Technique In High-risk Patients Research Articles

Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques.

This systematic review and meta-analysis examine preventive operative techniques in high-risk patients undergoing surgery for hemodialysis access to mitigate the risk of Dialysis Access-Associated Steal Syndrome (DASS). Chronic kidney disease often leads to end-stage renal disease (ESRD), necessitating dialysis. Successful vascular access is crucial for efficient dialysis, but complications, such as DASS, pose significant challenges. DASS redirects arterial blood flow, affecting populations undergoing arteriovenous access surgery. This study aims to assess preventive strategies, including distal revascularization with interval ligation (DRIL) and extension techniques. A systematic search of PubMed, Cochrane Library, EMBASE, and Web of Science until 2022 identified 11 relevant studies. The inclusion criteria comprised non-pediatric hemodialysis patients reporting outcomes related to patency and complications. The data were analyzed using Review Manager 5.3.5 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen). Meta-analysis indicated a significant association between DASS and arteriovenous fistula (AVF) or arteriovenous graft (AVG) procedures. Radiocephalic AVF (RC-AVF) and distal endovascular AVF procedures were favored. Various interventions addressed venous narrowing, including simple plication and loop interposition. The Modified by Inserted Latex Link for Endovascular Repair (MILLER) technique, DRIL, Extension Technique, and Proximalization of Arterial Inflow (PAI) were assessed for arterial bypass graft and blood supply preservation. This study underscores the importance of individualized strategies in preventing DASS during hemodialysis access surgery. Prophylactic measures, such as the extension technique, show promise, while DRIL remains effective in treatment. Ongoing research is imperative for optimizing outcomes in this complex patient population.

Symptomatic Posttreatment Edema after Stereotactic Radiotherapy for Intracranial Meningiomas: Patterns and Predictive Factors

Symptomatic posttreatment edema (SPTE) is a complication that may develop after radiotherapy for intracranial meningiomas. Our study aims at reviewing rates of SPTE in a large cohort of a single institution and identifying possible predictive factors. We retrospectively analyzed data of 293 patients with 304 intracranial meningiomas irradiated at our institution between 2005 and 2018. We evaluated rates of SPTE and investigated numerous factors by univariate and multivariate analysis. Kaplan Meier analysis was used for estimation of actuarial local control and overall survival. Median age was 60 years. Meningiomas were treated with fractionated stereotactic radiation therapy (70%), single fraction stereotactic radiosurgery (24%) or fractionated stereotactic radiosurgery (6%). Median imaging follow-up was 60 months, actuarial 10-year local control rate for patients with grade 1 meningiomas who received radiotherapy as definitive treatment was 99%. Local control at 5 years was 94% for grade 1 meningioma, 57% and 53% for grade 2 and 3 respectively. Sixteen patients (5.5%) developed SPTE, median time to onset was 3 months (range, 1-26 months). On univariate analysis, age > 60 years (p > 0.03), pre-treatment peritumoral edema (p = 0.014), medline location (p = 0.018), tumor size > 30 mm (p = 0.015) and grade 2 histology (p = 0.03) were predictive of SPTE. On multivariate analysis, only tumor location and size remained statistically significant. Based on our results, patients at high risk of SPTE can be identified based on patient and tumor characteristics. The best treatment technique in high-risk patients is yet to be defined.

Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique.

The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

A novel risk prediction tool for contrast-induced nephropathy in patients with chronic kidney disease who underwent diagnostic coronary angiography.

The incidence of contrast-induced nephropathy (CIN) is higher than 20% in patients with chronic kidney disease. In this study, we sought to define the predictors of CIN and develop a risk prediction tool in patients with chronic kidney disease. Patients aged 18 years and older who underwent invasive coronary angiography with an iodine-based contrast media between March 2014 and June 2017 were retrospectively analyzed. Independent predictors for CIN development were identified and a new risk prediction tool was created that included these predictors. In total, 283 patients included in the study were divided into those who developed CIN (n=39, 13.8%) and those who did not (n=244, 86.2%). Male gender (OR: 4.874, 95% CI: 2.044-11.621), LVEF (OR: 0.965, 95% CI: 0.936-0.995), diabetes mellitus (OR: 1.711, 95% CI: 1.094-2.677), and e-GFR (OR: 0.880, 95% CI: 0.845-0.917), were identified as independent predictors for the development of CIN in the multivariate analysis. A new scoring system has been designed that can score a minimum of 0 and a maximum of 8 points. Patients with a new scoring system score of ≥4 were at approximately 40 times higher risk of developing CIN than others (OR: 39.9, 95% CI: 5.4-295.3). The area under the curve value of CIN's new scoring system was 0.873 (95% CI, 0.821-0.925). We found that four easily accessible and routinely collected variables, including sex, diabetes status, e-GFR, and LVEF, were independently associated with the development of CIN. We believe that using this risk prediction tool in routine clinical practice may guide physicians to use preventive medications and techniques in high-risk patients for CIN.

Percutaneous transhepatic ultrasound-guided gallbladder aspiration: Still a safe option for gallbladder decompression in patients at high surgical risk.

Cholecystitis generally warrants immediate cholecystectomy; however, high-risk patients require non-surgical options for gallbladder decompression. The continuous evolution of endoscopic techniques makes it difficult for clinicians tochoose the best technique for high-risk patients. Here we aimed to show that percutaneous transhepatic gallbladder aspiration, a technique that has fallen into disuse, is a safe and rapid method for gallbladder decompression. In our local database, we identified 48 patients who had undergone transhepatic punctures of the biliary system,34 of whom were excluded because they had received bile duct punctures. The remaining 14 patients had received gallbladder punctures, of whom 9 were considered eligible for analysis. Cases were retrospectively analyzed for technical success, complications, and individual outcomes. Our analysis included 9 patients (3 female, 6 male; median age, 51 years; range, 32-84 years). Underlying malignancy was found in 5 patients, while 4 were in a palliative situation. Underlying infection was found in 8 cases. All punctures were technically successful without complications. In all patients, individual therapy goals were met,including clinical stabilization in palliative situations, stabilization before liver surgery, exclusion of gallbladder empyema and infection in gallbladder hydrops, and avoidance of gallbladder rupture. The white blood cell counts at the day of punction were significantly reduced one week after the puncture (p=0.023). When selecting an appropriate technique for high-risk patients, clinicians should remember that gallbladder aspiration is a feasible and successful bedside procedure in patients at high surgical risk, which does not require an experienced endoscopist.

Prevalence of operative complications in obstetric and gynecological surgeries requiring interventions by a general surgeon and their associated risk factors: A retrospective study in a tertiary care hospital in Vindhya region

Background: Surgical complications can occur in any surgery despite the best possible efforts, thereby affecting the prognosis. Gynecological and obstetric surgeries also result in some complications which require interventions by a general surgeon. These complications can be either causing hemodynamic instability, urinary tract injury, gastrointestinal tract injury, or infections. Aims and Objectives: The present study designed to identify and classify the various complication in obstetric and gynecological surgeries requiring interventions by a general surgeon and to correlate the various risk factors that predispose to these complications. Materials and Methods: The present retrospective study was conducted in the Department of Obstetrics and Gynecology and Department of Surgery, Shyam Shah Medical College and associated hospitals, Rewa, M.P., for 6 months from January 2021 to June 2021. Gynecological and obstetric surgeries resulting in complications requiring surgical intervention were identified and classified based on patients’ demographic characteristics, comorbidities, and type of complications. Results: A total of 1356 cases undergoing an obstetrical or gynecological procedure in the department of obstetrics and gynecology were studied. About 2.14% of the patients had some kind of intraoperative or post-operative complications, which required intervention by a general surgeon. The mean age of females having complications was 37.17±3.71 years. Overall the most common complication was surgical site infection with 48% of the total cases. Conclusion: In this present study, the incidence of surgical complications in obstetrical and gynecological surgeries, which is associated with higher morbidity postoperatively. These complications can be prevented by proper vigilance and surgical technique in high-risk patients.

Early and long-term results of ventricular septal defect repair in children with severe pulmonary hypertension and elevated pulmonary vascular resistance by the double or traditional patch technique.

In upper-income countries, infants undergo low-risk ventricular septal defect (VSD) repair. Children in low- and middle-income countries frequently present at older ages with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). Expensive interventions for pulmonary hypertensive crisis are not available, and children are often denied an operation due to the mortality risk. We report our early and late experiences with these patients who underwent VSD closure by traditional patch (TP) or double patch (DP) techniques. We extracted data from patients with VSD and PAH who underwent VSD closure operations from 1996 to 2016. Information regarding cardiac catheterizations, operations, time in the intensive care unit and follow-up information was found. We identified 129 children and analysed the differences between the TP (89/129) and the DP (40/129) in unidirectional groups. After 2005, the patients were pretreated with sildenafil 3 months before catheterization. The TP group was younger (P < 0.001). Hospital mortality (2.5%, DP; 10.1%,TP) was not significantly different (P = 0.17) between the 2 groups despite significant differences in baseline PVR, PVR/systemic vascular resistance and the number of children with a saturation less than 90%. The long-term survival and regression of PAH were better in the DP group (survival over 97% vs 93% in the TP group). Moreover, 61% of children with DP and 75% of those with TP had normal to mild elevations in pulmonary artery pressures at the last follow-up examination (P = 0.046). The DP operation is a low-risk procedure. Moreover, the long-term outcome with the use of this technique in high-risk patients with VSD and high PVR and PAH is favourable with respect to survival and showed a decrease in PAH at the last follow-up.

Parastomal hernia repair with onlay mesh remains a safe and effective approach

BackgroundParastomal hernia (PSH) management poses difficulties due to significant rates of recurrence and morbidity after repair. This study aims to describe a practical approach for PSH, particularly with onlay mesh repair using a lateral peristomal incision.MethodsThis is a retrospective review of consecutive patients who underwent PSH repair between 2001 and 2018.ResultsSeventy-six consecutive PSH with a mean follow-up of 93.1 months were reviewed. Repair was carried out for end colostomy (40%), end ileostomy (25%), ileal conduit (21%), loop colostomy (6.5%) end-loop colostomy (5%) and loop ileostomy (2.5%). The repair was performed either with a lateral peristomal incision (59%) or a midline incision (41%). Polypropylene mesh (86%), biologic mesh (8%) and composite mesh (6%) were used. Stoma relocation was done in 9 patients (12%). Eight patients (11%) developed postoperative wound complications. Recurrence occurred in 16 patients (21%) with a mean time to recurrence at 29.4 months. No significant difference in wound complication and recurrence was observed based on the type of stoma, incision used, type of mesh used, and whether or not the stoma was repaired on the same site or relocated.ConclusionOnlay mesh repair of PSH remains a practical and safe approach and could be an advantageous technique for high-risk patients. It can be performed using a lateral peristomal incision with low morbidity and an acceptable recurrence rate. However, for patients with significant adhesions and very large PSH, a midline approach with stoma relocation may also be considered.

Sternal closure methods in high-risk patients: Should they be specific to the patient?

Background: To analyze and investigate the most effective sternum closure method in high-risk patients undergoing median sternotomy, we compared a steel wire-titanium hooks combination with a steel wire-titanium plates and screws combination. Patients and Methods: We examined 67 patients who underwent median sternotomy between October 2018 and January 2020. Patients who needed postoperative chemotherapy or radiotherapy due to malignancy were excluded from the study. The patients were randomly divided into two groups with similar risk factors. In the first group, a steel wire – titanium hooks combination was used to close the sternum. A steel wire – titanium plates and screws combination was used in the second group of patients. Results: No dehiscence or mediastinitis were observed in either patient group. Superficial wound infection was seen in four patients from each group and was successfully treated with antibiotic therapy. There was no significant difference between the two groups regarding the intensive care stay, the duration of hospitalization, the amount of bleeding or the need for re-exploration (p > 0.05). Conclusion: The choice between sternal closure techniques in high-risk patients should be mainly based on the characteristics of the patient. Beyond this, the most cost-effective method in which the surgeon is most experienced should be preferred. Keywords: Titanium hooks; titanium plates and screws; tersonalized sternal closure methods

Transapical Aspiration of a Mitral Mass With the AngioVac System on a Beating Heart

The AngioVac System has already proved to be effective and safe in the treatment of thrombotic and endocarditic formations concerning the venous district and the tricuspid valve. We describe an innovative use of the AngioVac System to treat a left-sided heart mass. In a high-surgical-risk patient, we used a micro-invasive transapical access and a modified extracorporeal membrane oxygenation circuit to remove the mass from the mitral bioprosthesis without having to replace it. Further experiences are required to confirm the safety of this technique in high-risk patients.

P5982Transcatheter aortic valve replacement in elderly patients with severe symptomatic aortic stenosis

Abstract Introduction TAVR has proven to be a safe technique for high-risk patients. The objective of our work is to know the results of TAVR in patients older than 90 years; which are the riskiest and had more complications during the admission. Methods Observational retrospective analysis based on all a single-center registry of all consecutive TAVR (N=518) during the last 10 years (2008–2018). Patients older than 90 years old represent 5.8 of the procedures (N=30). We performed a descriptive analysis of the baseline characteristics of our patient cohort, and the development of events during follow-up. Results Our population, as reflected in TABLE 1, had a median age of 91,32 years old, and the majority were women (57.58%). The procedures were mostly elective, unless in 4 patients (12.12%) that were urgent. None valvuloplasty was done before TAVR in this cohort, neither Valve-in-valve. Stratification scores had a wide range, from 1.45 to 28.8% for EurSCORE II and from 4.19 to 17.19% for STS, with a median of 5.53 and 8.49% respectively. Mortality in the first 30 days and in the first year was 0.00%. Mortality after the first year was 71.40% due to non-cardiovascular events (median time of follow-up of 34.34 months). Finally, we would also like to remark that the incidence of heart failure during the first year was 14.29%, taking into account all the follow-up, the incidence was 37.04%. Despite these data, in our registry, the need for pacemaker after the valve implantation was higher than in younger populations (40.62%), probably due to the age-related fibrosis of the cardiac conduction system. Conclusions TAVR is a very safe procedure with very successful results in elderly patients, nevertheless, due to the frailty of this population, individualization is mandatory in order to optimize the resources. Acknowledgement/Funding None

Comparison of unilateral versus bilateral spinal anaesthesia using hyperbaric bupivacaine with clonidine in unilateral inguinal hernia surgery - A randomized controlled trial

Introduction: Unilateral spinal anaesthesia can be used for inguinal hernia surgery. The advantage is that it provides a stronger block on the side of surgery, accelerated recovery of the nerve block with better maintenance of cardiovascular stability. Hence it can be a valuable technique for high risk patients. Materials and Methods: The study design was randomized controlled trial including 60 patients undergoing elective hernioplasty. Patients were allocated to either group unilateral (U) or group bilateral (B) and received Inj Bupivacaine 0.5% heavy 12.5mg + inj Clonidine 15 microgram in sub-arachnoid block. Patients were kept in lateral position for 10min for group U & made supine immediately on the OT table for group B. Variation in hemodynamic parameters, onset, peak level, duration of sensory and motor block were noted. Results: At 10, 15 and 20 min minutes after giving anaesthesia, the mean heart rate, systolic and diastolic blood pressures, mean arterial pressure were significantly higher in patients receiving unilateral anaesthesia. Mean duration of sensory and motor block, total duration of analgesia were significantly more in bilateral anaesthesia. Conclusion: Unilateral spinal anaesthesia achieved stable hemodynamics, adequate duration of block for surgery and rapid recovery. So it can be a valuable technique in high risk patients. Keywords: Spinal anaesthesia, Unilateral spinal anaesthesia.

Thoraflex Graft in an Inverted Position for Post-Dissection Thoracoabdominal Aneurysm

We present the off-label use of a Thoraflex Hybrid Plexus prosthesis (Vascutek, Renfrewshire, Scotland, UK) to treat a post-dissection type IV thoracoabdominal aortic aneurysm (TAA) in a high-risk patient previously treated with a thoracic stent-graft for a chronic type B aortic dissection. The Thoraflex graft was used in a "reversed frozen elephant trunk" fashion: the stent graft portion deployed in the previously placed thoracic stent, and the branched portion used to revascularize visceral arteries and lower limbs. Our off-label use of the Thoraflex graft was technically successful. Further experiences are required to confirm the safety of this technique in high-risk patients.

Ultrasound-guided popliteal sciatic and adductor canal block for below-knee surgeries in high-risk patients

Background and Aims:Central neuraxial block and general anaesthesia in patients with significant comorbidities are associated with considerable peri-operative morbidity and mortality. This study aims to delineate peripheral nerve block as a suitable alternative technique in high-risk patients posted for below-knee surgery.Methods:Twenty patients with the American Society of Anesthesiologist's (ASA) physical status grade III and IV, aged 30–80 years, scheduled for below-knee surgery from May 2018 to February 2019 were enrolled in this prospective study. All patients received ultrasound-guided popliteal sciatic block with 20 ml 0.5% ropivacaine and adductor canal block with 10 ml 0.375% ropivacaine. The peripheral nerve block success rate, sensory and motor block onset time, haemodynamic parameters, duration of post-operative analgesia and patient's satisfaction were recorded. Descriptive statistics of the study were calculated and the data was analysed using an SPSS statistics 21.0 program.Result:Surgery was performed successfully with no additional analgesic requirement in all patients. The mean duration for sensory and motor block onset time was 3.35 ± 0.49 (mean ± standard deviation) and 4.65 ± 0.48 (mean ± standard deviation) minutes respectively. Haemodynamic parameters were maintained stable throughout the procedure. The average duration of postoperative analgesia was 7.5 ± 0.8 (mean ± standard deviation) hours. Patient overall satisfaction as assessed, by three-point Lickert's scale, was satisfactory.Conclusion:Ultrasound-guided combined popliteal sciatic and adductor canal block is an effective alternative anaesthetic technique for below-knee surgeries with stability of haemodynamic parameters and pain management in high-risk patients.

Peripheral nerve blocks for above knee amputation in high-risk patients

Background and Aims:Above knee amputation (AKA) is associated with considerable mortality and morbidity. There is paucity of data describing the use of peripheral nerve blocks (PNB) as the sole anesthetic technique in high-risk patients undergoing AKA. Our objectives were to evaluate the use of PNB as sole anesthetic technique in the above-mentioned population and its clinical outcomes.Material and Methods:This was a retrospective descriptive study conducted in a tertiary hospital. For this study, patients with American Society of Anesthesiologist [ASA] IV physical status underwent AKA using PNB between January 2010 and December 2016, were identified. The primary outcome measured was the success of the operation. The secondary outcomes were block details, intraoperative hemodynamics, usage of sedation and analgesia, patients’ comorbidities, mortality rates at 30 days and one year.Results:Out of fifty-seven patients, the median age (interquartile range) was 74 (57 – 81) years and 60% were males. The results show 91% successfully underwent surgery with PNB (95% CI 81% to 96%). 95% required intraoperative sedation and analgesia. 67% received combined femoral, obturator and sciatic nerve blocks, in which nine cases had an additional lateral femoral cutaneous nerve block. Interestingly, 33% only received combined femoral and sciatic nerve blocks, and they required higher sedation analgesia (p = 0.013). The 30-day and one-year mortality were 12.3% & 47.4%. Majority had stable hemodynamics during the surgery.Conclusion:This study shows that PNB is a viable option for reliable anesthesia for AKA in high-risk patients. Combined FOS nerve block would reduce the dose for sedation–analgesia during the operation.

66Hybrid minimally invasive approach for transvenous lead extraction: a feasible technique in high-risk patients

66Hybrid minimally invasive approach for transvenous lead extraction: a feasible technique in high-risk patients

P1515Hybrid minimally invasive approach for transvenous lead extraction: a feasible technique in high-risk patients

P1515Hybrid minimally invasive approach for transvenous lead extraction: a feasible technique in high-risk patients

Botulinum Toxin A Injection in the Bladder Neck: A Promising Treatment for Urinary Retention.

Secondary to failure of optimal medical therapy and the high morbidity that accompanies surgical techniques in high risk patients, the use of de novo treatments including botulinum toxin A is emerging in the treatment of benign prostatic hyperplasia (BPH). However, the treatment of urinary retention secondary to BPH via injecting botulinum toxin into the bladder neck is not well established in the literature. This case report describes the case of a 75-year-old male patient with a chronic history of obstructive lower urinary tract symptoms (LUTS) and multiple comorbidities who was admitted to the hospital for management of recurrent urinary retention. The patient was not a surgical candidate for transurethral incision of the prostate (TUIP) or transurethral resection of the prostate (TURP). Botulinum toxin injection into the bladder neck was performed with very satisfying results. Botulinum toxin injection in the bladder neck presents a promising minimally invasive, tolerated, and cost-effective approach for the treatment of urinary retention in patients with benign prostatic obstruction who are not candidates for surgery or in whom medical treatment has failed. More research is needed to identify the efficacy of this novel approach.

Blockade of the mental nerve for lower lip surgery as a safe alternative to general anesthesia in two very old patients.

PurposeRegional anesthesia is gaining popularity with anesthesiologists as it offers superb postoperative analgesia. However, as the sole anesthetic technique in high-risk patients in whom general anesthesia is not preferred, some regional anesthetic possibilities may be easily overlooked. By presenting two cases of very old patients with considerable comorbidities, we would like to bring the mental nerve field block under renewed attention as a safe alternative to general anesthesia and to achieve broader application of this simple nerve block.Patients and methodsTwo very old male patients (84 and 91 years) both presented with an ulcerative lesion at the lower lip for which surgical removal was scheduled. Because of their considerable comorbidities and increased frailty, bilateral blockade of the mental nerve was considered superior to general anesthesia. As an additional advantage for the 84-year-old patient, who had a pneumonectomy in his medical history, the procedure could be safely performed in a beach-chair position to prevent atelectasis and optimize the ventilation/perfusion ratio of the single lung. The mental nerve blockades were performed intraorally in a blind fashion, after eversion of the lip and identifying the lower canine. A 5 mL syringe with a 23-gauge needle attached was passed into the buccal mucosa until it approximated the mental foramen, where 2 mL of lidocaine 2% with adrenaline 1:100.000 was injected. The other side was anesthetized in a similar fashion.ResultsBoth patients underwent the surgical procedure uneventfully under a bilateral mental nerve block and were discharged from the hospital on the same day.ConclusionA mental nerve block is an easy-to-perform regional anesthetic technique for lower lip surgery. This technique might be especially advantageous in the very old, frail patient.

TAVI and Left Ventricular Hypertrophy - A Case Report

Introduction: Severe aortic valve stenosis in elderly patients is often accompanied by secondary left ventricular hypertrophy due to chronic pressure overload. Transaortic valve intervention is a valuable technique in high-risk patients, however in case of extensive left ventricular outflow tract obstruction surgery including enlargement of the left ventricular outflow tract (LVOT) may be indicated.