Is Inferior Mesenteric Artery Embolization Indicated Prior to Endovascular Repair of Abdominal Aortic Aneurysm?

Type II endoleak is a common condition occurring after endovascular repair of abdominal aortic aneurysms (EVAR), and may result in aneurysm sac growth and/or rupture in a small number of patients. A prophylactic strategy of inferior mesenteric artery (IMA) embolization before EVAR has been advocated, however, the benefits of this strategy are controversial. A clinical vignette allows the authors to summarize the available data about this issue and discuss the possible benefits and risks of prophylactic IMA embolization before EVAR. The authors performed a meta-analysis of available data which showed that the pooled rate of type II endoleak after IMA embolization was 19.9% (95% CI 3.4-34.7%, I2 93%) whereas it was 41.4% (95% CI 30.4-52.3%, I2 76%) in patients without IMA embolization (5 studies including 596 patients: p < .0001, OR 0.369, 95% CI 0.22-0.61, I2 27%). Since treatment for type II endoleaks is needed in less than 20% of cases and this complication can be treated successfully in 60-70% of cases resulting in an aneurysm rupture risk of 0.9%, these data indicate that embolization of patent IMA may be of no benefit in patients undergoing EVAR.

The effect of prior percutaneous coronary intervention on the immediate and late outcome after coronary artery bypass grafting: systematic review and meta-analysis.

INTRODUCTION: A number of studies reported on a possible increased risk of morbidity and mortality after coronary artery bypass grafting in patients with prior percutaneous coronary intervention. METHODS: A systematic review and meta-analysis of studies comparing the outcome of patients undergoing coronary surgery with or without prior percutaneous coronary intervention was performed. Only studies reporting results of adjusted analysis and excluding acute percutaneous coronary intervention failures were included in this meta-analysis. RESULTS: Literature search yielded nine studies reporting on 68,645 patients who underwent coronary surgery. Of them, 8,358 (12.2%) had a prior percutaneous coronary intervention. Patients without prior percutaneous coronary intervention were significantly older (p=0.002), had significantly higher prevalence of left main stenosis (p=0.005) and three-vessel disease (p<0.0001). Prior percutaneous coronary intervention was associated with higher risk of resternotomy for bleeding (p=0.04) and dialysis (p=0.003). Thirty-day/in-hospital mortality was significantly higher in patients with prior percutaneous coronary intervention (pooled rate: 2.7% vs 2.0%, risk ratio 1.39, 95% confidence interval 1.06-1.84, p=0.02) as confirmed also by generic inverse variance analysis (risk ratio 1.47, 95% confidence interval 1.12-1.93, p=0.005). Prior percutaneous coronary intervention did not affect late outcome (five studies included, risk ratio 1.07, 95% confidence interval 0.90-1.28, p=0.43). CONCLUSIONS: Prior percutaneous coronary intervention seems to be associated with an increased risk of immediate postoperative morbidity and mortality after coronary surgery, but does not affect late mortality. These results are not conclusive and need to be confirmed by studies of better quality evaluating the impact of indication, timing, type of stents, amount of treated vessels and number of previous percutaneous coronary interventions.

Angiosome-targeted lower limb revascularization for ischemic foot wounds: systematic review and meta-analysis.

OBJECTIVE: The efficacy of angiosome-targeted revascularization to achieve healing of ischemic tissue lesions of the foot and limb salvage is controversial. This issue has been investigated in this meta-analysis. METHODS: A systematic review of the literature and meta-analysis of data on angiosome-targeted lower limb revascularization for ischemic tissue lesions of the foot were performed. RESULTS: Nine studies reported on data of interest. No randomized controlled study was available. There were 715 legs treated by direct revascularization according to the angiosome principle and 575 legs treated by indirect revascularization. The prevalence of diabetes was >70% in each study group and three studies included only patients with diabetes. The risk of unhealed wound was significantly lower after direct revascularization (HR 0.64, 95% CI: 0.52-0.8, I2 0%, four studies included) compared with indirect revascularization. Direct revascularization was also associated with significantly lower risk of major amputation (HR 0.44, 95% CI: 0.26-0.75, I2 62%, eight studies included). Pooled limb salvage rates after direct and indirect revascularization were at 1 year 86.2% vs. 77.8% and at 2 years 84.9% vs. 70.1%, respectively. The analysis of three studies reporting only on patients with diabetes confirmed the benefit of direct revascularization in terms of limb salvage (HR 0.48, 95% CI: 0.31-0.75, I2 0%). CONCLUSIONS: The results of the present meta-analysis suggest that, when feasible, direct revascularization of the foot angiosome affected by ischemic tissue lesions may improve wound healing and limb salvage rates compared with indirect revascularization. Further studies of better quality and adjusted for differences between the study groups are needed to confirm the present findings.

Does blood transfusion affect intermediate survival after coronary artery bypass surgery?

BACKGROUND: The aim of this study was to investigate the impact of transfusion of blood products on intermediate outcome after coronary artery bypass surgery. PATIENTS: Complete data on perioperative blood transfusion in patients undergoing coronary artery bypass surgery were available from 2001 patients who were operated at our institution. RESULTS: Transfusion of any blood product (relative risk = 1.678, 95% confidence interval = 1.087-2.590) was an independent predictor of all-cause mortality. The additive effect of each blood product on all-cause mortality (relative risk = 1.401, 95% confidence interval = 1.203-1.630) and cardiac mortality (relative risk = 1.553, 95% confidence interval = 1.273-1.895) was evident when the sum of each blood product was included in the regression models. However, when single blood products were included in the regression model, transfusion of fresh frozen plasma/Octaplas® was the only blood product associated with increased risk of all-cause mortality (relative risk = 1.692, 95% confidence interval = 1.222-2.344) and cardiac mortality (relative risk = 2.125, 95% confidence interval = 1.414-3.194). The effect of blood product transfusion was particularly evident during the first three postoperative months. Since follow-up was truncated at 3 months, transfusion of any blood product was a significant predictor of all-cause mortality (relative risk = 2.998, 95% confidence interval = 1.053-0.537). Analysis of patients who survived or had at least 3 months of potential follow-up showed that transfusion of any blood product was not associated with a significantly increased risk of intermediate all-cause mortality (relative risk = 1.430, 95% confidence interval = 0.880-2.323). CONCLUSIONS: Transfusion of any blood product is associated with a significant risk of all-cause and cardiac mortality after coronary artery bypass surgery. Such a risk seems to be limited to the early postoperative period and diminishes later on. Among blood products, perioperative use of fresh frozen plasma or Octaplas seems to be the main determinant of mortality.

A multicentre observational study of the outcomes of screening detected sub-aneurysmal aortic dilatation.

OBJECTIVES: Currently most abdominal aortic aneurysm screening programmes discharge patients with aortic diameter of less than 30 mm. However, sub-aneurysmal aortic dilatation (25 mm-29 mm) does not represent a normal aortic diameter. This observational study aimed to determine the outcomes of patients with screening detected sub aneurysmal aortic dilatation. DESIGN AND METHODS: Individual patient data was obtained from 8 screening programmes that had performed long term follow up of patients with sub aneurysmal aortic dilatation. Outcome measures recorded were the progression to true aneurysmal dilatation (aortic diameter 30 mm or greater), progression to size threshold for surgical intervention (55 mm) and aneurysm rupture. RESULTS: Aortic measurements for 1696 men and women (median age 66 years at initial scan) with sub-aneurysmal aortae were obtained, median period of follow up was 4.0 years (range 0.1-19.0 years). Following Kaplan Meier and life table analysis 67.7% of patients with 5 complete years of surveillance reached an aortic diameter of 30 mm or greater however 0.9% had an aortic diameter of 54 mm. A total of 26.2% of patients with 10 complete years of follow up had an AAA of greater that 54 mm. CONCLUSION: Patients with sub-aneurysmal aortic dilatation are likely to progress and develop an AAA, although few will rupture or require surgical intervention.

Comparison of the use of minimized cardiopulmonary bypass with conventional techniques on the incidence of retinal microemboli during aortic valve replacement surgery.

OBJECTIVES: Minimized cardiopulmonary bypass (MCPB) circuits have been shown to reduce cerebral and retinal microembolisation during coronary artery bypass graft (CABG) surgery compared to conventional CPB (CCPB) circuits. Our aim was to evaluate whether the reduction of microembolisation is sustained in aortic valve surgery, as well as to evaluate the effects of MCPB on inflammatory, endothelial, and platelet activation markers. MATERIAL AND METHODS: Patients were randomized to undergo aortic valve replacement (AVR), with or without CABG, with MPCB (n=20) or CCPB (n=20). After anaesthesia induction and termination of CPB, standardized digital retinal fluorescein angiography images were obtained on both eyes and analyzed in a blinded fashion. Blood samples were collected at eight time points until the third postoperative day. RESULTS: Fewer patients in the MCPB group showed evidence of microembolic perfusion defects on postperfusion retinal fluorescein angiographs compared to the CCPB group (37% vs. 63%, absolute difference 26%, 95% CI -5% -51%, P = 0.194). Polymorphonuclear leukocyte (PMN) elastase and von Willebrand factor release were statistically significantly reduced in the MCPB group, but there were no significant differences in other markers of inflammation, coagulation or endothelial activation. A significantly higher three-fold increase in the amount of shed blood was collected to the cell saver with a higher rate of intraoperative platelet transfusion in the MCPB group compared to CCPB. CONCLUSIONS: The use of MCPB was associated statistically insignificantly with less retinal microemboli compared to CCPB. MCPB was complicated by excess bleeding and need for transfusion. The feasibility of MCPB techniques in valve surgery requires further studies.

Immediate and 5-year outcome after coronary artery bypass surgery in very high risk patients (additive EuroSCORE ≥ 10).

AIM: We have evaluated the outcome after coronary artery bypass surgery in very high risk patients (additive EuroSCORE ≥ 10). The impact of beating heart coronary artery bypass surgery (BHCAB) on their outcome has been evaluated. METHODS: Retrospective study including 160 consecutive patients with additive EuroSCORE ≥ 10. RESULTS: . The overall survival rates at 30-day, 1-year, 3-year and 5-year were 83.8%, 76.0%, 72.4% and 66.8%, respectively. Baseline cardiac index (O.R. 0.20, 95%C.I. 0.08-0.53), preoperative inotropic support (O.R. 4.55, 95%C.I. 1.41-14.73) and preoperative resuscitation (O.R. 3.937, 95%C.I. 1.02-15.26) were independent predictors of 30-day mortality. Baseline cardiac index (R.R. 0.48, 95%C.I. 0.28-0.85), left ventricular ejection fraction (P=0.032), preoperative use of intraaortic balloon pump (R.R. 3.22, 95% C.I. 1.50-6.93), preoperative tracheal intubation (R.R. 3.44, 95%C.I. 1.37-8.68) and creatinine (R.R. 1.004, 95%C.I. 1.00-1.01) were independent predictors of late death. OPCAB/BHCAB was associated with somewhat lower 30-day mortality rate (16.2% vs. 18.0%, P=0.73), stroke (2.0% vs. 4.9%, P=0.37), red blood cells transfusion (3.4 vs. 5.4 units, P=0.004) and combined adverse outcome (43.4% vs. 50.8%, P=0.42). OPCAB/BHCAB surgeons compared with surgeons with a prevalent conventional approach achieved slightly better the 30-day mortality rate (16.7% vs. 27.9%, P=0.15) and stroke rate (2.8% vs. 4.7%, P=0.60) and 5-year survival rate (65.3% vs. 57.4%, P=0.35). CONCLUSION: Despite their poor immediate postoperative outcome, 5-year survival of these high risk patients is satisfactory and supports efforts in the treatment of this very high risk population. A more confident approach toward OPCAB/BHCAB is also suggested in these patients.

Risk of retinal microembolism after off-pump and on-pump coronary artery bypass surgery.

AIM: In order to investigate the neuroprotective efficacy of off-pump coronary artery bypass surgery (OPCAB) over conventional on-pump coronary artery bypass surgery (CCAB), we have performed a prospective randomized study evaluating retinal circulation changes after OPCAB and CCAB. METHODS: Twenty patients were randomized to OPCAB or CCAB. Retinal fluorescein angiography and 60 degrees black-and-white as well as color fundus photographs of both eyes of each patient were taken 1 to 24 h before and 5 to 6 days after the operation. RESULTS: Patients undergoing OPCAB had more severely stenosed carotid arteries (P=0.075), higher incidence of slightly diseased ascending aorta (P=0.087) and higher Northern New England Cardiovascular Study Group stroke risk score (P=0.075). Neither stroke nor transient ischemic attack occurred postoperatively in these patients. Inferotemporal retinal arterial embolization and microinfarction was detected in one patient after CCAB, but in none of the OPCAB group. CONCLUSION: The risk of retinal embolism can be minimized by the use of OPCAB and, most likely, by adequate epiaortic ultrasound scanning of the ascending aorta and avoiding clamping in case of severely diseased aorta.

Off-pump versus on-pump coronary artery bypass surgery in high-risk patients (EuroSCORE >/= 6).

OBJECTIVE: The aim of this study was to review the results of off-pump (OPCAB) versus conventional on-pump coronary artery bypass surgery (CCAB) in high-risk patients. METHODS: In a cohort of patients with an additive EuroSCORE >/= 6, 67 underwent OPCAB and 112 underwent CCAB. RESULTS: Thirty-day postoperative death and stroke rates were 7.5 % and 6.0 % for the OPCAB group, and 5.4 % ( P = 0.75) and 8.0 % ( P = 0.77) for the CCAB group, respectively. No significant differences were observed for other major outcome endpoints other than cardiac troponin I (OPCAB: 117 +/- 428 ng/ml vs. CCAB: 58 +/- 99 ng/ml, P = 0.028), a result which was probably due to preoperative massive myocardial infarction in two very high-risk patients who underwent OPCAB. A similar outcome was also observed among propensity score-matched pairs. Congestive heart failure ( P = 0.006, OR: 6.366, 95 % CI: 1.682 - 24.093) and baseline cardiac index ( P = 0.018, OR: 0.171, 95 % CI: 0.040 - 0.735) were independent predictors of 30-day postoperative mortality. CONCLUSIONS: OPCAB can be safely performed in high-risk patients with results as satisfactory as those achieved with CCAB.

Anti-inflammatory effect of high-dose insulin treatment after urgent coronary revascularization surgery.

BACKGROUND: The administration of insulin has been shown to exert cardioprotective and immunomodulatory properties. Ischemia and inflammation are typical features of acute coronary syndrome, thus it was hypothesized that high-dose glucose-insulin-potassium (GIK) treatment could suppress the systemic inflammatory reaction and attenuate myocardial ischemia-reperfusion injury in patients with unstable angina pectoris after urgent coronary artery bypass surgery. METHODS: Forty patients with unstable angina pectoris scheduled for urgent coronary artery bypass surgery and cardiopulmonary bypass were randomly assigned to receive either high-dose insulin treatment (short-acting insulin 1 IU/kg/h with 30% glucose 1.5 ml/kg/h administered separately) or control treatment (saline). Blood glucose levels were targeted to 6.0-8.0 mmol/l in both groups by adjusting the rate of glucose infusion in the GIK group and by additional insulin in the control group as needed. RESULTS: High-dose insulin treatment was associated with significantly lower average C-reactive protein (23.8 vs. 40.1 mg/l, P= 0.008) and free fatty acid levels (0.22 vs. 0.41 mmol/l, P= < 0.001) post-operatively. Average blood glucose levels were comparable during the intensive care unit (ICU) stay (7.1 vs. 6.9 mmol/l, P= 0.5) and 95% of the control patients received supplemental insulin. The pro-inflammatory cytokine response [interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor-alpha (TNF-alpha)] did not differ between the groups and beneficial effects on myocardial injury were not detected. CONCLUSIONS: High-dose insulin treatment has potential anti-inflammatory properties independent of its ability to lower blood glucose levels. Even profound suppression of free fatty acid levels, the attenuation of myocardial ischemia-reperfusion injury was not detected.

Lower limb ischemic complications after the use of arterial puncture closure devices.

We report three cases of lower limb ischemia occurring after the use of arterial puncture closure devices (APCDs). In two patients, who have undergone percutaneous angioplasty of lower limb arteries, the Angio-Seal APCD led to thrombosis of the common femoral artery. In another patient who has undergone coronary angiography, this device has led to dissection of the common femoral artery. Since these observations seem to not be merely sporadic, radiologists and cardiologists as well as vascular surgeons should be aware of their possible occurrence in order to avoid these complications and to provide promptly an adequate treatment.

Glasgow Aneurysm Score predicts survival after endovascular stenting of abdominal aortic aneurysm in patients from the EUROSTAR registry.

BACKGROUND: The aim of the present study was to evaluate the efficacy of the Glasgow Aneurysm Score (GAS) in predicting the survival of 5498 patients who underwent endovascular repair (EVAR) of an abdominal aortic aneurysm (AAA) and were enrolled in the EUROpean collaborators on Stent-graft Techniques for abdominal aortic Aneurysm Repair (EUROSTAR) Registry between October 1996 and March 2005. METHODS: The GAS was calculated in patients who underwent EVAR and was correlated to outcome measurements. RESULTS: The median GAS was 78.8 (interquartile range 71.9-86.4, mean 79.2). Tertile 30-day mortality rates were 1.1 per cent for patients with a GAS less than 74.4, 2.1 per cent for those with a score between 74.4 and 83.6, and 5.3 per cent for patients with a score over 83.6 (P < 0.001). Multivariate analysis showed that GAS was an independent predictor of postoperative death (P < 0.001). The receiver-operator characteristic curve showed that the GAS had an area under the curve of 0.70 (95 per cent confidence interval 0.66 to 0.74; s.e. 0.02; P < 0.001) for predicting immediate postoperative death. At its best cut-off value of 86.6, it had a sensitivity of 56.1 per cent, specificity 76.2 per cent and accuracy 75.6 per cent. Multivariable analysis showed that overall survival was significantly different among the tertiles of the GAS (P < 0.001). CONCLUSION: The GAS was effective in predicting outcome after EVAR. Because its efficacy has also been shown in patients undergoing open repair of AAA, it can be used to aid decisions about treatment in all patients with an AAA.

Staged endovascular stent-grafting and surgical treatment of a secondary aortoduodenal fistula.

Secondary aortoenteric fistula is a dramatic, rather infrequent late complication occurring mostly after abdominal aortic surgery. Currently, graft excision and in situ bypass is considered the treatment of choice, but it is associated with significant mortality and morbidity. Herein, we describe the case of a secondary aortoduodenal fistula treated by staged endovascular stent-grafting and surgical closure of the fistula. Forty days after stent-grafting, Tc-99m-HMPAO labelled leukocyte scanning failed to identify leukocyte infiltration of the graft and there were no clinical signs of infection. At 8-month follow up, the patient was asymptomatic.

Baseline oxygen delivery is associated with an increased risk of severe postoperative complications after elective open repair of abdominal aortic aneurysm.

AIM: Oxyhemodynamic parameters have been shown to have a relevant impact on the immediate postoperative outcome after major surgery, but it is not known their specific impact on the outcome after elective repair of abdominal aortic aneurysm (AAA). METHODS: One-hundred and forty-one patients underwent elective open repair of infrarenal AAA and hemodynamic parameters were monitored perioperatively. RESULTS: One patient (0.7%) died postoperatively, 23 (16.3%) experienced a myocardial ischemic event and 9 of them (6.4%) had a myocardial infarction. Baseline oxygen delivery was not predictive of such myocardial ischemic events. Thirty-three patients (23.4%) suffered severe postoperative complications. The median baseline oxygen delivery was 429.5 mL/min/m2 among patients who had severe postoperative complications, whereas it was 505.5 mL/min/m2 among those who did not have severe complications (p=0.03). However, this parameter did not retain its significance at multivariate analysis. When only the preoperative variables were included in the logistic regression model, the Glasgow Aneurysm Score (P=0.004, Oddsratio 1.94, 95% C.I. 1.24-3.05) was the only predictor of severe postoperative complications. The Glasgow Aneurysm Score was significantly correlated with baseline oxygen delivery (P=-0.256, P=0.003). CONCLUSIONS: Baseline oxygen delivery is associated with an increased risk of severe postoperative complications after elective open repair of AAA. The value of preoperative optimization of oxygen delivery should be evaluated in this patient population.

Preoperative risk stratification in patients undergoing elective infrarenal aortic aneurysm surgery: evaluation of five risk scoring methods.

OBJECTIVE: To evaluate five risk scoring methods in predicting the immediate postoperative outcome after elective open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective evaluation of the Eagle score, Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score in a consecutive series of patients. PATIENTS: Two hundred and eighty-six consecutive patients undergoing elective infrarenal aortic aneurysm repair. RESULTS: Nine patients (3.1%) died in hospital and another 35 (12%) experienced severe postoperative complications. For the Glasgow aneurysm score, Leiden score, modified Leiden score and Vanzetto score receiver operating characteristics (ROC) curve analysis for prediction of in-hospital mortality showed area under the curve (AUC) of 0.749 (p=0.01), 0.777 (p=0.008), 0.788 (p=0.006) and 0.794 (p=0.005), respectively. The Eagle risk score was less accurate for predicting in-hospital mortality. The risk-scoring systems did not perform well in predicting post-operative complications, but multivariate analysis showed that the modified Leiden score was an independent predictor of postoperative complications. CONCLUSION: All scoring systems predict, with reasonable accuracy, the risk of in-hospital death in patients undergoing elective open repair of AAA, whereas the accuracy in predicting severe postoperative complications is less.

Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm.

BACKGROUND: This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of abdominal aortic aneurysm (AAA). METHODS: Some 403 patients underwent elective open repair of an infrarenal AAA and were classified retrospectively according to the criteria of the Glasgow Aneurysm Score (risk score = (age in years) + (7 for myocardial disease) + (10 for cerebrovascular disease) + (14 for renal disease)). RESULTS: Fourteen patients (3.5 per cent) died after operation, 23 (5.7 per cent) had a myocardial infarction and six (1.5 per cent) had a stroke. One hundred and nine patients (27.0 per cent) experienced severe postoperative complications. The Glasgow Aneurysm Score was predictive of postoperative death (area under the receiver-operator characteristic curve (AUC) 0.80, 95 per cent confidence interval (c.i.) 0.71 to 0.90), severe postoperative complications (AUC 0.67, 95 per cent c.i. 0.61 to 0.73), myocardial infarction (AUC 0.72, 95 per cent c.i. 0.62 to 0.82), myocardial infarction-related postoperative death (AUC 0.78, 95 per cent c.i. 0.63 to 0.94) and stroke (AUC 0.84, 95 per cent c.i. 0.74 to 0.95). Univariate analysis showed that this risk index was also predictive of long-term survival. CONCLUSION: The Glasgow Aneurysm Score is a good predictor of outcome after elective open repair of AAA. Its simplicity and accuracy make it useful for preoperative risk stratification.

Accuracy of hand-held Doppler in planning the operation for primary varicose veins.

OBJECTIVE: To evaluate whether hand-held Doppler (HHD) examination is an adequate screening test in planning surgical treatment for primary varicose vein. DESIGN: Prospective study. MATERIALS: One hundred and eleven consecutive patients (142 legs) with primary, uncomplicated varicose veins. METHODS: Legs were examined clinically, with HHD and duplex ultrasonography on the same day at the outpatient clinic. The plan for the subsequent treatment was recorded separately after each examination. RESULTS: At the sapheno-femoral junction and at the sapheno-popliteal junction, the sensitivity was 56 and 23%, the specificity 97 and 96%, the positive predictive values was 98 and 43%, the negative predictive value was 44 and 91%, and the Kappa coefficient was 38 and 24%, respectively. Clinical examination failed to correctly plan the treatment in 21 (26%) of 80 proposed operations. In 13 limbs (9.1%) the HHD-based treatment plan was modified on the basis of duplex ultrasound findings. In seven cases, patients would have undergone only stab avulsion procedure, whereas stripping of a saphenous vein was indicated on the basis of duplex ultrasound findings. In two other cases, HHD findings would have led to resect the wrong saphenous vein. In six cases, the treatment was wrongly planned because of assessment problems during HHD examination at the popliteal fossa. CONCLUSIONS: The accuracy of HHD in the preoperative evaluation of primary, uncomplicated varicose veins is unsatisfactory. These results suggest that duplex ultrasonography should be considered as the preoperative diagnostic method of choice.

Apoptotic activity is increased in brain cortex infarct after hypothermic circulatory arrest in a porcine model.

OBJECTIVE: It has been shown that apoptosis contributes to neuronal cell death after ischemia, and we evaluated the degree of apoptotic activity occurring in brain cortex of pigs after hypothermic circulatory arrest (HCA). DESIGN: Thirty-one pigs underwent 75 min of HCA at 20 degrees C. Histological examination of the brain was performed, and slides of brain cortex were evaluated for apoptotic activity by the TUNEL method. RESULTS: Ten animals died during the first postoperative day and 21 survived until the seventh postoperative day. Brain cortex infarcts were found in animals that survived 7 days and these were included in this study. The median histopathological score among animals that died on the first postoperative day was 3.0 (range, 2-4), whereas it was 4.0 (range, 2-4) among survivors (p = 0.019). The apoptotic index was particularly high in the area of the infarct, whereas only a few TUNEL-stained cells were observed in noninfarcted areas. The apoptotic index was nil in all pigs that died in the first postoperative period, whereas it was 2.0 (range, 0-6) among the animals that survived until the seventh postoperative day (p < 0.0001). CONCLUSION: The apoptotic index was significantly increased in brain cortex infarcts of animals that survived 7 days after HCA, whereas only a few apoptotic cells were observed in noninfarcted areas of these animals as well as in animals that died on the first postoperative day. Further studies are required to elucidate the timing of development of brain infarction after HCA and whether neuroprotective strategies targeting the apoptotic process may mitigate brain damage.

Effects of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery. A prospective, randomized study.

BACKGROUND: It is suggested that pericardial effusions after cardiac surgery can be managed with non-steroid anti-inflammatory drugs, but the efficacy of this therapy is not well established. This study was planned to evaluate the efficacy of the prophylactic use of diclofenac in the prevention of pericardial effusion after coronary artery bypass surgery. METHODS: In a prospective, randomized study, diclofenac sodium 50 mg was administered orally every 8 hours to 22 patients in the postoperative period. The control group consisted of 19 patients who were not given postoperatively either steroids or non-steroid anti-inflammatory drugs. RESULTS: Twelve patients of the diclofenac-treated group (54.5%) and 7 of the control group (36.8%) experienced supraventricular arrhythmias postoperatively. There was no statistically significant difference in the size of postoperative pericardial effusion as well as in the occurrence of pleural effusion in both groups. However, there was a higher rate of significant pericardial effusion (grade I-III) in the control group as compared with the diclofenac-treated group (52.6% vs 31.8%, p=ns). Based on chest X-ray findings, patients in the control group had higher incidence of pleural effusion either alone (42.1% vs 22.7%, p=ns) or combined with pericardial effusion (21.0% vs 13.6%, p=ns). Patients who received diclofenac had lower median C-reactive protein concentration (76.0+/-45.2 mg/L) than the patients of the control group (99.6+/-47.8 mg/L), (p=ns). CONCLUSIONS: The results of the present study suggest that diclofenac, even if without a striking effect, may lessen the degree of inflammatory reaction after cardiac surgery and may be useful in the prevention and in the management of early pericardial effusion after cardiac surgery.

Increased amount of type III pN-collagen in AAA when compared with AOD.

OBJECTIVE: the extent of the processing of type III procollagen to type III collagen was determined in nine human abdominal aortic aneurysms (AAA), and compared with ten samples of aortoiliac occlusive disease (AOD). METHODS: the aminoterminal propeptide (PIIINP) and telopeptide (IIINTP) of type III procollagen and collagen, respectively, were immunologically measured in the soluble and insoluble fractions of the extracellular matrix. The assay for PIIINP in the insoluble matrix was further validated. RESULTS: the insoluble matrices of AAAs contained at least 12 times more incompletely processed type III pN-collagen than AOD specimens (0.74% and 0.061%, respectively). Also, the soluble extracts of AAAs tended to contain more non-processed type III pN-collagen than free, properly cleaved aminoterminal propeptide. CONCLUSIONS: the larger amount of type III pN-collagen suggests an alteration in the metabolism of type III collagen in AAAs. This may partially explain the decreased tensile strength of the aortic tissue.