Peripheral Vascular Surgery Research Articles

Influence of Perioperative Serum Magnesium for Cardiac and Noncardiac Morbidity and Mortality Following Emergency Peripheral Vascular Surgery

To examine the influence of serum magnesium on 30-day mortality and cardiac and noncardiac morbidity. Retrospective cross-sectional observational study of routinely collected prospective data. Single-center tertiary vascular center in the United Kingdom. All patients undergoing arterial peripheral vascular surgery during an unplanned admission. Observational, no interventions implemented. In the study, n = 197. One hundred thirty-eight were male (70.1%). Median age at procedure was 70.0years (interquartile range 20.0). Of those with a documented history, 37.9% had diabetes, 81.7% had a smoking history, 63.7% had hypertension, and 26.5% had known ischemic heart disease or heart failure. There was a significant perioperative change in magnesium (p < 0.001), calcium (p<0.001), and creatinine (p = 0.004), with no significant alteration in potassium (p = 0.096). Thirty-day mortality was 4.6%. Thirty-day cardiac morbidity was 4.1%. Thirty-day noncardiac morbidity was 32.3%. Postoperative magnesium was independently predictive for 30-day mortality (p = 0.02, odds ratio [OR] 0.96, 95% confidence interval [CI] 0.94-0.99) and cardiac morbidity (p = 0.03, OR 0.97, 95% CI 0.95-1.00). Only a previous smoking history was independently predictive of noncardiac morbidity (p = 0.03, OR 9.67, 95% CI 1.20-78.15). Perioperative changes in serum magnesium may have an influence on short-term mortality and cardiac complications. This should be considered in the management of patients undergoing unplanned peripheral vascular surgery; however, further research is needed to examine the benefit of supplementation perioperatively and to explore the exact mechanisms.

PC150. A Comprehensive Quality Improvement Initiative to Reduce Surgical Site Infections Following Peripheral Vascular Surgery

PC150. A Comprehensive Quality Improvement Initiative to Reduce Surgical Site Infections Following Peripheral Vascular Surgery

Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results.

To assess the frequency, risk factors and outcomes of iatrogenic spleen injury during minimally invasive colo-rectal surgery with a particular focus on the routine splenic flexure mobilization tehcnique. Exclusion criteria: 1) topic not pertinent to the main topic of the review; 2) all case reports, editorials, conference highlights were excluded. After a title and abstract first selection and a final full-text analysis has been performed. The results of the selected articles are presented. The iatrogenic splenic injury rate during colorectal surgery is 0.96%. The iatrogenic injuries cause around 20% of all splenectomy. Ligaments over-traction is the most frequent mechanism of damage. The routine splenic flexure mobilization is a matter of scientific debate. Risk factors - open surgery, male sex, peripheral vascular disease, malignant neoplasia, diverticulitis, emergency surgery and teaching-hospital status. There is a risk difference according to the procedure: transverse colectomy has the highest risk, followed by left colectomy and total colectomy. The routine mobilization of the left colonic flexure is a debated topic. However, according to some authors (including our experience), this procedure is not a risk factor and it may be advantageous: 1) it does not excessively prolong the total operative time; 2) better surgical skills development; 3) the tension-related ischemia is avoided; 4) wider oncological dissection. Technical accuracy with cautious dissection/visualization can reduce the rate of iatrogenic splenic damage. Laparoscopy decreases the rate of splenic injury by almost 3.5 times. Robotic surgery may have the potential to further reduce this complication, but more data are needed on the topic.

The grafts modified by heparinization and catalytic nitric oxide generation used for vascular implantation in rats.

Small-diameter (<6 mm) vascular grafts are increasingly needed in peripheral vascular surgery but have few successes because of acute thrombosis, incomplete endothelialization and intimal hyperplasia after implantation. This study used electrospun poly(ε-caprolactone) as the matrix material. Heparin and selenium-containing catalyst-organoselenium modified polyethyleneimine were introduced through layer-by-layer assembly in order to build a vascular graft with in situ nitric oxide (NO) generation. The aim of this study was to explore the application of the graft with improved histocompatibility and biological function for vascular implantation in rats. After implantation in rats, compared to poly(ε-caprolactone), the modified grafts could promote the adhesion and proliferation of endothelial cells, and inhibit the adhesion of smooth muscle cells. The modified grafts remarkably promoted endothelialization, inhibited intimal hyperplasia and increased the ratio of alternatively activated macrophages (M2) to classical activated macrophages (M1). This work constructed a vascular graft with heparinization and catalytic NO generation for improving the vascularization, and accelerating the tissue regeneration by regulating the inflammatory response. The present study indicates that it is a promising method for regulating response and tissue regeneration of small diameter vascular grafts by a novel approach of combining heparinization and catalytic NO generation.

CHRONIC LIMB ISCHEMIA

Background: The Ankle brachial index (ABI) measurements are commonlyused inscreening and management of Peripheral Vascular Disease. In recent studies, Anklebrachial index (ABI) is utilized as a predictor of future atherosclerotic vascular disease andall-cause mortality. Purpose: The purpose of this study was to investigate utility of pre andpost peripheral vascular intervention ankle-brachial index (ABI) assessmentinpatientswith thechronic limb ischemia. Study Design: Quasi experimental study. Setting: National Instituteof Cardio-Vascular Disease (NICVD), Karachi, Pakistan. Period: January 2013 to June 2014.Methodology: The study included 23 patients hospitalized. According to study inclusion/exclusion criteria, patients of chronic limb ischemia on clinical ground and the vascular lesionsof lower limb according toTrans-Atlantic Inter-Society Consensus (TASC scoreclassification II)were evaluated and recruited. The lesions were further classified into three types, Aortoilliac,Femoropopliteal andTibioperoneal. Ankle brachial index (ABI) was classified according toAmerican Diabetic Association. The study was approved by the ethical committee of NICVD.Data was analyzed using SPSS 20. Inc. Results: The mean age of the enrolled patients was57.86±6.56 years. Majority of the patients were male 18(78.3%). The commonly found peripherallesion was femoropopliteal in 9(39%), TASC grade A was commonwith 8 (62%) of cases. ABIscore done pre and post procedure showed a significant difference with a (p-value&lt;0.05) andthere was an improvement of ABI scores in all the lesions after peripheral vascular intervention.Conclusion: The study results concluded that there was animprovement in ABI score afterintervention of peripheral vascular surgery for lower limb segment and recommended its utilityfor the assessment in Peripheral Vascular Disease intervention.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

Routine use of PICO dressings may reduce overall groin wound complication rates following peripheral vascular surgery

Approximately 19% of morbidity in peripheral vascular surgery is attributable to wound complications, which can result in delayed healing, and also arterial or graft infection leading to limb loss and even mortality in extreme cases. To determine whether groin wound complications were reduced following the routine introduction of PICO negative pressure wound therapy dressings in patients who underwent peripheral vascular surgery. Patients who underwent peripheral vascular surgery from 2011 to 2016 were identified and divided into PICO and non-PICO groups. Patient, procedure and wound characteristics were tabulated and analysed. Patients were followed-up for at least six weeks postoperatively. Wound complication rates, infection confirmed by microbiology, and requirement for re-admission due to wound complications were noted. Basic cost analysis was performed. In total, 151 patients were analysed (N=73 PICO, N=78 non-PICO). No difference in age (P=0.862), body mass index (P=0.673), diabetes (P=0.339), pre-operative albumin (P=0.196), use of drain (P=0.343) and history of meticillin-resistant Staphylococcus aureus (P=0.281) was observed between groups. The PICO group contained more smokers than the non-PICO group (45% vs 29%, P=0.034). Wound complications were seen in 8% (N=6) of the PICO group and 19% (N=15) of the non-PICO group (P=0.042). No significant difference in infection was found between the two groups (3% vs 6%, P=0.249), but fewer seromas were observed when PICO dressings were used (1.4% vs 7.7%, P=0.069). Haematoma (2.7% vs 3.8%, P=0.531) and dehiscence rates (1.4% vs 1.3%, P=0.735) were similar between the two groups. Routine use of PICO dressings is associated with a reduction in wound complication rates following peripheral vascular surgery, and is cost-effective.

Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management

Aims: Patients with critical limb ischemia (CLI) have an increased risk of major amputation. The initial treatment approach for CLI may significantly impact the subsequent risk of major amputation or death. The objective of this study was to describe the initial treatment approaches of patients with CLI and the limb outcomes associated with each approach.Methods: Data from MarketScan Commercial and Medicare Supplemental Databases from January 2006–December 2014 was utilized. Cohorts of CLI patients were defined as follows: (1) peripheral vascular intervention (PVI); (2) peripheral vascular surgery (PVS); (3) minor amputation without concomitant PVI or PVS (MinAMP); and (4) Patients without PVI, PVS, or MinAMP (conservative therapy). The odds of major amputation or inpatient death were estimated using the Cox proportional hazards model. For those patients requiring a major amputation, the incremental expenditures per member per month (PMPM) were estimated using a gamma log-link model.Results: Conservative therapy was associated with significantly higher odds of major amputation or inpatient death compared to patients who underwent minor amputation (1.59-times), PVI (2.08-times), or PVS (2.12-times). Patients treated with an initial strategy of minor amputation also had higher odds of major amputation or inpatient death compared to PVS (1.31-times) or PVI (1.33-times). The estimated incremental expenditures PMPM for patients with a major amputation was $5,165.Conclusions: Revascularization reduces the risk of a major amputation or inpatient death for patients with CLI when compared to conservative therapy. Major amputation is also associated with significantly higher healthcare expenditures.

Automated control of mechanical ventilation during general anaesthesia: study protocol of a bicentric observational study (AVAS)

IntroductionAutomated control of mechanical ventilation during general anaesthesia is not common. A novel system for automated control of most of the ventilator settings was designed and is available on an...

Outcomes of Diabetic Foot Patients Following Peripheral Vascular Bypass Surgery

Outcomes of Diabetic Foot Patients Following Peripheral Vascular Bypass Surgery

Rac1 Pharmacological Inhibition Rescues Human Endothelial Dysfunction.

BackgroundEndothelial dysfunction contributes significantly to the development of vascular diseases. However, a therapy able to reduce this derangement still needs to be identified. We evaluated the effects of pharmacological inhibition of Rac1, a small GTPase protein promoting oxidative stress, in human endothelial dysfunction.Methods and ResultsWe performed vascular reactivity studies to test the effects of NSC23766, a Rac1 inhibitor, on endothelium‐dependent vasorelaxation of saphenous vein segments collected from 85 subjects who had undergone surgery for venous insufficiency and from 11 patients who had undergone peripheral vascular surgery. The endothelium‐dependent vasorelaxation of the varicose segments of saphenous veins collected from patients with venous insufficiency was markedly impaired and was also significantly lower than that observed in control nonvaricose vein tracts from the same veins. Rac1 activity, reactive oxygen species levels, and reduced nicotine adenine dinucleotide phosphate (NADPH) oxidase activity were significantly increased in varicose veins, and NSC23766 was able to significantly improve endothelium‐dependent vasorelaxation of dysfunctional saphenous vein portions in a nitric oxide–dependent manner. These effects were paralleled by a significant reduction of NADPH oxidase activity and activation of endothelial nitric oxide synthase. Finally, we further corroborated this data by demonstrating that Rac1 inhibition significantly improves venous endothelial function and reduces NADPH oxidase activity in saphenous vein grafts harvested from patients with vascular diseases undergoing peripheral bypass surgery.ConclusionsRac1 pharmacological inhibition rescues endothelial function and reduces oxidative stress in dysfunctional veins. Rac1 inhibition may represent a potential therapeutic intervention to reduce human endothelial dysfunction and subsequently vascular diseases in various clinical settings.

Body Mass Index and Operating Times in Vascular Procedures.

IntroductionThe influence of body mass index (BMI) on operating times in central and peripheral vascular surgical procedures was investigated.ReportA national cohort of Danish patients who underwent a vascular procedure between 1983 and 2012 was used for analysis. Data were analysed with pairwise comparisons of BMI groups for operating times using the independent samples Kruskall–Wallis test.DiscussionA total of 3,255 carotid endarterectomies; 6,885 central vascular procedures; and 4,488 peripheral bypasses were included for the analysis. Median operating times for carotid endarterectomy and central vascular procedures were, respectively, 5 and 15 minutes longer in obese patients than in normal weight patients. This represents a 7% and 10% increase in median operating times, respectively. Linear and multi-adjusted linear regressions were conducted adjusting for confounders, showing a significant correlation between BMI and operating time. Obesity significantly increased the operating times in carotid endarterectomy and central vascular procedures. These may have ramifications for the individual operative stress but not necessarily on logistical operation planning.

First Application of an Absorbable Skin Stapler in Peripheral Vascular Surgical Procedures

Abstract Objective: Appropriate skin closure is essential and several techniques are available such as dermal sutures and metal staples. Absorbable staples have promising qualities. Our aim was to lower the surgical site infection (SSI) rate with the use of subcuticular absorbable skin (Insorb™) staples. Design and Patients: A long-term (IDEAL) phase 4 historical comparative effectiveness trial was performed during a 2-year period from December 2012 to December 2014 in patients undergoing an infra-inguinal femoro-popliteal bypass operation. We compared closure of the skin by means of absorbable stapler with a cohort of patients treated with intracutaneous sutures. Primary outcome: number of SSI’s. Secondary outcome: other complications, duration of surgery and hospital length of stay. Main Results: 44 patients were enrolled in the study; 6 patients underwent skin closure with the absorbable staples. 4 of them had an SSI. Of 38 patients treated with intracutaneous sutures 7 had an SSI (risk difference: 0.48, 95% CI 0.09-0.88). Duration of surgery (p= 0.84) and length of stay (p= 0.15) were similar. Conclusion: Due to a large proportion of SSI’s in the absorbable stapler group the use of these subcuticular staples was discontinued in our facility. We consider the absorbable staples not strong enough for wound closure in peripheral vascular surgery.

Electrospun poly-ε-caprolactone scaffold modified with catalytic nitric oxide generation and heparin for small-diameter vascular graft

Vascular grafts are significantly needed in peripheral vascular surgery; however, small diameter grafts are not always available, and synthetic grafts perform poorly because of acute thrombosis and neointimal proliferation after implantation.

Emphysematous cholecystitis in a young patient with no risk factors.

A 43-year-old, otherwise healthy, male patient presented at the emergency department, with a 3-day history of right upper quadrant abdominal pain and fever of 39°C. Physical examination revealed positive Murphy’s sign and jaundice. Laboratory values revealed leukocytosis (18,000/ml), elevated CRP and liver function tests (direct bilirubin, ALP, ³GT). Ultrasound scanning demonstrated distention of the gallbladder, with wall thickening, pericholecystic fluid and a gallstone impacted in cystic duct. The patient was empirically started on broad-spectrum antibiotics. An abdominal CT scan on the following day revealed gas in the gallbladder wall and lumen (A, B). A percutaneous cholecystostomy was placed (C) and his clinical condition improved dramatically over the following hours, with normalisation of inflammatory indices and liver chemistry. He is scheduled to undergo laparoscopic cholecystectomy in 8 weeks. Emphysematous cholecystitis usually begins as a typical case of acute cholecystitis, but ischemia and gangrene soon develop in the gallbladder wall, due to intramural translocation of gas-forming microorganisms ( Clostridium , E. coli , Klebsiella , Streptococci ). Predisposing factors include diabetes mellitus, immunosuppression, peripheral vascular disease, abdominal surgery and trauma. Initial assessment with ultrasound may show reverbation artifacts due to the presence of air. CT scans are considered more specific and sensitive, demonstrating a gaseous halo around the gallbladder as well as air within its lumen. Emphysematous cholecystitis is a surgical emergency. Early intervention with surgery or percutaneous cholecystostomy is the mainstay of therapy. Left untreated, it can progress to perforation, pericholecystic abscess or bile peritonitis. Mortality rate for uncomplicated emphysematous cholecystitis is 1.4%, whereas for complicated cases it can reach up to 25%.

Single bolus dose of epidural magnesium prolongs the duration of analgesia in cardiac patients undergoing vascular surgeries.

Background and Aims:Magnesium, a physiological antagonist of calcium and N-methyl-d-aspartate, has a role in the prevention of pain in patients undergoing surgery for peripheral vascular diseases with cardiac comorbidities such as ischaemic heart disease and coronary artery disease. The objective of our study was assessment of effects of epidural magnesium in cardiac patients undergoing vascular surgery.Methods:Sixty patients of either sex American Society of Anesthesiologists physical status III undergoing surgeries for peripheral vascular diseases were enrolled. The control group had 30 patients who received levobupivacaine 0.25% 10 ml with fentanyl 50 μg while 30 patients in study group received levobupivacaine 0.25% 10 ml with fentanyl 50 μg and magnesium 100 mg. The primary outcome was duration of analgesia. Sedation score, pain assessment using visual analogue scale (VAS), systolic blood pressure (SBP) and diastolic blood pressure (DBP), heart rate (HR), respiratory rate (RR) and fentanyl consumption were also recorded. Statistical analyses were performed using Minitab 15 statistical software.Results:Both groups were similar demographically and with respect to baseline HR, SBP, DBP and RR. In the study group, compared to the control group, duration of analgesia was 4.17 ± 1.07 h versus 1.55 ± 0.47 h (P < 0.01), sedation score were\\ better (P = 0.003) and the VAS scores was lower (P < 0.01).Conclusion:Epidural magnesium, added to levobupivacaine and fentanyl as a single bolus dose effectively prolongs the duration of analgesia in high-risk cardiac patients undergoing peripheral vascular surgery.

Diagnostic and prognostic value of a careful symptom evaluation and high sensitive troponin in patients with suspected stable angina pectoris without prior cardiovascular disease

Background and aimsTypical angina pectoris (AP) and high-sensitive troponin I (hs-TnI) are independently associated with coronary artery disease (CAD) and future cardiovascular events (CVE). This study aimed to assess the individual and combined diagnostic and prognostic impact of symptoms and hs-TnI in stable chest pain patients without prior cardiovascular disease. MethodsDuring a one-year period, 487 patients with suspected stable AP underwent invasive or CT-coronary angiography (significant stenosis ≥50%). At study inclusion, a careful symptom evaluation was obtained, and patients were classified as having typical AP, atypical AP, or non-cardiac chest pain. Hs-TnI was measured in all patients and divided into tertiles for analysis. Follow-up was a median of 4.9 years with cardiovascular death, non-fatal myocardial infarction, unstable AP, ischemic stroke, coronary-artery-bypass-grafting, percutaneous coronary intervention, and peripheral vascular surgery as combined endpoint. ResultsHs-TnI was detected in 486 patients (99.8%). By multivariate regression analysis, typical AP and hs-TnI elevation were associated with increased risk of having significant CAD (typical AP, OR: 3.46; 95% CI: 2.07–5.79; p < 0.0001, hs-TnI, OR: 1.50; 95% CI: 1.12–2.01; p = 0.007) and experiencing future CVE (typical AP, HR: 2.64; 95% CI: 1.74–3.99; p = 0.001, hs-TnI, HR: 1.26; 95% CI: 1.06–1.49; p = 0.008). Patients in the lowest hs-TnI tertile, without typical AP (n = 107) had a 1.9% absolute risk of significant CAD and a 3.7% absolute risk of long-term CVE. ConclusionsIn clinical stable patients without known cardiovascular disease, a thorough chest-pain history in combination with hs-TnI testing can identify a significant low-risk group. The prognostic need for coronary angiography in these patients seems limited.

Cirugía cardiovascular en España en el año 2015. Registro de intervenciones de la Sociedad Española de Cirugía Torácica-Cardiovascular

The Spanish Society of Thoracic-Cardiovascular Surgery presents the 2015 annual report of activity in cardiovascular surgery based on a voluntary and anonymous registration involving 62 centres. A total of 35.413 procedures were performed, 22.298 were major procedures of which 89,24% were performed with extracorporeal circulation. This is the year with the maximal participation of centres since the activity registration started in 1984 and the year in which the degree of completion has been the highest. According to this high participation, the number of procedures discreetly increased over previous year activity. Valve surgery is the most common in 33,29%, followed by miscellaneous procedures 27,88%, coronary surgery in 15,23%, and peripheral vascular surgery in 11,96% of cases. Less frequent but also important, are congenital heart surgery and surgery of the ascending aorta which represent respectively 6% and 5,64% of our activity. 79% of participants reported their preoperative surgical risk-adjusted data. The results in terms of observed mortality are excellent, and remain below expected mortality scores in most groups of pathologies. The detailed analysis of the data allows accurate and reliable information about the activity of cardiovascular surgery in our country, and it is a great tool to compare within an international framework, and to organize strategies in order to improve our results.

Cefazolin-based Antimicrobial Prophylaxis May Reduce Surgical Site Infections in Patients Undergoing Peripheral Vascular Bypass Surgery

Cefazolin-based Antimicrobial Prophylaxis May Reduce Surgical Site Infections in Patients Undergoing Peripheral Vascular Bypass Surgery

Postoperative Cardiac Ischemia Detection by Continuous 12-Lead Electrocardiographic Monitoring in Vascular Surgery Patients: A Prospective, Observational Study

Elderly patients undergoing vascular surgery are at major risk for perioperative cardiac complications. The authors investigated continuous electrocardiographic Holter monitoring in a postoperative setting to determine the degree of postoperative ischemic load and its possible associations with perioperative myocardial infarction. A prospective, observational study. One university hospital. The study comprised 51 patients aged 65 years or older undergoing peripheral arterial surgery. Continuous electrocardiographic monitoring with a Holter device was started postoperatively and continued for 72 hours or until discharge. Postural changes were recorded using a 3-axis accelerometer. Standard 12-lead electrocardiography, high-sensitive troponin T measurements, and an inquiry of ischemic symptoms were performed 4 times perioperatively. The primary outcomes were ischemic load (area under the function of ischemic ST-segment deviation and ischemic time) and perioperative myocardial infarction. During 3,262.7 patient-hours of monitoring, 17 patients (33.3%) experienced 608 transient ischemic events, all denoted by ST-segment depression. Of these 17 patients, 5 experienced perioperative myocardial infarction. The mean ischemic load in all patients was 913.2±2,797.3 µV×minute. Ischemic load predicted perioperative myocardial infarction, with an area under receiver operating characteristics curve (95% confidence interval) of 0.87 (0.75-0.99). Ischemic changes occurred most frequently during hours 24 to 60 of monitoring. Ischemia was asymptomatic in 14 of 17 patients (82.4%). Postoperative myocardial ischemia was common in peripheral vascular surgery patients and may progress to perioperative myocardial infarction. Ischemic load was a good predictor of perioperative myocardial infarction. Ambulatory electrocardiographic monitoring solutions for continuous postoperative ischemia detection are warranted in the surgical ward.