Major Vascular Surgery Research Articles

Safety and efficacy of tranexamic acid in major non-cardiac vascular surgery: a systematic review and meta-analysis

Background: Tranexamic acid (TXA) is a synthetic lysine analogue that inhibits fibrinolysis. The effectiveness of TXA in obstetrics, trauma and orthopaedic and cardiac surgery is well established. However, concerns regarding its prothrombotic potential remain, which is an important consideration for vascular surgery. We aimed to evaluate the safety and efficacy of TXA in adults undergoing major non-cardiac vascular surgery. Methods: A pre-specified protocol (PROSPERO CRD42023427282) was followed. Relevant databases (PubMed, MEDLINE, EMBASE) were searched for randomised controlled trials (RCTs). Data extraction and risk of bias assessments were performed in duplicate. A random effects model was used to synthesise data from RCTs. Measures of effect were reported as relative risk (RR) with 95% confidence intervals (CIs). The primary safety outcome was a composite of arterial and venous thromboembolic events (composite of myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis and symptomatic proximal venous thromboembolism). Certainty of evidence was assessed using the GRADE approach. Results: After screening 1989 records, three RCTs were included, cumulatively enrolling 1,560 participants. In all trials, patients received either TXA (intravenously or orally) compared with placebo. There was no evidence of the effect of intravenous TXA on thromboembolic events (RR 1.10, 95% CI 0.89 to 1.36, two RCTs, 1460 participants, low certainty of evidence) or on critical bleeding (composite of life-threatening, critical and major organ bleed) (RR 0.85, 95% CI 0.65 to 1.11, two RCTs, 1460 participants, low certainty of evidence). TXA may reduce postoperative blood loss, especially at 0–4 hours (Cliff’s delta −0.41, 95% CI −0.19 to −0.59) and 0–24 hours (Cliff’s delta −0.37, 95% CI −0.14 to −0.55) after surgery. There was no evidence of an effect of TXA on reducing perioperative red blood cell (RBC) transfusion requirements (RR 0.66, 95% CI 0.11 to 3.95, one RCT, 100 participants). One RCT assessed oral TXA and found no evidence of an effect on type II endoleak post endovascular aneurysm repair. No thrombotic complications were reported in this RCT during the study period. Conclusions: We found no evidence of an effect of TXA on thromboembolic complications. While TXA appears to reduce early postoperative bleeding, the clinical relevance of this is uncertain. Due to limitations of study design and the variety of vascular procedures, the role of TXA in vascular surgery is still unclear. Ongoing trials may reduce this uncertainty. Registration: Prospectively registered on PROSPERO (CRD42023427282)

Veliki neželjeni kardiovaskularni događaji kod vaskularnih hirurških pacijenata sa perifernom arterijskom bolešću

Introduction: Major adverse cardiac events (MACE) are the primary cause of morbidity and mortality in patients undergoing vascular surgical procedures. This is why it is essential to understand the relationship between coronary artery disease and peripheral arterial disease. In this paper, we aimed to determine predictors and risk factors related to the occurrence of MACE in patients undergoing vascular surgery for peripheral arterial disease. Material and Methods: This is a retrospective study of 310 in-hospital patients treated at a high-volume vascular centre. The outcome was classified through the three-point MACE (myocardial infarction, stroke and cardiovascular mortality). Results: We found that the majority of initial MACE happened in patients with aortobifemoral bypass surgery compared to other types of reconstruction (p=0.009). No significant correlation was established between the procedures performed and the short-term primary outcome. In the initial period, MACE was detected in 14 (5.8%) patients. Among them, six (1.9%) experienced a myocardial infarction (MI), three (1%) had a stroke, and five (1.6%) died within the first 30 days. All deaths were linked to cardiac ischemia, which ultimately culminated in cardiogenic shock and subsequent death. Short term MACE was observed in 2 (0.6%) patients both of whom had an MI. Conclusion: Major vascular surgery in patients with coronary artery disease is a highly morbid procedure and perioperative MACE places them at a significantly high risk of mortality. Early detection of coronary heart disease and preoperative optimization can play a major role in reducing the risk of MACE.

Prognostic value of simple frailty and malnutrition screening tools for determining surgical risk in patients with chronic limb threatening ischaemia undergoing major vascular surgery: a retrospective cross-sectional study

Abstract Background: This study aims to explore the prognostic value of simple frailty and malnutrition tools for determining postoperative outcomes at 30 days and one year in patients with chronic limb threatening ischaemia (CLTI) undergoing major surgery. Methods: This was a single-centre retrospective observational cross-sectional study in a tertiary UK Vascular Centre. We applied the Derby Frailty Index (DFI), the Acute Frailty Network Criteria (AFNC), the Prognostic Nutritional Index (PNI) and the Geriatric Nutritional Risk Index (GNRI) to routinely collect clinical audit data recorded from a combination of medical and nursing notes, blood test results and discharge letters. Results: We included 73 patients who had undergone amputation (mean age 69 (range 57–77) years; 71% male; mean body mass index (BMI) 27 (range 23–31) kg/m2) and 66 patients who had undergone bypass surgery (mean age 73 (range 64–81) years; 70% male; BMI 26 (22–30) kg/m2). The 30-day mortality rate of a frail patient (DFI and AFNC, respectively) was 21% (n=8/39) and 23% (n=6/26) compared with 7% (n=7/100) for non-frail patients. Frailty was associated with 30-day (DFI: odds ratio (OR) 3.4 (95% CI 1.2 to 10.2), p=0.027; AFNC: OR 3.4 (95% CI 1.1 to 10.7), p=0.034) and one-year (DFI: OR 7.95 (95% CI 3.4 to 18.6), p<0.001; AFNC: OR 5.9 (95% CI 2.4 to 14.7), p<0.001) mortality. Frailty, according to the AFNC, was also associated with an increased risk of re-admission. Neither of the malnutrition screening tools was associated with 30-day or one-year mortality (p>0.05). Conclusions: Our analysis confirms that both the DFI and AFNC tools identify patients with CLTI who are at the greatest risk of poor outcomes following major surgery. Frailty warrants further investigation and should be part of the consent and joint decision-making process in this patient population, to personalise care and minimise the risk of poorer outcomes.

Rotational Thromboelastometry: Enhancing Hemostasis Monitoring in Anesthesia

Rotational thromboelastometry (ROTEM) is a viscoelastic point-of-care coagulation test that measures the dynamics of clot formation and lysis in whole blood samples. A cylindrical shaft that oscillates while passing through a tiny amount of blood is used in the procedure. Blood exerts increasing pressure on the shaft as it thickens into a clot. We can track the strength of the forming clot over time by measuring this resistance. ROTEM® can provide valuable information about the coagulation status of patients who are at risk of bleeding or thrombosis in various peri-operative settings, such as trauma, obstetrics, cardiac surgery, liver transplantation, and major orthopedic and vascular surgeries. In addition, it can aid in the diagnosis and treatment of peri-operative coagulopathy, reduce unneeded transfusions, and enhance patient outcomes.

Safety of intranasal insulin administration in patients undergoing cardiovascular surgery: An open-label, nonrandomized, dose-escalation study

ObjectiveThis study aimed to determine the maximum safe dose of intranasal insulin administration during cardiac surgery. MethodsThis open-label, Phase 1, single-center, dose-escalation clinical trial recruited patients scheduled to undergo elective cardiac surgery or major vascular surgery requiring cardiopulmonary bypass between February and September 2021. They were grouped into 5 dose-escalation cohorts and administered 0, 40, 80, 160, and 240 IU insulin (n = 6 in each group) via a metered nasal dispenser after the induction of general anesthesia. Blood samples were collected at 10-minute intervals for the first 60 minutes and at 30-minute intervals thereafter. Hypoglycemia was defined as a blood glucose level <70 mg/dL. Patient recruitment was terminated after hypoglycemia was observed in 2 patients in any of the groups. ResultsIn total, 27 of 29 enrolled patients were administered intranasal insulin or saline. Hypoglycemia was not observed after the administration of intranasal insulin in the 0, 40, 80, or 160 IU groups; however, it was observed in 2 of 3 patients in the 240 IU group. The serum insulin concentration was elevated in the 160-IU group, but the C-peptide concentration was not elevated in any of the groups. ConclusionsThe administration of up to 160 IU intranasal insulin did not induce clinically significant hypoglycemia. However, 160 IU intranasal insulin should be administered cautiously because insulin can enter the systemic circulation in a dose-dependent manner.

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.

Association Between Complications after Vascular Surgery and Prolonged Postoperative Opioid Use

Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery. This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or non-ruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013-2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation (GEE) approach to account for the clustering of patients within physicians and institutions. This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an OR of 13.27 (95%CI10.63-16.57) for AAA, 11.24 (95%CI 9.18-13.75) for EVAR, and 4.69 (95%CI 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI:1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94). Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open lower extremity revascularization. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing lower extremity revascularization. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.

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.

Relationship between risk stratification scores and sublingual microcirculatory monitoring in major vascular surgery patients: preliminary results

Relationship between risk stratification scores and sublingual microcirculatory monitoring in major vascular surgery patients: preliminary results

Risk Prediction Models for Peri-Operative Mortality in Patients Undergoing Major Vascular Surgery with Particular Focus on Ruptured Abdominal Aortic Aneurysms: A Scoping Review.

The present scoping review aims to describe and analyze available clinical data on the most commonly reported risk prediction indices in vascular surgery for perioperative mortality, with a particular focus on ruptured abdominal aortic aneurysm (rAAA). A scoping review following the PRISMA Protocols Extension for Scoping Reviews was performed. Available full-text studies published in English in PubMed, Cochrane and EMBASE databases (last queried, 30 March 2023) were systematically reviewed and analyzed. The Population, Intervention, Comparison, Outcome (PICO) framework used to construct the search strings was the following: in patients with aortic pathologies, in particular rAAA (population), undergoing open or endovascular surgery (intervention), what different risk prediction models exist (comparison), and how well do they predict post-operative mortality (outcomes)? The literature search and screening of all relevant abstracts revealed a total of 56 studies in the final qualitative synthesis. The main findings of the scoping review, grouped by the risk score that was investigated in the original studies, were synthetized without performing any formal meta-analysis. A total of nine risk scores for major vascular surgery or elective AAA, and 10 scores focusing on rAAA, were identified. Whilst there were several validation studies suggesting that most risk scores performed adequately in the setting of rAAA, none reached 100% accuracy. The Glasgow aneurysm score, ERAS and Vancouver score risk scores were more frequently included in validation studies and were more often used in secondary studies. Unfortunately, the published literature presents a heterogenicity of results in the validation studies comparing the different risk scores. To date, no risk score has been endorsed by any of the vascular surgery societies. The use of risk scores in any complex surgery can have multiple advantages, especially when dealing with emergent cases, since they can inform perioperative decision making, patient and family discussions, and post hoc case-mix adjustments. Although a variety of different rAAA risk prediction tools have been published to date, none are superior to others based on this review. The heterogeneity of the variables used in the different scores impairs comparative analysis which represents a major limitation to understanding which risk score may be the "best" in contemporary practice. Future developments in artificial intelligence may further assist surgical decision making in predicting post-operative adverse events.

A case of sigmoid colon perforation due to segmental absence of intestinal musculature (SAIM) accompanied by vascular Ehlers–Danlos syndrome: a case report

BackgroundSegmental absence of intestinal musculature (SAIM) is a partial defect of the intrinsic muscular layer of the intestinal tract. In this report, we describe a case of perforation of the sigmoid colon due to SAIM accompanied by vascular Ehlers–Danlos syndrome (vEDS), which was successfully treated by surgical therapy.Case presentationA male in his 30 s was being followed up for vEDS diagnosed by genetic testing. He had undergone two major vascular surgeries, abdominal aortic artery revascularization and thoracic endovascular aortic repair for a residual dissection and enlarging abdominal aortic aneurysm. On postoperative day 11, the patient developed perforation of the sigmoid colon for which intraperitoneal lavage and drainage, Hartmann surgery, and transverse colostomy were performed. Histological findings showed no disturbance of blood flow or diverticulum but did show a defect in the intrinsic muscular layer around the perforation site, leading to the pathological diagnosis of SAIM and associated perforation of the sigmoid colon. Postoperatively, the patient had no complications and was discharged on postoperative day 18. The patient is being followed as an outpatient and has experienced no relapse.ConclusionsBoth SAIM and vEDS, which may be related diseases, are associated with the presence of tissue fragility and have a high potential to cause intestinal perforation Caution should be exercised during surveillance in patients with constipation and examinations that cause increased intestinal pressure.

Remote ischemic preconditioning does not provoke metabolomic alterations in patients undergoing major vascular surgery: A randomized controlled trial

Remote ischemic preconditioning does not provoke metabolomic alterations in patients undergoing major vascular surgery: A randomized controlled trial

Analysis of Risk Factors and Intervention Strategies for Acute Kidney Injury After Cardiac Valve Replacement.

To investigate the risk factors and intervention strategies for the development of acute kidney injury (AKI) after cardiac valve replacement with extracorporeal circulation. Retrospective analysis of the clinical data of a total of 106 patients diagnosed with heart valve disease and undergoing extracorporeal circulation heart valve replacement surgery from January 2021 to December 2021 in the Department of Cardiac and Major Vascular Surgery of our hospital. The two groups were divided into AKI and non-AKI groups according to whether acute kidney injury occurred after surgery, and the preoperative, intraoperative and postoperative clinical data were compared. Single-factor analysis and multi-factor logistic regression analysis were used to explore the risk factors for acute kidney injury after extracorporeal heart valve replacement, and to improve the prognosis by giving kidney function protection strategies as early as possible. Univariate analysis showed that age, preoperative blood creatinine >130umol/L, LVEF <45%, presence of subacute infective endocarditis (SIE), concurrent coronary artery bypass grafting (CABG), time to extracorporeal circulation, time to surgery, MAP <70mmHg, urine output <0.5mL/(kg-h), pulmonary infection, low cardiac output, and bacteraemia were risk factors for postoperative AKI. Multi-factor regression analysis showed that preoperative blood creatinine >130umol/l, LVEF <45%, combined infective endocarditis, extracorporeal circulation time >2h, intraoperative and postoperative hypotension, low cardiac output, and postoperative bacteremia were independent risk factors for postoperative AKI. Active intervention strategies in the perioperative period can reduce the occurrence of postoperative AKI and improve patient prognosis.

Persistent Acute Kidney Injury is Associated with Poor Outcomes and Increased Hospital Cost in Vascular Surgery

Postoperative acute kidney injury (AKI) is common after major surgery and is associated with increased morbidity, mortality, and cost. Additionally, there are recent studies demonstrating that time to renal recovery may have a substantial impact on clinical outcomes. We hypothesized that patients with delayed renal recovery after major vascular surgery will have increased complications, mortality, and hospital cost. A single-center retrospective cohort of patients undergoing nonemergent major vascular surgery between 6/1/2014 and 10/1/2020 was analyzed. Development of postoperative AKI (defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria: >50% or>0.3mg/dl absolute increase in serum creatinine relative to reference after surgery and before discharge) was evaluated. Patients were divided into 3 groups: no AKI, rapidly reversed AKI (<48hours), and persistent AKI (≥48hours). Multivariable generalized linear models were used to evaluate the association between AKI groups and postoperative complications, 90-day mortality, and hospital cost. A total of 1,881 patients undergoing 1,980 vascular procedures were included. Thirty five percent of patients developed postoperative AKI. Patients with persistent AKI had longer intensive care unit and hospital stays, as well as more mechanical ventilation days. In multivariable logistic regression analysis, persistent AKI was a major predictor of 90-day mortality (odds ratio 4.1, 95% confidence interval 2.4-7.1). Adjusted average cost was higher for patients with any type of AKI. The incremental cost of having any AKI ranged from $3,700 to $9,100, even after adjustment for comorbidities and other postoperative complications. The adjusted average cost for patients stratified by type of AKI was higher among patients with persistent AKI compared to those with no or rapidly reversed AKI. Persistent AKI after vascular surgery is associated with increased complications, mortality, and cost. Strategies to prevent and aggressively treat AKI, specifically persistent AKI, in the perioperative setting are imperative to optimize care for this population.

How does remote ischemic preconditioning (RIPC) compare with no RIPC for adults undergoing major vascular surgery?

How does remote ischemic preconditioning (RIPC) compare with no RIPC for adults undergoing major vascular surgery?

Bilateral renal artery stenosis impacts postoperative complications after major vascular surgery

BackgroundIncidental atherosclerotic renal artery stenosis (RAS) is common in patients undergoing vascular surgery and has been shown to be associated with postoperative AKI among patients undergoing major non-vascular surgeries. We hypothesized that patients with RAS undergoing major vascular procedures would have a higher incidence of AKI and postoperative complications than those without RAS. MethodsA single-center retrospective cohort study of 200 patients who underwent elective open aortic or visceral bypass surgery (100 with postoperative AKI; 100 without AKI) were identified. RAS was then evaluated by review of pre-surgery CTAs with readers blinded to AKI status. RAS was defined as ≥50 % stenosis. Univariate and multivariable logistic regression was used to assess association of unilateral and bilateral RAS with postoperative outcomes. Results17.4 % (n = 28) of patients had unilateral RAS while 6.2 % (n = 10) of patients had bilateral RAS. Patients with bilateral RAS had similar preadmission creatinine and GFR as compared to unilateral RAS or no RAS. 100 % (n = 10) of patients with bilateral RAS had postoperative AKI compared with 45 % (n = 68) of patients with unilateral or no RAS (p < 0.05). In adjusted logistic regression models, bilateral RAS predicted severe AKI (OR 5.82; CI 1.33, 25.53; p = 0.02), in-hospital mortality (OR 5.71; CI 1.03, 31.53; p = 0.05), 30-day mortality (OR 10.56; CI 2.03, 54.05; p = 0.005) and 90-day mortality (OR 6.88; CI 1.40, 33.87; p = 0.02). ConclusionsBilateral RAS is associated with increased incidence of AKI as well as in-hospital, 30-day, and 90-day mortality suggesting it is a marker of poor outcomes and should be considered in preoperative risk stratification.

Completeness of Reporting in Systematic Reviews and Meta-analyses in Vascular Surgery

Systematic reviews and meta-analyses (SRMAs) are essential in informing clinical guidelines and decision-making. Complete reporting of SRMAs through compliance to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines promotes transparency, reproducibility, and consistency across the literature. The purpose of this meta-epidemiological study is to assess the completeness of reporting of SRMAs in vascular surgery. MEDLINE and Embase were used to search through four major vascular surgery journals and four high-impact general medical journals (Table I) for SRMAs published between 2018 and October 2022, evaluating clinical treatments for any pathology treated by a vascular surgeon. Data screening and extraction were conducted in duplicate. The reporting completeness of each included SRMA was measured with reference to the 27-item PRISMA checklist. All 27 items were evaluated, and an SRMA scored 1 for the item if it was fully reported, or 0 otherwise, such that the maximum achievable “PRISMA score” was 27. The principal summary measure was the mean PRISMA score of all included SRMAs. Secondary analyses were performed to determine whether PRISMA compliance varied by publication year, funding status, or prospective registration. Overall, 1653 articles were captured in the initial search with 162 SRMAs included in the final analysis. SRMAs were most commonly published in the Journal of Vascular Surgery (46.3%, Table I). All SRMAs had more than one incomplete PRISMA item. The mean PRISMA score was 21.2 (standard deviation: 2.9, 78.5% compliance). The items reported least frequently were a complete structured summary (1.2%), protocol/registration information (25.9%), a replicable search strategy (42.6%), a method for assessing risk of bias across studies, and corresponding results (57.4% and 50.0%, respectively, Table II). There were no differences in reporting completeness over the study period (P = .067). However, prospective registration and funding were associated with improved PRISMA scores (22.9 vs 20.6, P < .001; 22.2 vs 20.9, P = .032, respectively). Overall, the reporting of SRMAs in vascular surgery is less than ideal, with several key items being consistently under-reported. Prospective registration and funding are positively associated with improved reporting. Authors, reviewers, and journal editors should consider these findings moving forward to encourage completeness of SRMA reporting. Raising awareness surrounding the value of complete reporting of SRMAs can aid in enhancing the quality of evidence in vascular surgery SRMAs moving forward.Table ICharacteristics of SRMAs and mean PRISMA scoresCategoryNumber of SRMAs, nMean PRISMA score (SD)Year 20182721.9 (2.0) 20193420.5 (3.8) 20203620.9 (2.9) 20213020.6 (3.0) 20223522.1 (2.3)Publishing journal AVS3120.0 (3.3) EJVES3821.7 (3.2) JVS7521.1 (2.6) VES620.3 (1.0) BMJ625.2 (1.0) JAMA621.3 (2.6)Disease state AAA3621.8 (2.3) CAS1319.8 (3.7) CVI1120.5 (2.6) Dialysis access1419.9 (2.9) PAD3421.6 (2.9) tAAA921.4 (2.3) TBAD421.0 (3.6) VTE1121.4 (3.6) Multiple1522.7 (2.3) Other1519.7 (3.2)Funding status Funded3322.2 (2.9)a Nonfunded12920.9 (2.9)Registered protocol Yes4222.9 (2.7)a No12020.6 (2.8)AAA, Abdominal aortic aneurysm; AVS, Annals of Vascular Surgery; BMJ, British Medical Journal; CAS, crotid artery stenosis; CVI, chronic venous insufficiency; EJVES, European Journal of Vascular and Endovascular Surgery; JAMA, Journal of the American Medical Association; JVS, Journal of Vascular Surgery; PAD, peripheral arterial disease; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SRMA, systematic review and meta-analyses; tAAA: thoracoabdominal aortic aneurysm; TBAD, type B aortic dissection; VES, Vascular and Endovascular Surgery; VTE, venous thromboembolism.aP < .05. Open table in a new tab Table IIPRISMA statement compliance per section and itemPRISMA sectionTotal compliance, %PRISMA itemArticles where item fully reported, No. (%)Title96Title155 (96)Abstract1Structured summary2 (1)Introduction72Rationale161 (99)Objectives72 (44)Methods75Protocol and registration42 (26)Eligibility criteria143 (88)Information sources162 (100)Search69 (43)Study selection126 (78)Data collection process140 (86)Data items134 (83)Risk of bias in individual studies151 (93)Summary measures151 (93)Synthesis of results150 (93)Risk of bias across studies93 (57)Additional analyses104 (64)Results85Study selection159 (98)Study characteristics157 (97)Risk of bias within studies144 (89)Results of individual studies158 (98)Synthesis of results156 (96)Risk of bias across studies81 (50)Additional analyses104 (64)Discussion96Summary of evidence161 (99)Limitations149 (92)Conclusions158 (98)Funding90Funding146 (90)PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SRMA, systematic review and meta-analyses.Total compliance calculated as the total number of completely reported items in this category divided by the total number of items in this category, across all SRMAs. 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Value of Routine Troponin Measurement in Open Abdominal Aortic Aneurysm Repair

Cardiovascular complications are a major cause of morbidity and mortality in the postoperative period after major vascular surgery. Depending on the study population, up to 25% of patients have troponin elevation after noncardiac surgery, yet many do not meet the diagnosis of myocardial infarction (MI). Although outcomes of routine troponin elevation in patients undergoing mixed major vascular surgery have been evaluated, this has not been studied exclusively in elective, open abdominal aortic aneurysm repair (oAAA), especially regarding perioperative and overall mortality. We conducted a single-center, retrospective review of routine troponin surveillance for consecutive, oAAA from 2014 to 2019. A total of 319 patients were identified and analyzed for management patterns and interventions. The cohort was stratified into groups for comparison based on those in whom troponin was routinely checked (RC) as part of a care strategy during the study period, not routinely checked (NRC), elevated troponin (ET) >0.001ng/mL, and not elevated. The median follow-up was 21.5±23.8months. Groups were compared on demographic data, cardiac comorbidities, 30-day and 3-year outcomes for MI and death using two-sample t-tests, Wilcoxon rank sum tests, Pearson chi-square tests, and Fisher exact tests when appropriate. Troponin was measured in 83.7% (267/319) of patients who underwent elective oAAA repair. Routine troponin checks were obtained in 79.9% (255/319) of patients. ET was identified in 16.5% of those with RC (42/255) and 4.7% of those with NRC (3/64). Of patients with ET, 37.8% (17/45) had a cardiology consultation, 4.4% (2/45) had a percutaneous coronary intervention (PCI), and 4.4% (2/45) had another cardiac intervention. All 4 patients undergoing PCI or other cardiac intervention had received routine troponin checks. Patients with ET were older (71.2 vs. 68.6; P=0.04), more likely to receive intraoperative blood products (P=0.003), had longer operative times (P=0.011), higher length of stay (9 vs. 7days; P<0.01), and higher 30-day MI rate (3 vs. 0; P=0.04). They had neither longer aortic clamp times nor worse preoperative cardiac function, and the proximal clamp position during oAAA repair did not impact troponin detection. Additionally, 3-year overall mortality was increased in patients who had ET but there was not a significant difference in 3-year mortality between groups receiving routine troponin checks versus not. ET, identified after elective oAAA repair, was associated with a higher risk of 30-day MI and lower overall survival. However, it was not demonstrated that routine assessment of troponin levels postoperatively leads to decreased 3-year mortality in this setting.

Determination of skill and knowledge requirements of an instrument nurse working in major vascular surgery for the development of a virtual reality training tool

BackgroundAn open abdominal aortic aneurysm (AAA) repair is a complex high-risk procedure, with limited opportunities for an instrument nurse to gain experience and develop the necessary skills to assist the surgeon in caring for the patient during surgery. The aim of the study was to inform the content for a virtual reality (VR) training tool to develop the skills of an instrument nurse when working in major vascular surgery. MethodsAn exploratory, descriptive qualitative design using focus groups and semistructured interviews was selected for this study to explore and understand the perceptions of consultant vascular surgeons and expert vascular instrument nurses about the skills required by an instrument nurse when caring for a patient undergoing major vascular surgery. Expert vascular instrument nurses (n = 9) and consultant vascular surgeon (n = 4) were recruited via the Australian College of Perioperative Nurses (ACORN) and the Australian and New Zealand Society for Vascular Surgery (ANZSVS), respectively. ResultsData were analyzed using thematic analysis (Braun & Clarke, 2012). Four themes emerged from the data analysis. These were: preparation for surgery, essential psychomotor skills, nontechnical skills, and the virtual reality training tool design and content. ConclusionExpert vascular instrument nurses and consultant vascular surgeons provided a detailed compilation of the knowledge and skills required by an instrument nurse which will inform the content and design of the proposed virtual reality training tool. Whilst this study is based on open AAA repair, it also provides a valuable insight into what surgeons and nurses consider important for an instrument nurse when assisting with a surgical procedure.

For people undergoing major vascular surgery, does tranexamic acid or fibrin sealant reduce bleeding and need for blood transfusions?

For people undergoing major vascular surgery, does tranexamic acid or fibrin sealant reduce bleeding and need for blood transfusions?