Search

An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed.Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications.One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively.Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients.Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators.Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction.DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.

Introduction The aim of this study was to establish if an elevated triglyceride to high-density lipoprotein (HDL) ratio (THR) is not only a risk factor for cardiovascular and overall morbidity as the updated evidence shows, but could also be employed as a significant predictor for surgical adverse outcomes and hence be a valid tool for risk stratification of candidates undergoing abdominal aortic surgery. Methods This is a single-centre retrospective analysis of 2224 patients who underwent open abdominal aortic surgery between January 1996 and 2009. This cohort was divided into quartiles of THR. A list of covariates has been entered with THR into a multiple logistic model with forwards stepwise selection. The obtained result is an adjusted model, conceived to establish the association between THR and perioperative adverse events. Discrimination of the model so obtained and comparison with vascular-specific risk stratification scoring systems were evaluated using the area under the receiver operating characteristic (AUROC). Results THR had the highest predictive value for the outcomes of interest. The adjusted odds ratios (ORs) per every 0.1 augmentation of THR were 1.41 (1.08–1.88) for cardiac, 1.38 (1.09–1.84) for respiratory, 1.27 (1.06–1.54) for renal adverse events and 1.02 (0.84–1.23) for mortality. Regarding mortality, either of the scoring systems Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and customised probability index (CPI) and the THR ranked as moderate discriminators, with THR performing the worst (AUROC 0.71) compared with Vascular POSSUM (AUROC 0.76) and CPI (AUROC 0.78). THR performed as a very strong predictor of morbidity (AUROC 0.86), ranking above Vascular POSSUM (AUROC 0.72). Conclusions THR is a significant predictor of perioperative morbidity and mortality. THR offers a broad outlook on the metabolic state of patients undergoing major abdominal aortic surgery and hence their propensity to adverse events, allowing us to risk-stratify the prognostic outcome of surgical intervention and possibly intervene preoperatively to optimise results.

Background Endovascular aneurysm repair (EVAR) reduces the morbidity and mortality associated with abdominal aortic aneurysm repair, but in some patients endoleak or aneurysm expansion may necessitate secondary open conversion (SOC). We reviewed the outcomes after delayed SOC following EVAR in consecutive patients at a single center. Methods We retrospectively reviewed all patients undergoing EVAR to identify a cohort undergoing delayed SOC in a single center between 1998 and 2008. We analyzed delayed SOC patients for operative indications, technique, and early outcomes. We made specific comment on the surgical techniques used, with respect to partial or total endograft explantation. Results Delayed SOC was carried out in 10/285 (3.5%) consecutive patients implanted with the Zenith endograft; during this period, two further patients had SOC after initial EVAR in another center. Graft types were Zenith ( n = 10), Talent ( n = 1), and AneuRx ( n = 1). Indications for open conversion were infected graft ( n = 3), sac expansion ( n = 3), type 1 endoleak ( n = 2), type 2 endoleak ( n = 2), juxtarenal aneurysm ( n = 1), and rupture ( n = 1). Explantation techniques were partial explantation with in situ replacement ( n = 7), full explantation with axillobifemoral bypass ( n = 3), in situ replacement ( n = 1), and suturing ( n = 1)Complete stent explantation was required in 4 patients with axillo-bifemoral bypass in three of them. 7 patients had partial stent explantation and one patient stent was left insitu. Postoperative morbidities included myocardial infarction ( n = 1), renal dialysis ( n = 1), and chest infection ( n = 3). No 30-day mortality was noted, and all patients were discharged from hospital and remain well with median follow-up of 5 months (interquartile range 1.7-26.7). Conclusion SOC after EVAR is feasible in selected patients with low morbidity and mortality. Partial explantation with in situ replacement, in the absence of sepsis, may be the preferred revascularization option but may require long-term follow-up.

Objectif Le traitement endovasculaire des anevrysmes (EVAR) reduit la morbidite et la mortalite associees a la reparation des anevrysmes de l’aorte abdominale et certains patients presentant des endofuites ou une expansion anevrysmale peuvent necessiter une conversion ouverte secondaire (COS). Nous avons revu les resultats de la COS differee apres EVAR chez des patients consecutifs dans un centre unique. Methodes Nous avons revu retrospectivement tous les patients ayant une EVAR afin d’identifier une cohorte de patients ayant une COS differee dans une seule institution entre 1998 et 2008. Nous avons analyse les patients ayant une COS differee en fonction des indications operatoires, des techniques et des resultats precoces. Nous avons analyse de maniere specifique les details de la technique chirurgicale utilisee en fonction de l’explantation partielle ou totale de l’endoprothese. Resultats Une COS differee a ete effectuee chez 10/285 (3,5%) patients consecutifs ayant eu l’implantation d’une endoprothese Zenith. Au cours de cette periode, deux autres patients ont eu une COS apres une EVAR effectuee initialement dans un autre centre. Le type de prothese etait une Zenith (n = 10), une Talent (n = 1) et une AneuRx (n = 1). Les indications de conversion ouverte etaient une infection de prothese (n = 3), une expansion du sac anevrysmal (n = 3), une endofuite de type I (n = 2), une endofuite de type II (n = 2), un anevrysme juxta-renal (n = 1) et une rupture (n = 1). Les techniques d’explantation ont ete l’explantation partielle avec un remplacement in situ (n = 7), l’explantation complete avec pontage axillo-bifemoral (n = 3), le remplacement in situ (n = 1) et la suture (n = 1). L’explantation complete du stent a ete necessaire chez quatre patients dont trois ont recu un pontage axillo-bifemoral. Sept patients ont eu l’explantation partielle du stent et le stent a ete laisse in situ chez un patient. La morbidite post-operatoire a inclus un infarctus du myocarde (n = 1), une dialyse renale (n = 1) et trois infections pulmonaires (n = 3). Le taux de mortalite a 30 jours a ete nul. Tous les patients ont pu quitter l’hopital pour rester en bonne forme avec un suivi median de 5 mois (extremes 1,7 a 26,7). Conclusion Une COS est possible avec de faibles taux de morbidite et de mortalite apres une EVAR, chez des patients selectionnes. L’explantation partielle avec remplacement in situ, en l’absence de sepsis, pourrait etre l’option preferable de revascularisation mais un suivi a long terme doit etre obtenu.

Endovascular aneurysm repair (EVAR) is an established therapy to prevent rupture in large infrarenal abdominal aortic aneurysms (AAA). As experience with this therapy has grown, treatment of more challenging anatomy has led to the identification of several new procedurally related complications. We report the case of a 67-year-old man with an asymptomatic, large infrarenal AAA with an associated left common iliac artery aneurysm. Endovascular therapy for an aortoiliac aneurysm involved prior coil embolization of his left internal iliac artery to allow conventional EVAR with extension to the external iliac artery of the left graft limb, thus excluding the left iliac aneurysm. He presented 6 weeks postoperatively with onset of left-sided scrotal pain and underwent emergency orchidectomy for ischemic infarction of his left testis. The histology report confirmed that the left testis was necrotic secondary to a thrombus in the testicular artery. To our knowledge, this is the first report of testicular infarction after EVAR.