Open Abdominal Aortic Surgery Research Articles

Open Abdominal Aortic Surgery in the Endovascular Era - Will We Have Enough Volume for Vascular Trainees?

Prior analysis in the previous decade predicted a shortfall in open abdominal aortic repair (OAR) experience for vascular trainees resulting from the rapid adoption of endovascular aortic repair (EVAR). We therefore sought to explore how EVAR has transformed contemporary open aortic surgical education.

Low-Volume Surgeons Performing Open Abdominal Aortic Surgery Have Similar Outcomes Independent of Hospital Volume

As the number of open abdominal aortic surgeries has decreased in the past few decades, the volume–outcomes relationship for these operations has become more pronounced, at both the surgeon and the hospital level. We evaluated whether lower volume surgeons have better outcomes when operating at higher volume hospitals for open aortic surgery.

Extended intensive care correlates with worsening of surgical outcome after elective abdominal aortic reconstruction

The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment. The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival. Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, P=0.0498; OR 4.42 [0.94-20.84]) and the rate of acute kidney injury (82.5% vs. 57.1%, P=0.0352; OR 3.55 [1.20-0.46]) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, P=0.0281; OR 0.27 [0.09-0.84]) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (P=0.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a Body Mass Index (BMI) of <25, chronic renal insufficiency, and coronary artery disease. Endovascular therapy was a positive predictive factor of short ICU stay of ≤3 days. The outcome after extended intensive care following elective aortic surgery is strongly dependent on the length of ICU stay.

One-year patient survival correlates with surgeon volume after elective open abdominal aortic surgery

ObjectiveVolume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons. MethodsWe evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models. ResultsIn 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001). ConclusionsThese data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.

Development of a pulsatile cadaver-based simulation for training of open abdominal vascular surgery skills

ObjectiveDeveloping competence in open aortic surgery is increasingly challenging in vascular surgery training programs. Although static cadaver models provide an opportunity for dissection and exposure, the lack of pulsatility limits further education in managing blood vessels. We developed an affordable pulsatile cadaver simulation model to improve training in open abdominal aortic surgery with the primary objective of determining whether it incorporated the fidelity required to teach critical surgical techniques. MethodsThe University of Minnesota Bequest program supported a pilot project to develop a fresh pulsatile cadaver. A written pretest on exposure of the aorta in various locations was given to all trainees. The external iliac artery was exposed, cannulated, then perfused in a pulsatile fashion using normal saline and a pump. Trainees were then evaluated and timed on location of the aorta, retractor placement, dissection, and creation of an aortic anastomosis. ResultsTwenty-six pulsatile cadaver procedures were performed with five fellows over 13 months. All procedures were performed under the supervision of the same faculty member. Total cost over the study period was $8800. Four abdominal aortic aneurysms were found (15%). With bilateral iliac artery ligation, adequate pulsatility was created for blind supraceliac aortic dissection. Abdominal wall and organ relationships were ideal for teaching proper retractor placement and techniques for vascular dissection, endarterectomy, and anastomosis. Although 100% of fellows documented written understanding of the steps for procedures on the pretest, no fellow successfully placed a supraceliac aortic clamp, properly positioned retractors for proper open AAA exposure, or placed all proximal aortic back wall sutures transmurally on the initial assessment. After training for a variable number of cases, all were able to place a supraceliac clamp blindly within 4 minutes from skin incision. Retractor placement and suturing technique improved significantly for all trainees during the study period. ConclusionsThe implementation of a pulsatile cadaver-based simulation model for abdominal vascular surgery has the potential to be both affordable and provide necessary haptics and fidelity for training fellows in critical abdominal vascular techniques.

The Inflammatory Systemic Response and Cytokines Release in Open Abdominal Aortic Surgery with Fast-track Versus Conventional Perioperative Management. A Prospective Randomized Study

The Inflammatory Systemic Response and Cytokines Release in Open Abdominal Aortic Surgery with Fast-track Versus Conventional Perioperative Management. A Prospective Randomized Study

Fast-track Protocol After Open Abdominal Aortic Surgery Enables Short Hospital Stay Same as EVAR

Introduction: Open aortic aneurysm repair is traditionally associated with an extended hospital stay. However, our fast-track protocols after abdominal aortic operation have resulted in a decrease in hospitalization after major surgical procedures, as well as in mortality and morbidity. The aim of this study is to examine the feasibility of reducing post-operative stay by implementing a fast-track and goal-directed clinical pathway for elective open aortic surgery. Methods: 138 patients who were undergone abdominal aortic surgery (75 for endovascular aortic stent graft (SG) and 63 for open surgery (OS)) between Feb 2011 and Jan 2018 were treated with our fast-track protocol, which consist early postoperative oral intake and mobilization starting on the day of the operation. The average age was 78.5 ± 7.9 years (SG group) and 71.0 ± 8.2 years (OS group) (p < .01). e GFR (ml / min / 1.73 m2) SG group 52.5 ± 17.4 vs. OS group 60.0 ± 23.5, D dimer (μg / ml) SG group 7.5 ± 7.0 vs. OS group 8.4 ± 8.0, HbA1C (%) SG group 6.0 ± 0.5 vs. OS group 5.9 ± 0.7. Results: The hospital stay was 1 1.4 ± 3.9 (SG group) vs. 13.7 ± 4.6 days (OS group) in 2014, but this protocol brought a significant reduction to 7.5 ± 1.3 days(OS group) in 2017. Importantly, mobility was safely achieved in the OS group; 0% 30-day mortality and 6.2% overall morbidity (3.1% pulmonary and 3.1% renal complications). No additional treatments were needed for the OS group in contrast to 6 cases (8.0%) in the SG group. Conclusion: Our fast-track protocol after abdominal aortic operation can safely be applied to patients undergoing conventional open abdominal grafting, which reduces the length of stay in ICU and total hospitalization. To optimize this model of cardiac recovery, the most important element is to facilitate the process of pre and post-operative care. Disclosure: Nothing to disclose

The Effect of Left Renal Vein Division on Renal Function Following Open Abdominal Aortic Surgery Using Propensity Score Matching Analysis

The Effect of Left Renal Vein Division on Renal Function Following Open Abdominal Aortic Surgery Using Propensity Score Matching Analysis

The Effect of Left Renal Vein Division on Renal Function Following Open Abdominal Aortic Surgery Using Propensity Score Matching Analysis

Open surgery of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD) sometimes requires left renal vein division (LRVD) to gain adequate exposure of the abdominal aorta. The aim of this study is to evaluate the effect of LRVD on the postoperative renal function using propensity score matching (PSM). From July 1996 to January 2018, we retrospectively reviewed 698 patients who underwent open aortic surgery, including 543 AAAs and 155 AIODs, at a single institution. 66 patients (9.6%, 47 AAAs, 19 AIODs) needed LRVD during the operation. A 1:3 ratio PSM was used to control the selective bias between the LRVD and non-LRVD groups. We investigated preoperative and postoperative renal function including serum creatinine (sCr) level and estimated glomerular filtration rate (eGFR, mL/min/1.73m2). Major complications, long-term renal function, and 30-day mortality were also compared. The LRVD group had a significantly higher rate of renal artery reconstruction (15.2% vs. 3.3%, P<0.001) and suprarenal clamping (54.6% vs. 9.5%, P<0.001) and higher incidence of juxtarenal AIOD (24.2% vs. 5.4%, P<0.001). With PSM, 63 patients in the LRVD group and 144 patients in the non-LRVD group were enrolled in this study. The baseline characteristics were well balanced in the groups after PSM. There were no significant differences in preoperative eGFR (72.4±21.3 vs. 76.1±25.0, P=0.306) and postoperative eGFR on day 3 (69.5±26.6 vs. 77.5±28.5, P=0.065), day 7 (73.3±24.8 vs. 78.5±27.4, P=0.264), and in the long-term follow-up period (69.0±22.2 vs. 68.9±27.1, P=0.986, 50.2month±45.50) in the 2 groups. Only the sCr level (1.40±0.59 vs. 1.21±0.62, P=0.045) and eGFR (59.5±23.9 vs. 71.4±26.0, P=0.002) were significantly worse on postoperative day 1 in the LRVD than in the non-LRVD group. There were no significant differences in 30-day mortality (1.6% vs. 1.6%, P=1.00). The patients in the LVRD group underwent initial drop in renal function; however, eGFR improved during the follow-up period. There was no difference in renal function and postoperative mortality between LRVD and non-LRVD groups. Therefore, LRVD is a safe and durable procedure during complex abdominal aortic surgery.

Allogenic Blood Transfusion During Elective Open Abdominal Aortic Surgery

Allogenic Blood Transfusion During Elective Open Abdominal Aortic Surgery

Reacción inflamatoria sistémica y activación de citoquinas tras la cirugía abierta de aorta abdominal con medidas perioperatorias fast-track. Estudio prospectivo aleatorizado

IntroductionThe aim of this study was to determine the incidence of systemic inflammatory response syndrome (SIRS) and cytokines release in patients after open abdominal aortic surgery with fast-track compared to those with conventional peri-operative management. Material and methodsA prospective, single centre, randomised study was conducted from October 2015-November 2017 that included consecutive patients undergoing open abdominal aortic surgery. Two groups were established: fast-track group (GFT) and conventional group (GC) depending on the peri-operative management. GFT peri-operative management consisted of: a carbohydrate drink 2hours before surgery, analgesia using pre-peritoneal elastomer, mobilisation, and early diet. The main demographic and perioperative variables were collected, and the levels of serum cytokines (TNFα, IL-1ß, IL-6, IL-8, IL-10, and IL-12p70) were analysed at baseline, 8, 24, and 48hours, post-operatively. The SIRS incidence was recorded in the first 72hours after surgery, as well as the mortality and complications rate during admission. ResultsA total of 49 patients were included (GFT: 26, GC: 23) with a mean age of 67.8±8.6 years, of whom 91.8% were men. Both groups were comparable in demographic and perioperative variables, except in terms of the pre-operative body mass index: GFT: 25.67±3.07 vs. GC: 29.29±4.66 (P=.008) and total clamping time: GFT: 52.4±12.63 vs. GC: 63.91±14.34min (P=.005). The incidence of SIRS in GFT vs. GC was 38.5% vs. 45.5%, 38.5% vs. 45.5%, 23.1% vs. 26.1%, 15.4% vs. 19% (P>.05) at 8, 24, 48, and 72h postoperatively, respectively. As regards serum cytokines, a higher release of IL-6, IL-8, IL-10 and TNFα in GC was observed compared to GFT. At 8h, IL-6 reached a statistically significant increase compared to baseline in GC (P=.045). At 24h, the IL-10 increased compared to the baseline, and was statistically higher in GC compared to GFT (P=.024). Acute renal failure was observed in the GC (6/23, 26.1%) and 1/26 (3.8%) in GFT (P=.041). ConclusionsOpen abdominal aortic surgery showed a high incidence of SIRS. Although IL-6, IL-8, IL-10, and TNFα serum increased after open abdominal aortic surgery in both groups, fast-track peri-operative management seemed to modulate only IL-6 and IL-10 release. More studies are required to evaluate cytokines as biomarkers to measure outcome.

Endovascular treatment of para-anastomotic aneurysms after open abdominal aortic surgery.

The repair of long-term complications of open abdominal aortic repair such as para-anastomotic aneurysm (PAA) and pseudoaneurysm (PSA) is very challenging. The aim of this study was to assess the outcomes of endovascular repair of PAA/PSA after previous open aortic surgery for aneurismal or occlusive disease. A systematic review was undertaken; a search was performed (PRISMA) in MEDLINE, CENTRAL, Cochrane databases and key references of all studies of endovascular treatment of PAA/PSA after open aortic surgery. Eighteen studies included totally 433 patients (86.3% males) with mean age of 71±2.5 years were identified. Most of the patients were asymptomatic (76%) and diagnosed with PAA (60.5%), while 81.6% had history of open aortic reconstruction for aneurismal disease. The mean diameter of para-anastomotic aneurysms was 59.7 mm (from 23 mm to 110 mm) and the mean duration until their diagnosis was 10±2 years. Standard bifurcated (23.7%), fenestrated (23.4%) and aorto-uni-iliac stent-grafts (16.3%) were mostly used. The technical success rate was 97.8% (391/400) with 1.4% (6/433) 30 day-mortality rate and mean hospital stay of 6±3 days. The mean 1- and 2- year survival rate was 87.8% and 78.8%, respectively. The follow-up ranged from 9 to 43 months, with presenting complications such as endoleak type I (24/378; 6.3%), type II (15/354; 4.3%), type III (3/378;0.8%), migration (4/378; 1%) and limb occlusion (5/310;1.6%). Additionally, 5.7% (19/332) of the patients underwent open conversion, while the total re-intervention rate was 11.4% (39/340; time of reintervention ranged from 7 to 30 months). In cases in which a stent was used for splanchnic vessels (renal artery: 188, superior mesenteric artery: 98, celiac artery: 64), the primary patency rate was 97.4% (341/350). Endovascular treatment of PAAs and PSAs after previous open aortic surgery is a feasible and efficient option with high technical success rate, low 30-day mortality and good mid-term outcomes.

Immediate postoperative plasma neutrophil gelatinase-associated lipocalin to predict acute kidney injury after major open abdominal aortic surgery: A prospective observational study

IntroductionPlasma neutrophil gelatinase-associated lipocalin (pNGAL) has been used as a biomarker in acute kidney injury (AKI). AKI is a common postoperative complication of aortic surgery. We sought to evaluate the performance of the immediately postoperative pNGAL level in comparison with the serum creatinine (SCr) level in predicting AKI and the need for renal replacement therapy (RRT). Patients and methodsProspective non-interventional study in a university hospital. Fifty patients undergoing elective or emergent major intra-abdominal aortic surgery were included. Comparisons between groups of patients with or without postoperative AKI, according to KDIGO staging, were made. Performance of NGAL was determined by examining the area under receiver operating characteristic (AUROC) curve. ResultsThe incidence of AKI was 36%. At H+2, pNGAL values in AKI and non-AKI patients, respectively, were 221 [133–278] versus 50 [50–90] ng/mL (P<0.0001), and SCr values were 115 [96–178] versus 90 [72–99] μmol/L (P<0.0008). The AUROC of pNGAL for prediction of AKI was 0.90 (95% CI: 0.81–0.98) with an optimal cutoff of 112ng/mL, a sensitivity of 83%, specificity of 84%, and positive and negative predictive values of 75% and 90%, respectively. SCr produced an AUROC curve of 0.79 (0.65–0.92) at a cutoff of 110μmol/L. The diagnostic performance of pNGAL was significantly better than that of SCr (P=0.039). PNGAL at H+2 better predicted the RRT requirement [0.96 (0.90–1.0)] compared to SCr [0.86 (0.73–0.98)], but this difference was not statistically significant. ConclusionsA 2-hour postoperative determination of pNGAL outperformed SCr level in predicting postoperative AKI after major aortic surgery.

Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery

ObjectiveFailure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR. MethodsThe Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals). ResultsA total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897). ConclusionsAfter adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery.

Transient atrial fibrillation after open abdominal aortic revascularization surgery is associated with increased length of stay, mortality, and readmission rates

BackgroundIt is well established that transient postoperative atrial fibrillation (TPAF) is associated with adverse postoperative outcomes after major cardiac and noncardiac operations. The purpose of this study was to elucidate the incidence, impact, and risk factors associated with the development of TPAF in patients undergoing revascularization surgery for occlusive diseases of the abdominal aorta and its branches (AAB). MethodsBy use of the Healthcare Cost and Utilization Project State Inpatient Database from Florida and California, patients who underwent open revascularization of AAB between 2006 and 2011 were identified. Patients diagnosed with aortic dissection or abdominal aortic aneurysm were excluded to limit the study cohort to include only patients with occlusive etiology. Also excluded were those with a pre-existing diagnosis of atrial fibrillation and those who underwent thoracic aortic repair and peripheral artery revascularization procedures. Multivariable logistic and linear regression analyses with treatment effects were conducted to analyze the association between TPAF and length of stay (LOS); the mortality rates at index admission, 1 month, and 1 year; and the readmission rates at 1 month and 1 year (adjusted for comorbidities and surgical and demographic factors). A backwards stepwise logistic regression model was built to identify predictors of TPAF. ResultsA total of 4462 patients were identified; 3253 underwent aortoiliac/femoral bypasses (72.9%), 1514 endarterectomies of AAB (33.9%), and 288 bypasses of AAB (6.5%). The incidence of TPAF was 2.4% (109 patients). Multivariate regression analysis with treatment effects showed that TPAF was associated with significantly increased LOS, mortality, and readmission rates. Factors identified as predictors of TPAF by backwards stepwise logistic regression modeling include electrolyte disorders, increasing age, and Charlson Comorbidity Index (C statistic = .69; accuracy = 58%). ConclusionsTPAF after revascularization of AAB is associated with increased LOS, inpatient mortality, 1-year mortality, and hospital readmissions. Strategies to identify patients at risk for development of TPAF and implementation of appropriate prophylactic measures may improve surgical outcomes and reduce cost of care.

Pulmonary Complications After Open Abdominal Aortic Surgery: A Systematic Review and Meta-Analysis

Postoperative pulmonary complications (PPC) are among the most common complications after noncardiac surgery. Men, smokers, and elderly patients with chronic obstructive pulmonary disease or heart failure are more likely to experience PPC. The majority of patients undergoing vascular surgery belong in these categories and are at higher risk of developing PPC. Moreover, the surgical site is one of the most important risk factors associated with PPC, and aortic surgery carries the highest risk. The aim of this systematic review was to obtain an additional understanding of the real incidence of PPC after open abdominal aortic surgery and the impact of PPC on survival. Systematic review and meta-analysis. Hospitals PARTICIPANTS: Patients who underwent open abdominal aortic surgery. None. A literature search was performed on BioMedCentral, PubMed, Embase, and the Cochrane Register of clinical trials. All prospective or retrospective studies reporting data on PPC after open abdominal aortic surgery were included. Co-primary endpoints were the PPC rate and the correlation between PPC and perioperative mortality. The secondary endpoint was the difference in the PPC rate and mortality between elective and urgent surgery. Data on 269,637 patients from 213 studies were analyzed. The overall median incidence of PPC was 10.3% (interquartile range 5.55%-19.1%). Pneumonia, respiratory insufficiency, prolonged mechanical ventilation, need for unplanned mechanical ventilation, atelectasis, acute respiratory distress syndrome, pulmonary edema, and pleural effusions were the most common PPC reported in the literature. Occurrence of PPC was associated with postoperative mortality (r = 0.65, p<0.01) and was significantly higher in urgent procedures (p<0.001). Incidence of PPC after open abdominal aortic surgery is high and is associated with increased postoperative morbidity and mortality.

Graft type for open abdominal aortic surgery

Graft type for open abdominal aortic surgery

Perioperative glutamine supplementation restores disturbed renal arginine synthesis after open aortic surgery: a randomized controlled clinical trial.

Postoperative renal failure is a common complication after open repair of an abdominal aortic aneurysm. The amino acid arginine is formed in the kidneys from its precursor citrulline, and citrulline is formed from glutamine in the intestines. Arginine enhances the function of the immune and cardiovascular systems, which is important for recovery after surgery. We hypothesized that renal arginine production is diminished after ischemia-reperfusion injury caused by clamping of the aorta during open abdominal aortic surgery and that parenteral glutamine supplementation might compensate for this impaired arginine synthesis. This open-label clinical trial randomized patients who underwent clamping of the aorta during open abdominal aortic surgery to receive a perioperative supplement of intravenous alanyl-glutamine (0.5 g·kg(-1)·day(-1); group A, n = 5) or no supplement (group B, n = 5). One day after surgery, stable isotopes and tracer methods were used to analyze the metabolism and conversion of glutamine, citrulline, and arginine. Whole body plasma flux of glutamine, citrulline, and arginine was significantly higher in group A than in group B (glutamine: 391 ± 34 vs. 258 ± 19 μmol·kg(-1)·h(-1), citrulline: 5.7 ± 0.4 vs. 2.8 ± 0.4 μmol·kg(-1)·h(-1), and arginine: 50 ± 4 vs. 26 ± 2 μmol·kg(-1)·h(-1), P < 0.01), as was the synthesis of citrulline from glutamine (4.8 ± 0.7 vs. 1.6 ± 0.3 μmol·kg(-1)·h(-1)), citrulline from arginine (2.3 ± 0.3 vs. 0.96 ± 0.1 μmol·kg(-1)·h(-1)), and arginine from glutamine (7.7 ± 0.4 vs. 2.8 ± 0.2 μmol·kg(-1)·h(-1)), respectively (P < 0.001 for all). In conclusion, the production of citrulline and arginine is severely reduced after clamping during aortic surgery. This study shows that an intravenous supplement of glutamine increases the production of citrulline and arginine and compensates for the inhibitory effect of ischemia-reperfusion injury.

Serum Procalcitonin as a Valuable Diagnostic Tool in the Early Detection of Infectious Complications after Open Abdominal Aortic Repair

Aortic aneurysm repair is a resolutive and effective surgical operation, which can be associated with severe postoperative complications. Procalcitonin (PCT) in clinical practice could play a role in early diagnosis and monitoring of therapy for complications, especially infections, making for timely and more effective interventions. Our aim was to investigate whether PCT could be a predictive marker in early diagnosis of infectious complications after open abdominal aortic surgery. Eighty-three consecutive patients who underwent elective open aortic repair at ourinstitution were enrolled. Blood samples were taken before surgery, and each day over the 7-day postoperative period, and measurement of serum PCT, C-reactive protein (CRP), and leukocytes levels were carried out. Data regarding clinical progress, instrumental examinations, and blood chemistry were prospectively collected. Postoperative infectious complications occurred in 24 patients. Within 30days, 1 death occurred. In the study sample, we found a significant difference in PCT curves of patients with and without infectious complications, especially on third postoperative day (POD; P=0.004). On analysis of the area under the curve (AUC curve), PCT was shown to be a fair predictor in distinguishing cases with infectious complications (AUC, 0.765 on third POD; CI, 0.638-0.877). Conversely, other inflammatory markers commonly used (leucocytes and CRP) had similar trends in patients with and without postoperative infections. On the basis of the results collected in this pilot study, despite some limitations, PCT could be considered a better marker of infectious complications after open abdominal aortic repair, when compared with other routinely used parameters.

Open Abdominal Aortic Surgery: Principles and Anesthetic Considerations.

Open Abdominal Aortic Surgery: Principles and Anesthetic Considerations.