg/kg administration of amantadine was more beneficial than 90 mg/kg.

The Ongoing Evolution of Abdominal Aortic Surgery

Abdominal aortic surgery has witnessed significant paradigm shifts in recent years with the introduction of structured screening programs, as well as the evolution of endovascular aortic aneurysm repair (EVAR), which has allowed physicians to promptly identify and successfully treat an increasing number of patients, even including those previously considered unfit for open repair [...].

Gas detection in the portal vein after aortobifemoral bypass: a case report

We present a case report of early surgical treatment of abdominal compartment syndrome after aortobifemoral bypass. A 73-year-old man was admitted to the I.I. Mechnikov North-Western State Medical University with critical lower limb ischemia. Aortobifemoral bypass with a synthetic prosthesis was performed via laparotomy. The postoperative period was complicated by the dynamic bowel obstruction. The patient's condition worsened (hypovolemic and septic shock, respiratory failure due to severe pneumonia). Initial tactics was conservative. Signs of bowel ischemia (pneumatosis of the intestinal wall, gas in the portal vein) were identified using “point of care” ultrasound, which led to a change in the treatment tactics. On the same day, decompression relaparotomy was performed and the intestinal decompression tube was inserted. The postoperative period proceeded with positive dynamics: early extubation with acceptable parameters of gas exchange, minimal dosages of vasopressor support. Bowel function improved and stool appeared on the 2nd day after surgery.Gas in the portal vein is an ultrasound phenomenon, which in 70 % of cases suggests necrosis of the intestinal wall. The detection of such a symptom in patients after the abdominal aorta surgery may indicate bowel ischemia, since mesenteric circulation disorders primarily develop in the inferior mesenteric artery. This condition requires urgent surgical intervention, but its differential diagnosis with postoperative paralytic ileus is not always possible, especially in the early stages. We demonstrate a case of early gas detection in the portal vein and the emergency intervention that allowed preventing irreversible ischemic damage of the bowel. “Point of care” ultrasound can help suspect this condition and determine the indications for early surgical intervention, which can positively influence the outcome. Received 19 April 2022. Revised 29 May 2022. Accepted 1 June 2022. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authors: The authors contributed equally to this article.

Kinetics of d-lactate and ischemia-modified albumin after abdominal aortic surgery and their ability to predict intestinal ischemia

ObjectivesAcute intestinal ischemia is a severe complication of abdominal aortic surgery that is difficult to diagnose early and therefore to treat adequately and timely. In this study the perioperative kinetics of d-lactate and ischemia-modified albumin (IMA) are described and the predictive value of these markers for the early diagnosis of acute intestinal ischemia is assessed. Design & methodsThis non-randomised, single-centre cohort study enrolled 50 patients with abdominal aortic aneurysm (AAA) and 30 patients with aortoiliac occlusive disease (AOID). Serum d-lactate and IMA were assessed pre-, intra-, and postoperatively at eight defined time points. ResultsThe highest serum d-lactate was at 6 h after complete declamping of the vascular graft. The highest predictive power of d-lactate was at 3 h after complete declamping (AUC 0.857). IMA was found to be higher in the AAA group in ischemic patients 10 min after complete declamping than in the AOID group. The highest predictive values of IMA were at 1 h after aortic cross-clamping (AUC 0.758) and 3 and 6 h after complete declamping (0.745 and 0.721, respectively). Moreover, the multivariate model with both markers at 3 h after complete declamping improved the detection of intestinal ischemia (AUC 0.894). ConclusionsSerum levels of IMA and d-lactate seem to be influential predictive markers for postoperative intestinal ischemia, especially after 3 h from complete declamping of vascular reconstruction.

RELIABILITY OF BIOREACTANCE AND PULSE POWER ANALYSIS IN MEASURING CARDIAC INDEX DURING OPEN ABDOMINAL AORTIC SURGERY

<h3>Objective</h3> Pulmonary artery catheter (PAC) is considered as the gold standard for measuring cardiac output, but less invasive monitors have recently been developed. We compared the accuracy, precision and trending ability of non-invasive bioreactance-based Starling SV and mini-invasive pulse power device LiDCOrapid to bolus thermodilution technique with pulmonary artery catheter (TDCO) when measuring cardiac index (CI) in the setting of open abdominal aortic surgery. <h3>Design and Methods</h3> Forty-one patients undergoing open abdominal aortic surgery were monitored with Starling SV, LiDCOrapid and TDCO during surgery, resulting in 627 simultaneous CI measurements. We used the Bland-Altman method and percentage error to investigate the agreement between the devices and four-quadrant plots with error grids to assess the trending ability. <h3>Results</h3> The agreement between TDCO and Starling SV was associated with a bias of 0.18 L/min/m2 (95% confidence interval, 95% CI 0.13 to 0.23), wide limits of agreement (LOA, -1.12 to 1.47 L/min/m2) and a percentage error (PE) of 63.7 (95% CI 52.4-71.0). (Figure 1a) The agreement between TDCO and LiDCOrapid was associated with a bias of -0.15 L/min/m2 (95% CI -0.21 to -0.09), wide LOA (-1.56 to 1.37) and PE of 68.7 (95% CI 54.9-79.6). (Figure 1b) Trending abilities were not acceptable, since with Starling SV only 33.6% and with LiDCOrapid only 41.2 % of the measurements changed in the same direction to the same extent as with TDCO. <h3>Conclusions</h3> CI measurements with Starling SV and LiDCOrapid were not interchangeable with TDCO, and their ability to track changes in CI was poor. These results do not support their use in monitoring CI reliably during open abdominal aortic surgery.

Capturing the complexity of open abdominal aortic surgery in the endovascular era.

Volume and quality benchmarks for open abdominal aortic surgery and particularly open aortic aneurysm repair (OAR) in the endovascular era are guided by the Society for Vascular Surgery guidelines, but the Vascular Quality Initiative (VQI) OAR module fails to capture the full spectrum of complex OAR. We hypothesized that VQI-ineligible complex OAR would be the dominant form of open repairs performed at a VQI-participating tertiary center. All OAR cases performed at a single tertiary care center from 2007 to 2020 were reviewed. The VQI OAR criteria were applied with exclusions (non-VQI) defined as concomitant renal bypass, clamping above the superior mesenteric artery or celiac artery, repairs performed for trauma, anastomotic aneurysm, isolated iliac aneurysm, or infected aneurysms. Linear regression was used to assess temporal trends. Among a total of 481 open abdominal aortic operations, 355 (74%) were OAR. The average annual OAR volume remained stable over 14years (25± 6; P= .46). Non-VQI OAR comprised 54% of all cases and persisted over time (R2=0.047, P= .46). Supraceliac clamping (35%) was often necessary. The proportion of endograft explantation cases significantly increased over time from 4% in 2007 to 20% in 2019 (P= .01). Infectious indications represented 20% (n= 70) of cases. Visceral branch grafts were performed in 16% of all cases. OAR for ruptured aneurysm constituted 10% of cases. Thirty-day mortality was significantly higher in non-VQI vs VQI-eligible OAR cases (10% vs 4%; P= .04). Complex OAR comprises a majority of OAR cases in a contemporary tertiary referral hospital, yet these cases are not accounted for in the VQI. Creation of a "complex OAR" VQI module would capture these cases in a quality-driven national registry and help to better inform benchmarks for volume and outcomes in aortic surgery.

Patient blood management using dedicated personnel in the operating room-you get what you pay for.

A patient blood management (PBM) strategy can be applied to the process of intraoperative cell salvage for re-infusion during surgery. Stoneham et al. describe an effective PBM strategy applied to abdominal aortic aneurysm repair and emphasise the importance of a qualified and experienced intraoperative cell salvage practitioner to improve the safety and effectiveness of the approach. Commentary on: Stoneham et al. Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss. Br J Haematol 2023;200:652-659.

Rescue therapy for symptomatic spinal cord ischemia after thoracic endovascular aortic repair

ObjectiveSpinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. MethodsOur institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. ResultsNine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. ConclusionsPermanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.

An overview of surgical site infection and prophylactic antibiotics in vascular surgery

Background: Vascular surgery is a complex procedure with many complications such as surgical site infections, graft infections, pneumonia, myocardial infarction, hemorrhage, and thromboembolism or thrombosis, in which, the most common complications are surgical site infection, and graft infection. Currently, antibiotic prophylaxis is considered the most effective practice to suppress surgical site infection in surgical procedures including vascular surgery. The aim of this paper is to review the surgical site infection and prophylactic antibiotics in vascular surgery.[1]&#x0D; Method: A search was made by using Medline, PubMed, Scopus and Web of Science databases, and databases of journals in Vietnam.&#x0D; Result: 1227 records were identified, of which 112 were included in this review. This included 90 researches, and 22 guidelines.&#x0D; Conclusion: In vascular surgery, antibiotic prophylaxis is recommended in most guidelines for abdominal aortic surgery, lower limb vascular surgery, vascular surgery with prosthetic grafts or stents. The common antibiotic regimens are 1st generation cephalosporins – C1G (cefazolin), 2nd generation cephalosporins – C2G (cefuroxim) administrated 60 minutes before incision, and discontinued within 24 hours of surgery.

Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss.

The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5(13)g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.

Cardiac stress testing prior to abdominal aortic surgery: Widely variable utilization, costly, and of unclear benefit

Cardiac stress testing prior to abdominal aortic surgery: Widely variable utilization, costly, and of unclear benefit

Postoperative myocardial injury and platelet reactivity in patients undergoing vascular surgery: The platelet reactivity and postoperative myocardial injury after major vascular surgery (PROMISE) study

BackgroundPostoperative myocardial injury (PMI) after major vascular surgery, detected by elevated cardiac troponin (cTn), has been associated with morbidity and mortality. It is unclear whether the pathophysiology of PMI is determined by increased platelet activity. ObjectiveTo examine the relationship between platelet activation (P-selectin expression) and PMI in patients undergoing elective open abdominal aortic surgery. MethodsThis prospective, single-centre, observational, cohort study included 33 patients undergoing elective open abdominal aortic surgery between March 2018 and April 2021. Patients were routinely treated with aspirin. Unstimulated platelet activation was measured by platelet bound P-selectin expression (range 0–100 %). Explorative coagulation measurements were: stimulated platelet aggregation measured with the VerifyNow® assay (aspirin cartridge), with the Multiplate® analyzer (ASPI, ADP and TRAP) and stimulated coagulation status evaluated by the TEG® Hemostasis Analyzer System (global hemostasis cartridge). The primary outcome was cTn release assessed by the fifth generation high-sensitive cTn assay. Multivariable generalized linear mixed models were used to evaluate the association between platelet function and cTn concentrations over time. ResultsTen patients (30.3 %) developed PMI. Increased P-selectin expression directly after surgery was associated with the cTn concentrations over 48 h (β = 1.39 (1.1–1.75), P = 0.0064). No association was found between P-selectin measured later after surgery (at 24 h or 48 h) and cTn concentrations. Furthermore, there was no association between the explorative coagulation parameters and cTn release. ConclusionPlatelet reactivity, assessed by P-selectin expression measured directly after surgery is associated with PMI, assessed by elevated cTn concentrations in the early postoperative period in patients undergoing elective open abdominal aortic surgery.

Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population.

Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.

Continuous Transversus Abdominis Plane Infusion via Surgically Inserted Catheter for Postoperative Analgesia After Abdominal Aortic Surgery by Retroperitoneal Approach: TAPCACAO Study

The purpose of our study was to evaluate the analgesic properties of continuous transversus abdominis plane (TAP) infusion with ropivacaine compared to placebo for postoperative analgesia in elective surgery of the abdominal aorta by retroperitoneal exposure. We conducted a prospective, single-center, randomized, double-blind study comparing a group of patients with a TAP catheter undoing ropivacaine infusion with a placebo group. Patients received a left retroperitoneal pararectal exposure for abdominal aortic surgery. A continuous infusion catheter was placed under visual control by the surgeon before closure and removed after 48hr. All patients had postoperative patient-controlled analgesia with morphine. The primary endpoint was morphine consumption during the first 24hr. The analysis included 25 patients in the placebo group and 24 in the ropivacaine group. The average morphine consumption during the first 24hr was significantly different, with 31±16mg in the ropivacaine group and 41±17mg in the placebo group (P=0.019). At 48hr, morphine consumption was still lower in the ropivacaine group (42±26mg) than in the placebo group (64±25mg) (P=0.003). The opioid narcotic-related side effects of opioid infusion (postoperative nausea and vomiting, constipation) and length of hospital stay were similar in both populations. Our study showed that continuous TAP block with ropivacaine via surgically inserted catheter significantly decreased morphine consumption at 24 and 48hr after elective abdominal aortic surgery by retroperitoneal exposure.