Follow-up Results of Endovascular Aneurysm Repair Following Abdominal Visceral Debranching

ABSTRACT Introduction: The aim of this study is to present a series of six cases with thoracoabdominal aneurysm treated with hybrid technique in our center. Methods: Between May 2015 and December 2018, the data of six patients with thoracoabdominal aneurysms and various comorbidities who underwent visceral debranching followed by endovascular aortic aneurysm repair were reviewed retrospectively. Results: Patients' mean age was 65.3±19.6 years. All of them were male. Comorbidities were old age, congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, previous surgical interventions, and/or esophageal hemangioma. Except for one patient who underwent coronary artery bypass grafting (inflow was taken from ascending aorta), debranching was performed from the right iliac artery. Debranching of four visceral arteries (superior mesenteric artery, celiac trunk, and bilateral renal right arteries) was performed in three patients, of three visceral arteries (superior mesenteric artery, celiac trunk, right renal artery) was performed in one, and of two visceral arteries (superior mesenteric artery, celiac trunk) was performed in two patients. Great saphenous vein and 6-mm polytetrafluoroethylene grafts were used in one and five patients, respectively, for debranching. Endovascular aneurysm repair was performed following debranching procedures as soon as the patients were stabilized. In total, three patients died at the early, mid, and long-term follow-up due to multiorgan failure, pneumonia, and unknown reasons. Conclusion: Hybrid repair of thoracoabdominal aneurysms may be an alternative to fenestrated or branched endovascular stent grafts in patients with increased risk factors for open surgical thoracoabdominal aneurysm repair; however, the procedure requires experience and care.

Effects of cerebral oxygen changes during coronary bypass surgery on postoperative cognitive dysfunction in elderly patients: a pilot study / Efeitos das alterações no oxigênio cerebral durante cirurgia de revascularização do miocárdio sobre a disfunção cognitiva no pós-operatório em pacientes idosos: estudo piloto

Abstract Background and objectives: Postoperative cognitive dysfunction is common after cardiac surgery. Adequate cerebral perfusion is essential and near infrared spectroscopy (NIRS) can measure cerebral oxygenation. Aim of this study is to compare incidence of early and late postoperative cognitive dysfunction in elderly patients treated with conventional or near infrared spectroscopy monitoring. Methods: Patients undergoing coronary surgery above 60 years, were included and randomized to 2 groups; control and NIRS groups. Peroperative management was NIRS guided in GN; and with conventional approach in control group. Test battery was performed before surgery, at first week and 3rd month postoperatively. The battery comprised clock drawing, memory, word list generation, digit spam and visuospatial skills subtests. Postoperative cognitive dysfunction was defined as drop of 1 SD (standard deviation) from baseline on two or more tests. Mann-Whitney U test was used for comparison of quantitative measurements; Chi-square exact test to compare quantitative data. Results: Twenty-one patients in control group and 19 in NIRS group completed study. Demographic and operative data were similar. At first week postoperative cognitive dysfunction were present in 9 (45%) and 7 (41%) of patients in control group and NIRS group respectively. At third month 10 patients (50%) were assessed as postoperative cognitive dysfunction; incidence was 4 (24%) in NIRS group (p:0.055). Early and late postoperative cognitive dysfunction group had significantly longer ICU stay (1.74 + 0.56 vs. 2.94 + 0.95; p < 0.001; 1.91 + 0.7 vs. 2.79 + 1.05; p < 0.01) and longer hospital stay (9.19 + 2.8 vs. 11.88 + 1.7; p < 0.01; 9.48 + 2.6 vs. 11.36 + 2.4; p < 0.05). Conclusion: In this pilot study conventional monitoring and near infrared spectroscopy resulted in similar rates of early postoperative cognitive dysfunction. Late cognitive dysfunction tended to ameliorate with near infrared spectroscopy. Early and late cognitive declines were associated with prolonged ICU and hospital stays.

Resumo Justificativa e objetivos: A disfunção cognitiva no pós-operatório é comum após cirurgia cardíaca. A perfusão cerebral adequada é essencial e a espectroscopia no infravermelho próximo (NIRS) pode medir a oxigenação cerebral. O objetivo deste estudo foi comparar a incidência de disfunção cognitiva no pós-operatório, precoce e tardio, em pacientes idosos tratados com monitoração convencional ou espectroscopia no infravermelho próximo. Métodos: Os pacientes submetidos à cirurgia coronariana, acima de 60 anos, foram incluídos e randomicamente alocados em dois grupos: grupo controle e grupo NIRS. O manejo dos pacientes no período perioperatório foi feito com NIRS no grupo NH e com abordagem convencional no grupo controle A bateria de testes foi feita antes da cirurgia, na primeira semana e no terceiro mês de pós-operatório. A bateria incluiu o desenho do relógio, a memória, a geração de uma lista de palavras, a sequência de dígitos e subtestes que exigem habilidades visuoespaciais.Disfunção cognitiva no pós-operatório foi definida como queda de um DP (desvio-padrão) da fase basal em dois ou mais testes. O teste U de Mann Whitney foi usado para comparação de medidas quantitativa e o teste exato do qui-quadrado para comparar dados quantitativos. Resultados: Vinte e um pacientes do grupo controle e 19 do grupo NIRS concluíram o estudo. Os dados demográficos e operacionais foram semelhantes. Na primeira semana, nove pacientes (45%) do GC e sete pacientes (41%) do grupo NIRS apresentaram disfunção cognitiva no pós-operatório. No terceiro mês, 10 pacientes (50%) foram avaliados como disfunção cognitiva no pós-operatório; a incidência foi de quatro (24%) no grupo NIRS (p = 0,055). O grupo que apresentou disfunção cognitiva no pós-operatório precoce e tardio teve uma permanência significativamente maior na UTI (1,74 + 0,56 vs. 2,94 + 0,95; p < 0,001; 1,91 + 0,7 vs. 2,79 + 1,05; p < 0,01) e permanência hospitalar mais longa (9,19 + 2,8 vs. 11,88 + 1,7; p < 0,01; 9,48 + 2,6 vs. 11,36 + 2,4; p < 0,05). Conclusão: Neste estudo piloto, a monitoração convencional e a espectroscopia no infravermelho próximo resultaram em taxas semelhantes de disfunção cognitiva no pós-operatório precoce. A disfunção cognitiva tardia tende a melhorar com espectroscopia no infravermelho próximo. Os declínios cognitivos precoces e tardios foram associados a internações prolongadas tanto em UTI quanto hospitalares.

The effect of two different glycemic management protocols on postoperative cognitive dysfunction in coronary artery bypass surgery / Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio

Abstract Introduction: Postoperative cognitive dysfunction (POCD) is an adverse outcome of surgery that is more common after open heart procedures. The aim of this study is to investigate the role of tightly controlled blood glucose levels during coronary artery surgery on early and late cognitive decline. Methods: 40 patients older than 50 years undergoing elective coronary surgery were randomized into two groups. In the "Tight Control" group (GI), the glycemia was maintained between 80 and 120 mg dL-1 while in the "Liberal" group (GII), it ranged between 80-180 mg dL-1. A neuropsychological test battery was performed three times: baseline before surgery and follow-up first and 12th weeks, postoperatively. POCD was defined as a drop of one standard deviation from baseline on two or more tests. Results: At the postoperative first week, neurocognitive tests showed that 10 patients in the GI and 11 patients in GII had POCD. The incidence of early POCD was similar between groups. However the late assessment revealed that cognitive dysfunction persisted in five patients in the GII whereas none was rated as cognitively impaired in GI (p = 0.047). Conclusion: We suggest that tight perioperative glycemic control in coronary surgery may play a role in preventing persistent cognitive impairment.

Resumo Introdução: A disfunção cognitiva pós-operatória (DCPO) é um resultado adverso cirúrgico que é mais comum após cirurgias cardíacas abertas. O objetivo deste estudo foi investigar o papel dos níveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declínio cognitivo precoce e tardio. Métodos: Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos à cirurgia coronariana eletiva. No grupo "controle rigoroso" (GI), a glicemia foi mantida entre 80-120 mg.dL-1; enquanto no grupo "liberal" (GII), variou entre 80-180 mg.dL-1. A bateria de testes neuropsicológicos foi feita três vezes: fase basal, antes da cirurgia e na primeira e 12ª semana de acompanhamento no pós-operatório. DCPO foi definida como uma queda de um desvio padrão da fase basal em dois ou mais testes. Resultados: Na primeira semana de pós-operatório, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidência de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliação tardia revelou que a disfunção cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI (p = 0,047). Conclusão: Sugerimos que o controle glicêmico rigoroso no perioperatório de cirurgia coronariana pode desempenhar um papel na prevenção da deterioração cognitiva persistente.

Endarterectomy of the Totally & Subtotally Occluded Carotid Artery Facilitates the Surgery of the Stenosed Contralateral Side.

Purpose: Patients with one side total/subtotal occlusion and contralateral side critical stenosis are high risk candidates for carotid interventions for the stenosed carotid side. We present our experiences with carotid endarterectomy of the stenosed side after revascularization of the occluded side. Methods: Between March 2010 and September 2013, 85 carotid endarterectomies were performed in seventy-four patients. Among the patients, 6 had one side total/subtotal occlusion and contralateral side ³ 70% carotid stenosis. Patients received revascularization for the occluded side first followed by of the endarterectomy of the contralateral stenosed part. Results: Four patients had cerebrovascular symptoms ipsilateral to the occluded side. Operations were performed with local anesthesia. Endarterectomy priority was given to the occluded side which was followed by the endarterectomy of the contralateral side after 17.2±4.6 days. No neurologic deficit occured during the surgeries and shunt was not required. Mortality did not occur and patients are followed a mean of 18.4±6.3 months event free. Conclusion: Endarterectomy of the stenosed carotid artery contralateral to the totally/subtotally occluded side is challenging and carries high risk. The treatment of the occluded side first facilitates the endarterectomy of the contralateral carotid stenosis.