Vascular Emergency Research Articles

P132 TRAVERSING: Transfer of thoracic Aortic Vascular Emergencies to Regional Specialist Institutes Group

IntroductionThe incidence of Acute Aortic Syndrome (AAS) is rising. The Department of Health is considering a supra regional tier of centralisation for complex aortic care. No standardised pathway exists to guide the transfer of patients with AAS, despite increasing evidence from coroners and the Healthcare Safety Investigation Board of delayed transfers and miscommunication costing lives. This study aims to deliver a pathway for the safe transfer of patients with suspected AAS to a specialist aortic centre through multidisciplinary Delphi consensus.MethodsThe researchers will create an interdisciplinary Steering Group to oversee the study, which will identify appropriate stakeholders for inclusion in the Delphi process. A systematic review will be performed to summarise existing evidence and highlight gaps in knowledge where consensus is required. The Steering Group will create, circulate and interpret the Delphi questionnaire. The outcomes will also enable determination of criteria for audit that should become the standard for ensuring a safe and efficient process for patient transfer to a complex aortic centre.ResultsResults will provide inter-disciplinary guidance to healthcare professionals for early management and transfer of patients with suspected AAS, and prevent unnecessary transfer, thereby improving outcomes, ensuring equity of access to specialist aortic care for patients. Results will also provide audit standards through which future improvements can be realised.ConclusionThis study is reliant upon collaboration between multidisciplinary healthcare providers, qualitative researchers and patients. Its success will streamline emergency pathways in the management of AAS, saving lives and resources, with inbuilt mechanisms for continuous review and improvement.

Risk Factors for Fasciotomy After Revascularization for Acute Lower Limb Ischaemia.

Background: Acute lower limb ischaemia (ALI) is a life and limb threatening vascular emergency. Acute compartment syndrome (ACS) may develop upon revascularization. The risk of fasciotomy was hypothesized to be decreased in women due to their lower calf muscle mass. The main aim was to evaluate risk factors for fasciotomy after revascularization for ALI.Methods: This is a retrospective observational study of patients undergoing revascularization for ALI between 2001 and 2018. Factors associated with outcome at 1 year in univariable analysis (p < 0.1) were chosen for multi-variable analysis and expressed in Odds Ratios (OR) with 95% confidence intervals (CI).Results: The median age for women (n = 394) was 75 years and men (n = 449) was 70 years (p < 0.001). The frequency of fasciotomy was 10.0% (84/843). The median in-hospital stay was 28 vs. 6 days for patients undergoing fasciotomy and not, respectively (p < 0.001). In adjusted analysis, renal insufficiency (OR 1.77, 95% CI 1.04–3.01), motor deficit (OR 4.40, 95% CI 2.45–7.92), popliteal artery aneurysm thromboembolism (OR 2.26, 95% CI 1.06–4.80), and open vascular surgery (OR 3.43, 95% CI 1.97–5.98) were associated with an increased risk of fasciotomy. Female patients (OR 0.49, 95% CI 0.28–0.84) and anemia (OR 0.52, 95% CI 0.28–0.84) had a lower risk. The major amputation/mortality rate at 1-year was 27.7%; fasciotomy (OR 1.94, 95% CI 1.11–3.40), anemia (OR 1.84, 95% CI 1.24–2.73) and female gender (OR 1.44, 95% CI 1.00–2.08) were independently associated with an increased risk.Conclusions: Female patients had lower rates of fasciotomies, but subsequent higher risk of major amputation/mortality, which may be attributed to inferior results of revascularization. Lower muscle mass and underdiagnosis of ACS could also explain the lower frequency of fasciotomy for female patients. Further studies are needed to better understand gender differences in presentation of ALI, revascularization results and diagnosis of ACS.

Should We Urgently Modify the Management of SARS-CoV-2 Infected Patients Suffering from Acute Limb Ischaemia?

In their paper, Behrendt et al.1 explored whether there was an association between the COVID-19 pandemic and in hospital mortality in patients admitted with a vascular emergency. The data were drawn from health insurance claims using ICD-10 and OPS codes. The authors concluded that confirmed SARS-CoV-2 infection was associated with increased mortality in patients with stroke, transient ischaemic attack, and acute limb ischaemia (ALI).1 These results are of importance since this study contributes to the search for optimal vascular disease management during the current pandemic.

Acute Limb Ischemia in Critically ill COVID-19 Patients: a Case Series and Literature Review

Background: The vascular burden increased by COVID-19 infection and including acute limb ischemia (ALI) quickly emerged as a major medical challenge with devastating consequences such as limb loss, multiorgan dysfunction and death. We report a case series of COVID-19 infection associated with ALI to raise awareness and knowledge towards this life-threatening association. Methods: COVIDS-19 patients with acute limb ischemia (ALI) managed in a Moroccan 14 beds COVID-19 ICU between March 2020 and January 2021, were reviewed. Data collected included demographics, clinical presentation, treatments and outcomes. Results: Over the 10-month period, our ICU cared for 407 hospitalized patients with confirmed COVID-19. A total of 6 COVID-19 patients with ALI were identified. The mean age was 61 years (52 - 70) and 5 were men. The most common preexisting condition was diabetes (50%). The mean CRP level was 219 mg/L. Five patients had thrombus in multiple locations. No concomitant deep vein thrombosis was identified. Four patients presented with signs of acute No arterial ischemia with or without respiratory symptoms and were subsequently diagnosed with COVID-19. The remaining two patients developed ischemia during hospitalization. Mean SOFA score was 5 (2 -9). Respiratory support, corticosteroids and heparin therapies were used in all patients. Intubation and vasopressors were required in four patients. Revascularization was performed in five patients and reintervention was necessary in three cases. Four patients died in the ICU while two were successfully discharged. Conclusion: ALI in COVID-19 patients is a challenging life-threatening vascular emergency that requires appropriate multidisciplinary management (intensivists, anesthesiologists, vascular surgeons and interventionists, radiologists, haematologists…) and further studies focused on anticoagulation. Keywords: Acute Limb ischemia, Coagulopathy, COVID-19, SARS-CoV-2, Thrombosis

Anti-inflammatory and antioxidant effects of the nanocomposite Fullerol decrease the severity of intestinal inflammation induced by gut ischemia and reperfusion

Intestinal ischemia is a vascular emergency that arises when blood flow to the intestine is compromised. Reperfusion is necessary to restore intestinal function but might lead to local and systemic inflammatory responses and bacterial translocation, with consequent multiple organ dysfunction syndrome (MODS). During reperfusion occurs production of reactive oxygen species. These species contribute to intestinal injury through direct toxicity or activation of inflammatory pathways. Fullerol is a nanacomposite which has been shown to act as reactive oxygen species and reactive nitrogen species (RNS) scavengers. Thus, our aim was to evaluate whether Fullerol confer anti-inflammatory activity during intestinal ischemia and reperfusion (IIR). Intestinal ischemia was induced by total occlusion of the superior mesenteric artery. Groups were treated with vehicle or Fullerol 10 min before reperfusion. Mice were euthanized after 6 h of reperfusion, and small intestines were collected for evaluation of plasma extravasation, leukocyte influx, cytokine production and histological damage. Bacterial translocation to the peritoneal cavity and reactive oxygen and nitrogen species production by lamina propria cells were also evaluated. Our results showed that treatment with Fullerol inhibited bacterial translocation to the peritoneal cavity, delayed and decreased the lethality rates and diminished neutrophil influx and intestinal injury induced by IIR. Reduced severity of reperfusion injury in Fullerol-treated mice was associated with blunted reactive oxygen and nitrogen species production in leukocytes isolated from gut lamina propria and decreased production of pro-inflammatory mediators. Thus, the present study shows that Fullerol is a potential therapy to treat inflammatory bowel disorders associated with bacterial translocation, such as IIR.

Covid-19: As a Fear Factor in Response to Stroke Code and Other Interventional Radiology Emergencies?

The COVID-19 coronavirus crisis has posed an international challenge for all health systems. The first patient registered in Spain with the COVID-19 coronavirus was known on January 31, and the state of alarm was declared on March 14, 2020. The advance of the infection worldwide has caused a modification of the usual pattern in hospital emergency responses. This study describes the incidence of emergencies in the interventional radiology section of the Marqués de Valdecilla University Hospital and analyzes whether the presence of COVID-19 caused a decrease in the number of patients treated especially for ischemic strokes. A descriptive cross-sectional study was carried out on a sample of 236 patients treated at the interventional radiology on call between June 1, 2019 and May 10, 2020, at the Marqués de Valdecilla University Hospital. No specific results were found that indicate a decrease in the incidence of urgent procedures, especially mechanical thrombectomies in patients with ischemic strokes performed by the interventional radiology team since the establishment of the alarm state by COVID-19 in Cantabria. Patients' fear of contracting COVID-19 infection in the hospital environment has not led to a decrease in urgent procedures, especially for ischemic strokes.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

ObjectivesThis study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome.MethodsThis study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas.ResultsOnly one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail.ConclusionsWith the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Acute aortic thrombosis as a presenting feature of COVID-19: case report and review of literature

Acute aortic thrombosis is an uncommon vascular emergency that can present with neurologic symptoms like acute paraplegia due to spinal cord ischemia. It frequently causes mortality unless appropriate diagnosis is followed immediately by proper management. Individuals with COVID-19 have coagulopathy with hyper inflammatory response which predisposes to both venous and arterial thrombotic events, especially in severe patients. We report a rare case of 63-year-old COVID-19 patient presenting as acute flaccid paraplegia with hematuria secondary to acute extensive aortic thrombus. CT scan showed bilateral COVID-19 pneumonia inspite of absence of respiratory symptoms. All patients with thrombotic events should be investigated for COVID-19 pneumonia as patients may not have typical respiratory symptoms.

Emergency endovascular repair of aortoiliac aneurysms in COVID-19 times.

In this paper, we describe a case series of four patients who were admitted with emergencies related to aortic aneurysms over a 3-day period and were treated with endovascular repair. The first patient was an 81-year-old female with a history of abdominal pain and a ruptured aortic aneurysm diagnosed by AngioCT-scan. The second patient was a 63-year-old male with a history of oral digestive bleeding and an AngioCT-scan showing an aortoenteric fistula. The third patient was a 77-year-old female with sudden-onset abdominal pain and ruptured right common iliac aneurysm. The fourth patient presented with abdominal pain and an AngioCT-scan showed aortic rupture. All four patients were discharged with no major complications or surgical mortality. These case series show that despite the Covid-19 pandemic situation, since elective surgeries decreased, vascular emergencies have increased.

The Management of the Open Abdomen - A Literature Review.

An essential component of the concept of "Damage control surgery", laparostomy is the procedure by which the abdomen is deliberately abandoned open, the visceroperitoneal contents being temporarily protected by multiple technical means. Actual classification: Grade 1, without viscero-parietal adhesions or fixity of the abdominal wall (lateralization), divided into: 1A clean, 1B contaminated and 1C enteral fistula -cutaneous skin is considered clean); Grade 2, which develops fixation is subdivided into: 2A clean, 2B contaminated and 2C enteral fistula; Grade 3, "frozen abdomen", is divided into: 3A clean and 3B contaminated; Grade 4, defined as enteroatmospheric fistula, is a permanent fistula associated with the presence of granulation tissue and a frozen abdomen. Indications of the open abdomen are: damage control surgery, abdominal compartment syndrome, peritonitis, severe acute pancreatitis, vascular emergencies. Temporary abdominal closure may be achieved by following methods: skin only closure, â??Bogota bagâ?Â, opsite Sandwich technique, absorbable mesh, non-absorbable mesh or commercial zipper, vaccum asisted closure, each with its own advantages and disadvantages. Regarding the definitive closure this can be achieved by non mesh and mesh mediated techniques. Component separation technique anterior and posterior should be considered the elective repair procedure in parietal defects after laparostomy. Although several studies have been published, there is still no consensus in the literature on the positioning of prosthetic material in relation to parietal planes. Some authors suggest better results (relative to the rate of recurrence and complications) for implantation in the "sublay" position. Open abdomen is an important tool in the arsenal of the emergency surgery. Classification, indications, methods of temporary abdominal closure are evolving, as well as management of enterocutaneous fistulas and fascial closure, therefore permanent update is neccessary to offer patients the best care.

The Vascular Surgery Emergency Department in Times of COVID-19 Pandemic

The Vascular Surgery Emergency Department in Times of COVID-19 Pandemic

COVID-19 and its Repercussions on Vascular and Abdominal Medical Emergency Scenario. Interinstitutional, Multidisciplinary Approach

Objective: To identify the causes related to a rise in morbidity and mortality due to COVID in the most frequent events of acute abdomen and vascular disease.

Acute Renal Ischaemia, a Surgical Vascular Emergency With Still Unknown Evolution

Acute Renal Ischaemia, a Surgical Vascular Emergency With Still Unknown Evolution

Outcomes of management of patients with acute mesenteric ischemia: A prospective study

Introduction:Acute mesenteric ischemia (AMI) is the sudden onset of small intestinal hypoperfusion, which can be due to reduction or cessation of arterial inflow. It can be embolic or thrombotic. AMI is a potentially fatal vascular emergency, with overall mortality of 60%–80%. The present study was designed to study presentation, risk factors, and various outcomes of AMI patients, who were treated in the tertiary hospital.Methodology:All patients with features suggestive of AMI were taken in study. All patients underwent explorative laparotomy with exteriorization of bowel after initial resuscitation. Postoperatively, refeeding enteroclysis was done.Observation and Results:The total mortality rate was 62.50%. In patients with functional bowel length of 1 foot, 90.90% patients died. In patients with functional bowel length of 5–6 feet, only 12.50% died. It was observed that the mortality rate was more in the age group of 50–59 years with functional bowel length of 1 foot or <1 foot. Refeeding enteroclysis is an effective technique to use distal bowel. Contrast-enhanced computed tomography of the abdomen more suggestive of this pathology.Conclusions:A strong clinical suspicion and an aggressive approach should be considered in dealing with this condition because the outcome mainly depends on rapid diagnosis and treatment. With understanding of the pathogenesis of AMI and the better utilization of available radiological investigations, an improved outcome can be achieved. Mortality rates with refeeding enteroclysis are comparable with that of bowel anastomosis. This condition needs future research.

Vascular emergencies in neuro-ophthalmology.

The cerebral vascularization is assured by the 2 internal carotids and 2 vertebral arteries, and the Willis circle. Carotid artery obstruction is the most common abnormality associated with ocular ischemic syndrome. Obstruction may be due to atheromatous plaque, external compression, arteritis, or dissection of the artery. An atheromatous lesion of the carotid artery is the most frequent lesion responsible for ocular ischemic syndrome. The signs and symptoms of ocular ischemic syndrome are associated with severe hypoperfusion of the eye. Inflammatory lesions of the carotid artery are responsible for decreased flow in the carotid system. Other vascular emergencies are carotid artery dissection, Horton arteritis, aneurysms and carotid-cavernous fistula. The most common ocular signs and symptoms are transient monocular blindness, persistent monocular blindness, ocular ischemia, Claude Bernard Horner syndrome and oculomotor palsies.The carotid pathology can be a life-threatening pathology and it is important to recognize all these signs and symptoms. A multi-specialty approach will prevent misdiagnosis and lead to a better patient management.Abbreviations: OIS = ocular ischemic syndrome, TMB = transient monocular blindness, TIA = transient ischemic attack, ESR = erythrocyte sedimentation rate, CRP = C reactive protein, NVE = neovascularization elsewhere in the retina, NVD = neovascularization on the disc, AION A = anterior ischemic arteritic optic neuropathy, CBH = Claude Bernard Horner syndrome, MRI = magnetic resonance imaging

738: Pulseless Extremity! Vascular Emergency or Par for the Course in a Traumatic Brain-Injured Patient

738: Pulseless Extremity! Vascular Emergency or Par for the Course in a Traumatic Brain-Injured Patient

Metformin protects against myocardial ischemia-reperfusion injury and cell pyroptosis via AMPK/NLRP3 inflammasome pathway.

Ischemia/reperfusion (I/R) injury is a life-threatening vascular emergency following myocardial infarction. Our previous study showed cardioprotective effects of metformin against myocardial I/R injury. In this study, we further examined the involvement of AMPK mediated activation of NLRP3 inflammasome in this cardioprotective effect of metformin. Myocardial I/R injury was simulated in a rat heart Langendorff model and neonatal rat ventricle myocytes (NRVMs) were subjected to hypoxi/reoxygenation (H/R) to establish an in vitro model. Outcome measures included myocardial infarct size, hemodynamic monitoring, myocardial tissue injury, myocardial apoptotic index and the inflammatory response. myocardial infarct size and cardiac enzyme activities. First, we found that metformin postconditioning can not only significantly alleviated myocardial infarct size, attenuated cell apoptosis, and inhibited myocardial fibrosis. Furthermore, metformin activated phosphorylated AMPK, decreased pro-inflammatory cytokines, TNF-α, IL-6 and IL-1β, and decreased NLRP3 inflammasome activation. In isolated NRVMs metformin increased cellular viability, decreased LDH activity and inhibited cellular apoptosis and inflammation. Importantly, inhibition of AMPK phosphorylation by Compound C (CC) resulted in decreased survival of cardiomyocytes mainly by inducing the release of inflammatory cytokines and increasing NLRP3 inflammasome activation. Finally, in vitro studies revealed that the NLRP3 activator nigericin abolished the anti-inflammatory effects of metformin in NRVMs, but it had little effect on AMPK phosphorylation. Collectively, our study confirmed that metformin exerts cardioprotective effects by regulating myocardial I/R injury-induced inflammatory response, which was largely dependent on the enhancement of the AMPK pathway, thereby suppressing NLRP3 inflammasome activation.

Vascular emergencies-The new COVID-19 crisis?

Vascular emergencies-The new COVID-19 crisis?

Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement

HintergrundSowohl Chest Pain Units (CPU) als auch Stroke Units (SU) haben sich als essenzielle Komponenten der klinischen Akutversorgung etabliert. Für beide Instanzen existieren Zertifizierungsverfahren. Bis Mitte 2020 sind 290 CPU und 335 SU zertifiziert.Ziel der ArbeitIn der aktuellen Übersicht sollen die Strukturen und der aktuelle Zertifizierungsstand beleuchtet werden. Dabei soll die jüngere CPU-Zertifizierungs-Initiative dem langjährig etablierten SU-Konzept gegenübergestellt werden.Material und MethodenDer Vergleich erstreckt sich auf die historischen Hintergründe, den Zertifizierungsprozess, die Qualitätserfassung, mögliche additive Strukturen, den aktuellen Zertifizierungsstand, die Übertragbarkeit der Konzepte auf die europäische Ebene sowie die wirtschaftlichen Faktoren.ErgebnisseBeide Zertifizierungskonzepte weisen deutliche Parallelen auf. Für die SU gibt es eine positive Cochrane-Analyse, für die CPU bestehen zahlreiche positive Registerarbeiten. Wesentliche Unterschiede betreffen ein einheitliches CPU-System gegenüber einem abgestuften SU-Konzept. Darüber hinaus existieren für SU obligate Elemente der Qualitätsdokumentation. In ökonomischer Hinsicht gewährleisten OPS(Operationen- und Prozedurenschlüssel)-Ziffern eine bessere Abbildung des Ressourceneinsatzes in der Schlaganfallkomplextherapie, was für die CPU bislang nicht etabliert werden konnte.DiskussionDas gut etablierte CPU-Konzept könnte von einer übergeordneten Qualitätskontrolle zusätzlich profitieren. Adäquates Benchmarking ist Grundvoraussetzung zur Potenzialanalyse sowie zur Schaffung einer gesonderten Vergütungsstruktur. Hier ist die Deutsche Gesellschaft für Kardiologie als zertifizierende Institution gefordert, im Rahmen der regelmäßigen Kriterienupdates einen entsprechenden Mechanismus zu etablieren.

Predictors of hospital mortality after surgery for ischemic mitral regurgitation: the Toronto General Hospital experience.

The benefit of mitral valve repair (MVr) over replacement in patients with severe ischemic mitral regurgitation (IMR) is still controversial. We report our early postoperative outcomes of repair versus replacement. Data were collected for patients undergoing first-time mitral valve surgery for severe IMR between 1990 and 2009 (n = 393). Patients who underwent combined procedures for papillary muscle rupture, post-infarction ventricular septal defect, endocarditis, or any previous cardiac surgery were excluded. Preoperative demographics, operative variables, and hospital outcomes were analyzed, and multivariable regression analysis was employed to identify independent predictors of hospital mortality. Valve repair was performed in 42% (n = 164) of patients and replacement in 58% (n = 229). Patients who underwent replacement were older and had a higher prevalence of unstable angina, New York Heart Association Class IV symptoms, preoperative cardiogenic shock, preoperative myocardial infarction, peripheral vascular disease, renal failure, and urgent or emergency surgery (all p < .05). Unadjusted hospital mortality was higher in patients undergoing valve replacement (13% vs. 5%; p = .01). Valve repair was associated with a lower prevalence of postoperative low cardiac output syndrome. Multivariable analysis revealed that age, urgency of operation, and preoperative left ventricular (LV) function were independent predictors of hospital mortality. Importantly, MVr versus replacement was not an independent predictor of hospital mortality. Our data did not suggest an early survival benefit to MVr over replacement for IMR. However, age, LV dysfunction, and the need for urgent surgery were independently associated with hospital mortality.