Postoperative Ischemia Research Articles

Endoscopic-assisted, minimally invasive versus sternotomy total arterial multivessel bypass grafting.

This single center study compared the perioperative outcomes after total arterial multivessel revascularization through endoscopic-assisted, minimally invasive surgery compared to a conventional sternotomy approach. In this retrospective, propensity score matched (PSM) cohort study, a total of 740 patients were analyzed (Endo-CAB, N = 92; Sternotomy N = 648). After PSM (1:2 ratio), 73 Endo-CAB and 137 sternotomy patients were compared with an equal number of distal anastomoses (Endo-CAB 2.3 vs Sternotomy 2.4 anastomoses per patient, p = 0.082). We used "textbook outcome" as a patient-orientated outcome measure, defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischaemia, cardiac tamponade, cerebrovascular events, wound infection, new onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (>7 days). Patients undergoing Endo-CAB had significantly more often a textbook outcome compared to the sternotomy group (78.1% vs 59.1%, p = 0.009). Endo-CAB patients had shorter hospital stay (4.0 vs 6.0 days, p < 0.001), less postoperative blood loss (360 vs 490 ml, p < 0.001) and a significant reduction of new onset postoperative atrial fibrillation (5.5% vs 17.5%, p = 0.015). Other postoperative outcomes were comparable for both groups. Total arterial Endo-CAB demonstrates excellent postoperative outcomes compared to a sternotomy approach for multivessel coronary artery disease. These findings provide a strong basis for further expanding the multivessel Endo-CAB program.

Do anomalous aortic origin of a coronary artery patients have higher risk of myocardial ischaemia and adverse cardiac events during aortic and mitral valve replacements?

We assessed the effect of anomalous aortic origin of a coronary artery on the risk of early and late postoperative events after aortic or mitral valve replacement in adults. Between 2005 and 2022, 29,579 adults underwent surgical aortic or mitral valve replacement at Cleveland Clinic. Among these, 29 had an unrepaired coronary artery rising anomalously from the aorta that was not intervened upon during valve surgery, 19 (65%) an anomalous circumflex, and 9 (31%) an anomalous right. Operative outcomes were compared between the 29 patients with anomalous coronary arteries and 87 balancing score (1:3) matched patients with normal coronary origin. Median follow-up was 6.5 years. Among matched groups, major morbidity and mortality 24% (n = 7) in patients with anomalous coronaries and 20% (n = 17) among patients with normal coronary origin (P = .7). Ten-year freedom from coronary reintervention was 83% versus 100% (P[log-rank] = .005), and 10-year survival was 59% versus 53% (P[log-rank] = .8). One patient experienced a coronary injury from valve surgery, in which the incidentally found anomalous retroaortic circumflex was immediately repaired without further complication. There was no coronary reintervention after discharge in the normal coronary origin group and three in the anomalous coronary group; however, only one of these patients required intervention on the anomalous coronary. Anomalous coronaries were uncommon in surgical valve replacement patients at a high-volume centre. The origin and course of each coronary should be assessed before valve replacement. With careful planning, valve replacement does not result in a significantly higher prevalence of postoperative ischaemia, mortality, or reintervention.

034. Arterials Re-Repair with Saphenous Vein Graft for Acute Limb Ischemia in Previously Repaired Patient: A Complicated Case Report

Background: Acute upper extremity ischemia following trauma is a potentially limb-threatening condition that requires prompt diagnosis and intervention. We presented a complicated case of a patient who had previously undergone repair for his left arm but developed post-operative acute limb ischemia. Case: A 51-year-old male presented to the emergency room (ER) with acute numbness in his left hand. He previously underwent a muscle, artery, and nerve repair for his left arm due to a wooden impaled wound. Other comorbidities were denied, and the patient’s hemodynamics were stable. Physical examination showed left antebrachial covered with Backslab, tenderness upon palpation, and limited range of motion. The left fingers’ oxygen saturation were lower (90-93%). Left antebrachial imaging revealed no fracture. Vascular exploration, thrombectomy, and left radial and ulnar arteries repair using the saphenous vein graft were performed. The post-surgical outcome was great, and the numbness began to fade away. Left fingers’ oxygen saturation rose dramatically (94-95%). The patient was satisfied with the outcomes, followed by discharge from the hospital. Conclusion: Prompt recognition and surgical intervention of vascular trauma complications effectively restore function and alleviate symptoms.

Comparative insights into type non-A non-B vs type B acute aortic syndromes and their blood pressure management: a monocentric, retrospective, 11-year study

Abstract Background Acute aortic syndromes (AAS) are classified either as type A, if the ascending aorta is involved, or as type B, if only the descending aorta is; AAS affecting the aortic arch, alone or in combination with the descending aorta, have recently been classified as type non-A-non-B (NANB). Few and discordant data are available about the differences between type B and type NANB AAS, especially in terms of presentation, management and prognosis. Little evidence also exists about the effects of blood pressure (BP) management, peaks and variability on in-hospital outcomes in such context. In particular, the largest international AAS registry suggests a comparable course and prognosis, while a recent meta-analysis indicates a poorer clinical outcome with higher rate of complications, need of invasive treatment and mortality in the case of type NANB AAS. Methods We conducted a monocentric, observational, analytical, retrospective registry study including all patients ≥ 18 years old admitted to our tertiary referral hospital with a diagnosis of type B or type NANB AAS from January 2011 to December 2021. Epidemiological, clinical, operative and outcome data were analyzed by comparing type B and type NANB AAS patients. We also focused on systolic and diastolic BP, in terms of both peak values as well as BP variability (BPV); BPV was defined as the difference between the peak and the through value on a certain day. Blood pressure variables were analyzed in relationship with mortality and the failure of an initial conservative management. Results 274 type B and 44 type NANB AAS patients were enrolled. The only significant differences between the two groups were a higher rate of pre-operative complications in type NANB patients (p=0.002) resulting in a higher rate of invasive management (p=0.005), particularly as failure of an initial conservative strategy (p=0.018). However, comparable rates of post-operative complications and in-hospital mortality (overall 7%) were observed. In the overall population, lower limb ischemia, ST segment depression, and post-operative visceral ischemia were associated with higher in-hospital mortality. Peri-aortic effusion was independently associated with failure of conservative management, whereas diagnosis of intramural hematoma (as opposed to other subtypes of AAS) appeared to be protective. Among all BP variables (including anti-hypertensive treatment intensity and daily systolic or diastolic BP peaks and variability), only peak systolic BP on day 5 was found to be non-independently associated with a higher risk of in-hospital mortality and failure of an initially conservative strategy. Conclusions In our study type NANB AAS were more often complicated and treated invasively than type B AAS, while having the same rates of post-operative complications and overall mortality. BP peaks had only a minor effect on outcomes, while BPV and BP management intensity did not have any significant impact.OutcomesBlood Pressure

The Relationship Between Peri-Operative Systemic Inflammation and Survival in Patients With Abdominal Aortic Aneurysm

An association between pre-operative markers of systemic inflammation and inferior mortality following AAA repair has been observed. The prognostic value of the post-operative inflammatory response remains unreported in patients with AAA. The present study aimed to describe the association between the peri-operative inflammatory response & mortality in patients undergoing endovascular aneurysm repair (EVAR) and open surgical repair (OSR) for infrarenal AAA. Consecutive patients undergoing either emergency (EVAR or OSR) or elective (OSR) intervention for infrarenal AAA were retrospectively recruited from 3 centres. Pre-operative systemic inflammation was assessed using the modified Glasgow Prognostic Score (mGPS). Post-operative day 3 CRP (≤ 300mg/L, > 300mg/L) was chosen as the covariate of interest. The primary outcome was thirty-day mortality in the emergency cohort and twelve-month mortality in the elective cohort. There were 167 emergency cases (120 (72%) OSR) and 207 elective (207 (100%) OSR) cases, with a median (IQR) follow-up of 85 (52) months in the emergency cohort and 63 (57) months in the elective cohort. There were 56% vs. 44% of patients in the emergency cohort day 3 CRP ≤300mg/l vs. >300mg/L compared with 82% vs. 18% of patients in the elective cohort (p < 0.001). On univariate binary logistic regression analyses in the emergency cohort, open repair (p < 0.05), pre-operative mGPS 2 (p < 0.05), post-operative mesenteric ischaemia (p < 0.01), and day 3 post-operative CRP > 300mg/L (p < 0.05) were associated with increased odds of thirty-day mortality. On multivariate binary logistic regression analyses, only pre-operative mGPS 2 (OR 2.11, 95% CI 1.12 - 3.98, p < 0.05) retained independent association with thirty-day mortality. In the elective cohort, mean (95% CI) survival in the day 3 CRP ≤300mg/l vs. >300mg/L was 112.0 (101.8 - 122.2) months vs. 67.2 (54.1 - 80.2) months (p < 0.001). On univariate binary logistic regression analyses in the elective cohort, age ≥ 75 (p < 0.05), ischaemic heart disease (p < 0.05), and day 3 post-operative CRP > 300mg/L (p < 0.001) were associated with increased odds of twelve-month mortality. On multivariate binary logistic regression analyses, both age ≥ 75 (OR 5.15, 95% CI 1.25 - 21.30, p < 0.05) and day 3 post-operative CRP > 300mg/L (OR 15.68, 95% CI 3.61 - 68.15, p < 0.001) retained independent association with twelve-month mortality. Pre- and post-operative markers of systemic inflammation were independently associated with inferior survival following emergency and elective repair of AAA respectively. Further investigation of the peri-operative systemic inflammatory response is warranted in this patient group, with a particular focus on identifying targets for intervention.

Clinical application of endoscopic radical mastectomy for breast cancer combined with total pectoral muscle reconstruction with breast implants

To investigate the effectiveness of endoscopic radical mastectomy for breast cancer combined with total pectoral muscle reconstruction with breast implants. The clinical data of 138 female patients with breast cancer who met the selection criteria between April 2019 and December 2023 were retrospectively analyzed. The mean age of the patients was 43.8 years (range, 27-61 years). The maximum diameter of the tumors ranged from 1.00 to 7.10 cm, with an average of 2.70 cm. Pathological examination showed that 108 cases were positive for both estrogen receptor and progesterone receptor, and 40 cases were positive for human epidermal growth factor receptor 2. All patients underwent endoscopic radical mastectomy for breast cancer combined with total pectoral muscle reconstruction with breast implants. The operation time, intraoperative blood loss, prosthesis size, and occurences of nipple-areola complex (NAC) ischemia, flap ischemia, infection, and capsular contracture were recorded. The Breast-Q2.0 score was used to evaluate breast aesthetics, patient satisfaction, and quality of life (including the social mental health score, breast satisfaction score, and chest pain score). Patients were divided into two groups based on the time of operation after the technique was implemented: group A (within 1 year, 25 cases) and group B (after 1 year, 113 cases). The above outcome indicators were compared between the two groups. Furthermore, based on the postoperative follow-up duration, patients were classified into a short-term group (follow-up time was less than 1 year) and a long-term group (follow-up time was more than 1 year). The baseline data and postoperative Breast-Q2.0 scores were compared between the two groups. The average operation time was 120.76 minutes, the average intraoperative blood loss was 23.77 mL, and the average prosthesis size was 218.37 mL. Postoperative NAC ischemia occurred in 21 cases (15.22%), flap ischemia in 30 cases (21.74%), infection in 23 cases (16.67%), capsular contracture in 33 cases (23.91%), and prosthesis removal in 2 cases (1.45%). The operation time of group A was significantly longer than that of group B ( P<0.05), and there was no significant difference in intraoperative blood loss, prosthesis size, and related complications between the two groups ( P>0.05). All patients were followed up 3-48 months (mean, 20 months). There were 33 cases in the short-term group and 105 cases in the long-term group. There was no significant difference in baseline data such as age, body mass index, number of menopause cases, number of neoadjuvant chemotherapy cases, number of axillary lymph node dissection cases, breast cup size, degree of breast ptosis, and postoperative radiotherapy constituent ratio between the two groups ( P>0.05). At last follow-up, the breast satisfaction score in the patients' Breast-Q2.0 score ranged from 33 to 100, with an average of 60.9; the social mental health score ranged from 38 to 100, with an average of 71.3; the chest pain score ranged from 20 to 80, with an average of 47.3. The social mental health score of the long-term group was significantly higher than that of the short-term group ( P<0.05); there was no significant difference in breast satisfaction scores and chest pain scores between the two groups ( P>0.05). No patient died during the follow-up, and 2 patients relapsed at 649 days and 689 days postoperatively, respectively. The recurrence-free survival rate was 98.62%. Endoscopic radical mastectomy for breast cancer combined with total pectoral muscle reconstruction with breast implants has fewer complications and less damage, and the aesthetic effect of reconstructed breast is better.

Frailty as an Independent Predictor of Adverse Outcomes in Patients Undergoing Direct Myocardial Revascularization.

The study included 387 patients admitted to the clinic for a scheduled primary CABG. A seven-item questionnaire, "PRISMA-7", was used to identify frail elderly patients before the procedure. We divided the study sample into two groups, taking into account the results of the survey: patients without frailty, n0 = 300 (77.5%), and patients with frailty, n1 = 87 (22.5%). The anamnestic and laboratory data, outcome of the surgical intervention, perioperative and early complications, and adverse outcomes were analyzed. We detected frailty in 22.5% of the patients with CAD before the procedure. According to the anamnestic data and paraclinical and intraoperative findings, the groups of patients with and without frailty were comparable. The differences were revealed in the intraoperative and early postoperative periods of CABG. Thus, postoperative rhythm disturbances (19.5% vs. 10.5%, p = 0.025, V = 0.115, respectively) and transient ischemic attacks/stroke (5.7% vs. 1.3%, p = 0.031, V = 0.122, respectively) occurred significantly more often among the frail patients. There were no significant differences between the groups in the frequency of other intraoperative and early postoperative complications. In the group of frail patients, four fatal outcomes due to early postoperative ischemia were recorded, and among patients without frailty, one fatal outcome was recorded (4.5% vs. 0.3%, p = 0.010, V = 0.156, respectively). At the 1-year follow-up visit, the presence of frailty in history served as a predictor of mortality (11.5% vs. 0.6%, p ˂ 0.001, V = 0.290, respectively). The presence of frailty can be used as an independent predictor of an unfavorable prognosis in patients with CAD, both in the perioperative and early survival period after CABG. It should be taken into account during surgical risk assessment.

Sex Differences in Outcome of Aneurysmal Subarachnoid Hemorrhage and Its Relation to Postoperative Cerebral Ischemia.

Whether there is a sex difference in the outcome of aneurysmal subarachnoid hemorrhage (aSAH) remains controversial, and clarifying the role of women in postoperative cerebral ischemic events can help us to understand its relationship with poor prognosis. Therefore, the purpose of this study was to elucidate the relationship between the three aspects of sex differences, postoperative cerebral ischemia, and poor prognosis after aSAH. A total of 472 patients admitted within 72h after aSAH between January 2018 and December 2022 were included. We systematically analyzed the characteristics of sex differences in aSAH and explored the relationship between delayed cerebral ischemia (DCI), surgery-related cerebral infarction (SRCI), and poor prognosis (modified Rankin Scale > 2). Compared with women, men were in worse condition and had more intracerebral hematoma (p = 0.001) on admission, whereas women were older (p < 0.001) and had more multiple aneurysms (p = 0.002). During hospitalization, men were more likely to experience emergency intubation (p = 0.036) and tracheotomy (p = 0.013). Women achieved functional independence at discharge at a similar rate to men (p = 0.394). Among postoperative complications, the incidence of DCI (22% vs. 12%, p = 0.01) and urinary tract infection (p = 0.022) was significantly higher in women. After adjusting for age, multivariable regression analysis showed that hypertension (odds ratio [OR] 2.139, 95% confidence interval [CI] 1.027-4.457), preoperative rerupture (OR 12.240, 95% CI 1.491-100.458), pulmonary infection (OR 2.297, 95% CI 1.070-4.930), external ventricular drainage placement (OR 4.382, 95% CI 1.550-12.390), bacteremia (OR 14.943, 95% CI 1.412-158.117), SRCI (OR 8.588, 95% CI 4.092-18.023), venous thrombosis (OR 5.283, 95% CI 1.859-15.013), higher modified Fisher grades (p = 0.003), and Hunt-Hess grades (p = 0.035) were associated with poor prognosis, whereas DCI (OR 1.394, 95% CI 0.591-3.292) was not an independent risk factor for poor prognosis. The proportion of patients who fully recovered from cerebral ischemia was higher in the DCI group (p < 0.001) compared with the SRCI group, and more patients were discharged with modified Rankin Scale > 2 in the SRCI group (p = 0.005). Women have a higher incidence of DCI, but there is no sex difference in outcomes after aSAH, and poor prognosis is associated with worse admission condition and perioperative complications. SRCI is a strong independent risk factor for poor prognosis, whereas DCI is not.

Improved rates of postoperative ischemia, completeness of aneurysm occlusion and neurological deficits in elective clipping of anterior circulation aneurysms over the past 20 years – association with technical improvements

Background/PurposeSeveral periprocedural adjuncts for elective surgical aneurysm treatment have been introduced over the last 20 years to increase safety and efficacy. Besides the introduction of IONM in the late-1990s, ICG-videoangiography (ICG-VAG) since the mid-2000s and intraoperative CT-angiography/-perfusion (iCT-A/-P) since the mid-2010s are available. We aimed to clarify whether the introduction of ICG-VAG and iCT-A/-P resulted in our department in a stepwise improvement in the rate of radiologically detected postoperative ischemia, complete aneurysm occlusion and postoperative new deficits.MethodsPatients undergoing microsurgical clip occlusion for unruptured anterior circulation aneurysms between 2000 and 2019 were included, with ICG-VAG since 2009 and iCT-A/-P (for selected cases) since 2016. Baseline characteristics and treatment-related morbidity/outcome focusing on differences between the three distinct cohorts (cohort-I: pre-ICG-VAG-era, cohort-II: ICG-VAG-era, cohort-III: ICG-VAG&iCT-A/-P-era) were analyzed.Results1391 patients were enrolled (n = 74 were excluded), 779 patients were interventionally treated, 538 patients were surgically clipped by a specialized vascular team (cohort-I n = 167, cohort-II n = 284, cohort-III n = 87). Aneurysm size was larger in cohort-I (8.9 vs. 7.5/6.8 mm; p < 0.01) without differences concerning age (mean:55years), gender distribution (m: f = 1:2.6) and aneurysm location (MCA:61%, ICA:18%, ACA/AcomA:21%). There was a stepwise improvement in the rate of radiologically detected postoperative ischemia (16.2vs.12.0vs.8.0%; p = 0.161), complete aneurysm occlusion (68.3vs.83.6vs.91.0%; p < 0.01) and postoperative new deficits (10.8vs.7.7vs.5.7%; p = 0.335) from cohort-I to -III. After a mean follow-up of 12months, a median modified Rankin scale of 0 was achieved in all cohorts.DiscussionAssociated with periprocedural technical achievements, surgical outcome in elective anterior circulation aneurysm surgery has improved in our service during the past 20 years.

Hybrid treatment of recurrent venous mesenteric thrombosis with small intestinal necrosis

The article presents a clinical case of a 39-year-old patient with thrombosis and postoperative rethrombosis of the superior mesenteric vein. The disease was complicated by the small intestine necrosis and abdominal surgical infection. Successful thrombectomy and bowel resection made it possible to restore mesenteric blood supply, to stabilize the patient’s condition and to perform an enteroenteroanastomosis. Due to antithrombin III deficiency, rethrombosis in the early postoperative period was complicated by anastomotic leak, unformed intestinal fistula and peritonitis. A hybrid treatment (surgical, parasurgical and conservative) was performed, which included selective infusion of a thrombolysis activator at the superior mesenteric artery mouth. The patient recovered.Clinical and laboratory manifestations of superior mesenteric vein thrombosis, in contrast to acute circulatory disorders in the arteriomesenteric system, are nonspecific and do not always allow timely diagnosis of intestinal ischemia. MSCT angiography identifies venous mesenteric thrombosis in most cases. The ineffectiveness of anticoagulant therapy against the background of antithrombin III deficiency caused superior mesenteric vein thrombosis and rethrombosis. The treatment of the small intestine critical postoperative ischemia included an increase in the volume of antithrombin III and frozen plasma intravenous infusion and selective administration of a thrombolysis activator (actilyse) into the superior mesenteric artery, which made it possible to restore the arteriolovenular intramural blood flow of the small intestine and to prevent another stem rethrombosis of the superior mesenteric vein. Laparostomy using a silicone plate made it possible to constantly monitor the course of the abdominal infectious process and to make timely decisions about the next intervention if medically required. The vacuum assisted design provided permanent lavage of the abdominal cavity without trauma to the soft tissues of the abdominal wall and presenting intestinal loops.

Fenestrated/Branched Endovascular Aortic Repair Patients With Peripheral Artery Disease Have Significantly Lower Long-Term Survival and Higher Incidence of Postoperative Mesenteric Ischemia

Fenestrated/Branched Endovascular Aortic Repair Patients With Peripheral Artery Disease Have Significantly Lower Long-Term Survival and Higher Incidence of Postoperative Mesenteric Ischemia

Thoracoscopic-assisted, minimally invasive versus off-pump bypass grafting for single vessel coronary artery disease – A propensity matched analysis

ObjectiveThis study compared perioperative outcomes after off-pump revascularization through a thoracoscopic-assisted (non-robotic) minimally invasive approach (Endo-CAB) or sternotomy approach (OPCAB) for patients with single vessel left anterior descending (LAD) disease. MethodsIn this retrospective, propensity matched cohort study, 266 consecutive patients were included in the Endo-CAB group (n = 136) and OPCAB group (n = 130). After propensity score matching 116 Endo-CAB and 116 OPCAB patients were compared. ‘Textbook outcome’ was defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischemia, cardiac tamponade, cerebrovascular events, wound infection, new-onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (> 7 days). Multivariable regression analysis was performed to identify independent predictors for textbook outcome. ResultsTextbook outcome occurred significantly more frequent in the Endo-CAB group compared to the OPCAB group (81.9% vs. 59.5%, p < 0.001). Patients undergoing Endo-CAB surgery had shorter hospital admission (3.0 [3.0–4.0] vs. 5.0 [4.0–6.0] days, p < 0.001), less blood loss (225 [150–355] vs. 450 [350–600] mL, p < 0.001). Other perioperative outcomes were comparable for both groups. Regression analysis demonstrated that Endo-CAB approach was an independent positive predictor for textbook outcome (OR 3.02, 95% CI 1.61–5.66, p < 0.001). ConclusionsOur study suggests that patients undergoing Endo-CAB surgery have improved perioperative outcome resulting in higher rates of textbook outcome for the treatment of single vessel CAD. This technique could be widely available since routine thoracoscopic instruments are used.

Features and outcomes of female and male patients requiring postcardiotomy extracorporeal life support

ObjectivesAlthough cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support. MethodsThis retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models. ResultsThis analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments. ConclusionsThis study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.

Utility of motor-evoked potentials in contemporary open thoracoabdominal aortic repair

ObjectiveParaplegia remains one of the major complications of contemporary open thoracoabdominal aortic aneurysm (TAAA) repair. Intraoperative motor-evoked potentials (MEPs) act as a surrogate measure for spinal cord homeostasis. The purpose of this study was to evaluate the results of intraoperative neuromonitoring in contemporary TAAA repair and its association with postoperative spinal cord ischemia (SCI). MethodsPatients who underwent open type 2 or 3 TAAA or completion aortic repair using intraoperative neuromonitoring were identified between May 2006 and November 2023. Patient demographics, comorbidities, indication for the procedure, procedural details, and outcomes were recorded. The groups were divided based on type of repair, and univariate statistics were then used to evaluate the association of these metrics vs the type of repair. ResultsSeventy-nine patients underwent open type 2 (N = 41) and 3 (N = 23) TAAA and completion aortic (N = 15; open in 14 and endovascular in 1) repairs by a single surgeon. The cohort was predominantly male (N = 48, 60.8%) with a mean age of 52.5 ± 16.2 years. There was a high incidence of hypertension (N = 53, 67.1%), smoking history (N = 42, 53.1%), and connective tissue disorders (N = 37, 46.8%). Operative indications included dissection-related (N = 50, 63.3%) and degenerative (N = 26, 32.9%) TAAA and dissection-related malperfusion (N = 3, 3.8%). Left heart bypass was often (N = 73, 92.4%) used for distal aortic perfusion, and cerebrospinal fluid drainage (N = 77, 97.5%) was a common adjunct. MEPs were classified as no change (N = 43, 54.4%), reversible change (N = 26, 32.9%), irreversible change (N = 4, 5.1%), and unreliable (N = 6, 7.6%). MEP changes were predominantly bilateral (N = 70, 88.6%) and occurred most often during repair of the abdominal aortic segment (N = 13, 16.5%). The median number of replaced vertebral levels was associated with MEP changes (P = .013). SCI was only observed in repairs greater than 6 replaced vertebral levels with an overall frequency of 17.7%. It was most prevalent in completion aortic repairs (26.7%). Immediate and delayed SCI occurred in 10.1% and 7.6% of patients, respectively; it was most commonly (71.8%) reversible. Permanent paraplegia occurred in four patients (5.1%), with equal immediate and delayed onsets. MEPs demonstrated poor sensitivity (53.9%) and specificity (62.3%) for SCI; however, there was a high negative predictive value (86.4%) in this population. In-hospital mortality occurred in five (6.3%) patients. ConclusionsNo changes in intraoperative MEPs are highly predictive of spinal cord homeostasis. The number of replaced vertebral levels and previous aortic repair should guide intraoperative neuroprotective measures including intercostal reimplantation and should take precedence over intraoperative monitoring, especially when MEP changes occur.

Age is not a sole predictor of outcomes in octogenarians undergoing complex endovascular aortic repair

ObjectiveTo examine the perioperative, postoperative, and long-term outcomes of fenestrated/branched endovascular aneurysm repair (F/BEVAR) in octogenarians compared with nonoctogenarians. MethodsA multicenter, retrospective cohort study was conducted using the Vascular Quality Improvement database, which prospectively captures information on patients who undergo vascular surgery across 1021 academic and community hospitals in North America. All patients who underwent F/BEVAR endovascular aortic repair from 2012 to 2022 were included. Patients were stratified into two groups: those aged <80 years and those aged ≥80 years at the time of the procedure. The preoperative, intraoperative, and postoperative factors were compared between the two groups. The primary outcome was long-term all-cause mortality; secondary outcomes included aortic-specific mortality and aortic-specific reintervention. ResultsA total of 6007 patients (aged <80 years, n = 4860; aged ≥80 years, n = 1147) who had undergone F/BEVAR procedures were included. No significant difference was found in technical success, postoperative length of stay, length of intensive care unit stay, postoperative bowel ischemia, and spinal cord ischemia. After adjustment for baseline covariates, octogenarians were more likely to suffer from a postoperative complication (odds ratio [OR]: 1.16; [95% confidence interval (CI): 0.98-1.37], P < .001) and be discharged to a rehabilitation center (OR: 1.60; [95% CI: 1.27-2.00], P < .001) or nursing home (OR: 2.23; [95% CI: 1.64-3.01], P < .001). Five-year survival was lower in octogenarians (83% vs 71%, hazard ratio [HR]: 1.70; [95% CI: 1.46-2.0], P < .0001). Multivariate Cox proportional hazard analysis demonstrated that age was associated with increased all-cause mortality (HR: 1.72, [95% CI: 1.39-2.12], P < .001) and aortic-specific mortality (HR: 1.92, [95% CI: 1.04-3.68], P = .038). Crawford extent II aortic disease was associated with an increase in all-cause mortality (HR 1.49; [95% CI: 1.01-2.19], P < .001), aortic-specific mortality (HR: 5.05; [95% CI: 1.35-18.9], P = .016), and aortic-specific reintervention (HR: 1.91; [95% CI: 1.24-2.93], P = .003). Functional dependence was associated with increased all-cause mortality (HR: 2.90; [95% CI: 1.87-4.51], P < .001) and aortic-specific mortality (HR: 4.93; [95% CI: 1.69-14.4], P = .004). ConclusionsOur findings suggest that octogenarians do have a mildly increased mortality rate and rate of adverse events after F/BEVAR procedures. Despite this, when adjusted for other risk factors, age is on par with other medical comorbidities and therefore should not be a strict exclusion criterion for F/BEVAR procedures, rather considered in the global context of patient’s aortic anatomy, health, and functional status.

Development and validation of machine learning models to predict postoperative infarction in moyamoya disease.

Cerebral infarction is a common complication in patients undergoing revascularization surgery for moyamoya disease (MMD). Although previous statistical evaluations have identified several risk factors for postoperative brain ischemia, the ability to predict its occurrence based on these limited predictors remains inadequately explored. This study aimed to assess the feasibility of machine learning algorithms for predicting cerebral infarction after revascularization surgery in patients with MMD. This retrospective study was conducted across two centers and harnessed data from 512 patients with MMD who had undergone revascularization surgery. The patient cohort was partitioned into internal and external datasets. Using perioperative clinical data from the internal cohort, three distinct machine learning algorithms-namely the support vector machine, random forest, and light gradient-boosting machine models-were trained and cross-validated to predict the occurrence of postoperative cerebral infarction. Predictive performance validity was subsequently assessed using an external dataset. Shapley additive explanations (SHAP) analysis was conducted to augment the prediction model's transparency and to quantify the impact of each input variable on shaping both the aggregate and individual patient predictions. In the cohort of 512 patients, 33 (6.4%) experienced postrevascularization cerebral infarction. The cross-validation outcomes revealed that, among the three models, the support vector machine model achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at mean ± SD 0.785 ± 0.052. Notably, during external validation, the light gradient-boosting machine model exhibited the highest accuracy at 0.903 and the largest ROC-AUC at 0.710. The top-performing prediction model utilized five input variables: postoperative serum gamma-glutamyl transpeptidase value, positive posterior cerebral artery (PCA) involvement on preoperative MRA, infarction as the rationale for surgery, presence of an infarction scar on preoperative MRI, and preoperative modified Rankin Scale score. Furthermore, the SHAP analysis identified presence of PCA involvement, infarction as the rationale for surgery, and presence of an infarction scar on preoperative MRI as positive influences on postoperative cerebral infarction. This study indicates the usefulness of employing machine learning techniques with routine perioperative data to predict the occurrence of cerebral infarction after revascularization procedures in patients with MMD.

Experimental study on the preservation of amputated limb by low-temperature HTK preservation solution arterial perfusion

Objective: To evaluate the effect of HTK (Histidine-Tryptophan-Ketoglutarate solution) infusion on the protection and replantation of amputated limb. Methods: In experiment 1, the amputated limbs of male New Zealand white rabbits were preserved by different preservation methods, including low-temperature HTK solution perfusion group, low-temperature normal saline perfusion group, low-temperature preservation group and non-perfusion group at normal temperature. The homogenates of muscle tissue at different time points were collected for biochemical detection. H&amp;E (hematoxylin and eosin) staining was performed on muscle tissue. Bax, Bcl-2 protein immunohistochemical staining and Tunel method were used to detect apoptosis in muscle, nerve, and vascular tissues. The ultrastructure of cells was observed by transmission electron microscope. In experiment 2, the amputated limbs of rabbits were treated with HTK perfusion and cryopreservation without perfusion, respectively. The survival of rabbits and their limbs were observed, and detected by H&amp;E, TUNEL (Terminal deoxynucleotidyl transferase dUTP Nick End Labeling) and scanning electron microscopy. Statistical analysis was performed using SPSS 22 (SPSS Inc., Chicago, IL, USA). χ2 test, student’s t-test, and ANOVA (Analysis of Variance) were used to compare the categorical and continuous variables. Results: Experiment 1: With the extension of disconnection time, there were statistical differences between the biochemical indexes of the HTK liquid perfusion group and those of the non-low temperature non-perfusion group, while some indexes of the other groups were different. Immunohistochemical staining of tissues (muscle, nerve, and blood vessel) in each group showed that the number of cells stained by anti-apoptotic protein BCL-2 in each group significantly increased with the extension of time, while the number of cells stained by pro-apoptotic protein BAX2 in each group significantly decreased. Tunel test showed that compared with other treatment groups, the apoptosis rate of the HTK liquid group was significantly decreased. Experiment 2: The survival rate of the experimental group was 60%, and that of the control group was only 30%. H&amp;E staining, the TUNEL method and scanning electron microscopy suggested that HTK infusion could reduce ischemia-reperfusion injury in muscle tissue. Conclusion: 1. Perfusion preservation of severed limbs at 4 ℃ can effectively reduce tissue damage caused by ischemia and hypoxia, and the effect is stronger than direct preservation. 2. HTK solution and normal saline were used for one-time perfusion of the severed limbs of rabbits, and the preservation effect of HTK solution was the best. 3. HTK solution was used for one-time perfusion of severed hind limbs of rabbits, which was refrigerated at 4 ℃ and then replanted (ischemia time was 3–5 h). Compared with the replanted limbs after cold storage alone, the survival rate was higher, and the postoperative ischemia and hypoxia injury of surviving limbs were less.

Superomedial Pedicle Technique and Management of Circulation Problems in Gigantomastia : Treatment of Gigantomastia.

Breast reduction surgeries encompass a wide range of methods that are continuously evolving to discover more reliable and satisfactory techniques. This presentation aims to address the research gap by sharing outcomes and experiences using the superomedial pedicle in gigantomastia, as well as the implemented protocol for managing nipple-areola complex (NAC) ischemia. The Wise pattern and superomedial pedicle reduction mammaplasty method were utilized in treating 19 patients (38 breasts). The average age of the patients was 41.47 years, with a basal mass index (BMI) of 33.27 kg/m2. The mean sternal notch to nipple (SN-N) length for the entire population was found to be 40.97 cm. On both sides, this length was statistically similar at 41.11 cm on the right side and 40.84 cm on the left side. The average weight of resected tissue from all patients was calculated to be 1793.42 g, with slightly higher weight on the right side at 1800 g compared to the left side's weight of 1786.84 g. Postoperative NAC ischemia occurred in three patients, one bilateral case, and two unilateral cases. The study revealed that in both the groups with and without NAC ischemia, the average values were as follows: age, which ranged from 45.33 to 40.75 years; BMI, ranging from 35.01 kg/m2 to 32.95 kg/m2; SN-N distance, which varied from 40 cm to 41.09 cm; and excision material weights, ranging from 1650 g to 1810.29 g. The p-value in the comparisons was found to be greater than 0.05. These results indicate that age, BMI, SN-N distance, and excision material weight did not have an impact on NAC vascularity issues. All NACs were successfully saved through a protocol involving hyperbaric oxygen therapy (HOT) and vacuum-assisted therapy (VAT). The study suggests that utilizing a superomedial flap is a viable option for treating gigantomastia and highlights the effectiveness of their outlined protocol in managing postoperative complications. While acknowledging the need for comparative studies, the study proposes incorporating HOT and VAT into protocols aimed at saving NACs.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Positive effects of low-dose S-ketamine on preventing myocardial injury after thoracoscopic lobectomy in patients aged 70 to 85

ObjectiveTo investigate the effects of low-dose S-ketamine on marker of myocardial injury (BNP, hs-cTnT and HFABP) after thoracoscopic lobectomy in patients aged 70 to 85.MethodsOne hundred patients (four cases excluded) aged 70–85 years, with body mass index 18–24 kg·m−2 and American Society of Anesthesiologists physical status II–III, scheduled for elective lobectomy from April 2022 to April 2023, were selected. The patients were divided into two groups by a random number table method, namely, the low-dose S-ketamine combined with GDFT group (group S) and the control group (group C), with 48 cases in each group. In group S, a low dose of S-ketamine (0.2 mg/kg) was given 1 min before intubation, and the maintenance dose was 0.12 mg·kg−1·h−1. Fluid therapy, guided by cardiac index (CI), changes in stroke volume (△SV), and other dynamic indicators, was used for rehydration during the operation. Group C was given the same amount of normal saline (0.2 mg/kg) 1 min before intubation, and the same rehydration therapy was adopted during the operation. The mean arterial pressure (MAP) and heart rate (HR) of the two groups were observed and recorded immediately after entering the operating room (T0), immediately after intubation (T1), immediately after the beginning of one-lung ventilation (OLV) (T2), immediately after the beginning of surgery (T3), immediately after the end of OLV (T4), and at the end of surgery (T5). The intraoperative fluid intake and output and the use of vasoactive drugs were recorded. The plasma levels of heart-type fatty acid–binding protein (HFABP), high-sensitivity troponin T (hs-cTnT), brain natriuretic peptide (BNP), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α (TNF-α) were recorded 24 h before operation and 24 and 48 h after operation. Visual analogue scale (VAS) pain scores at rest were recorded at 2 (V1), 6 (V2), 12 (V3), 24 (V4), and 48 h (V5) after operation, and the occurrence of myocardial ischemia during hospitalization was noted.ResultsCompared with group C, MAP was significantly higher at T1–T5 in group S (P < 0.05), and the plasma concentrations of IL-6, IL-8, TNF-α, BNP, hs-cTnT, and HFABP were significantly lower at 24 and 48 h after operation (P < 0.05). The VAS pain scores at 2, 6, 12, 24, and 48 h after operation, the number of effective patient-controlled intravenous analgesia (PCIA) compressions, and the total number of PCIA compressions within 48 h after operation were significantly decreased (P < 0.05). Compared with group C, The hospitalization days, and the incidence of postoperative myocardial ischemia in group S were lower (P < 0.05). There were no significant intergroup differences in urine volume, extubation time, the incidence of postoperative atrial fibrillation, bleeding volume, colloid infusion volume, total fluid infusion volume, and the incidence of rescue analgesia.ConclusionsLow-dose S-ketamine can reduce the levels of hs-cTnT, HFABP, and BNP in older patients after pulmonary lobectomy, which has a positive effect on preventing myocardial injury.Trial registrationThis study was registered on CHICTR (registration No. ChiCTR2300074475). Date of registration: 08/08/2023.

The Safety and Outcome of Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) Prior Thoracoabdominal Aortic Aneurysm Repair: A Single-Center Study, Systematic Review, and Meta-Analysis.

Minimally Invasive Staged Segmental Artery Coil Embolization (MIS2ACE) is a novel technique of spinal cord preconditioning used to reduce the risk of paraplegia in thoracoabdominal aortic aneurysm (TAAA) repair. In this study, we report our experience with MIS2ACE, including both degenerative and post-dissection TAAA, while we attempt to systematically summarize relevant data available in the literature. single-center observational study with systematic review of the literature and meta-analysis. Initial retrospective analysis of 7 patients undergoing MIS2ACE over 12 sessions with a subsequent systematic review of the literature and meta-analysis of the available published data (PROSPERO protocol number: CRD42023477411). Baseline patient and aneurysm characteristics, along with procedural technique and outcomes, were analyzed. One-arm pooling of proportions was used to summarize available published data. We treated seven patients (5 males, 71%) with a median age of 69 years (IQR 55,69). According to the Crawford classification, five patients (1%) had extent II TAAA, and two (29%) had extent III TAAA. Five patients (71%) had post-dissection -TAAA; four of them were after Stanford type A dissection, and one had a chronic type B dissection. Three patients (43%) had connective tissue disease. Of the seven patients, six (86%) underwent previous aortic surgery, while the median aneurysm diameter was 58 mm (IQR 55,58). MIS2ACE was successful in 11 sessions (92%). The median number of embolized arteries was 4 (IQR 1,4). There were no periprocedural complications in any embolization. The median embolization-operation time interval was 37.0 days (IQR 31,78). Two patients had open and five endovascular treatment. There were no events of spinal cord ischemia either after MIS2ACE or after the aortic repair. Out of the 432 initially retrieved articles, we included two studies in the meta-analysis, including patients with MIS2ACE for spinal cord preconditioning in addition to our cohort. The prevalence of pooled postoperative spinal cord ischemia among MIS2ACE patients is 1.9% (95% CI -0.028 to 0.066, p = 0.279; 3 studies; 81 patients, 127 coiling sessions). While the current published data is limited, our study further confirms that MIS2ACE is a technically feasible and safe option for spinal cord preconditioning.