Prediction and Management of Surgical Site Infections in Hybrid Vascular Surgery for Peripheral Artery Disease.

OBJECTIVES: Postoperative complications are an important problem that all surgeons face. Among all possible complications, local and systemic infections are one of the most prevalent postprocedural adverse events. It is difficult to assess whether or not a patient will develop a surgical site infection (SSI), but there are certain basic investigations that can suggest the probability of such an event. We also investigated some clinically assessable signs to help us better predict the occurrence of SSIs. Every bit of information brings us closer to an ideal where we can bring postoperative complications to a minimum. Close examination and attention to detail is crucial in the prediction and prevention of SSIs. Methods: A multicenter, retrospective and prospective observational study was carried out between 01.01.2019 â?" 01.09.2021. All adult patients with peripheral artery disease (PAD) who had disabling intermittent claudication or rest pain, were included in this study. We excluded minor or vascular surgery emergencies (ruptured aneurysms, acute ischemia or vascular trauma). We followed the postoperative complications as well as their management with an emphasis on surgical site infections (SSIs). Receiver Operating Characteristic (ROC) curves were used to determine key values of statistical relevance by calculating the Area Under the Curve (AUC). Multivariate analysis was used to assess the statistical relevance of our data. Results: The study evaluates 128 patients diagnosed with PAD, aged between 47 and 97, with a mean age of 71.26 Ã+- 10.8 years. There were significantly more male than female patients 71.09% vs. 28.91% (p 0.01). All patients were treated using hybrid vascular techniques. All complication rates were recorded but we focused on SSIs, which was the most prevalent complication (25%). C-Reactive Protein with values higher than 5 mg/dl, was confirmed as a positive predictive factor for postoperative surgical site infections (AUC = 0.80). Another positive predictive factor for SSIs is hyperglycemia. Glycemic values higher than 140mg/dl are more frequently associated with postoperative infections (p = 0.02), a predictability curve of statistical significance was also obtained (AUC = 0.71). Postoperative SSIs were more prevalent in patients with preoperative distal trophic lesions (p 0.01). The presence of other complications such as edema and lymphoceles were also linked to SSIs (p 0.01). Nevertheless, patients who underwent surgery over negative wound pressure therapy (NWPT) for infection management had significantly shorter hospital stays (p 0.01). Conclusions: There are multiple clinical or paraclinical predictors of SSIs. The coexistence of several such factors can carry an additional risk of developing a SSI and should be evaluated and controlled separately in the preoperative phase as much as possible. Admission to a diabetes center and regulation of glycemic values prior to elective vascular surgery, for patients who can be surgically postponed is an effective method of preventing infections. Surgical management remains the most reliable form of treatment of SSIs, being the most efficient therapy and offering immediate results, while simultaneously shortening hospital stays.

Exploring the fate of inhaled monoclonal antibody in the lung parenchyma by microdialysis.

Therapeutic antibodies (Abs) are emerging as major drugs to treat respiratory diseases, and inhalation may provide substantial benefits for their delivery. Understanding the behavior of Abs after pulmonary deposition is critical for their development. We investigated the pharmacokinetics of a nebulized Ab by continuous sampling in lung parenchyma using microdialysis in non-human primates. We defined the optimal conditions for microdialysis of Ab and demonstrated that lung microdialysis of Ab is feasible over a period of several days. The concentration-profile indicated a two-phase non-linear elimination and/or distribution of inhaled mAbX. Lung exposition was higher than the systemic one over a period of 33 hours and above MabX affinity for its target. The microdialysis results were supported by an excellent relationship with dosages from lung extracts.

Extracorporeal membrane oxygenation for grade 3 primary graft dysfunction after lung transplantation: Long-term outcomes.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is an efficient and innovative therapeutic tool for primary graft dysfunction (PGD). However, its effect on survival and long-term lung function is not well known. This study evaluated those parameters in patients with PGD requiring ECMO. METHOD: This single-center, retrospective study included patients who underwent LTx at our institute between January 2007 and December 2013. Patients and disease characteristics, survival, and pulmonary function tests were recorded. RESULTS: A total of 309 patients underwent LTx during the study period and 211 were included. The patients were predominantly male (53.5%), the median age was 39 years, and the primary pathology was suppurative disease (53.1%). ECMO for PGD was mandatory in 24 (11.7%) cases. Mortality at 3 months in the ECMO group was 50% (N = 12). However, long-term survival after PGD did not correlate with ECMO. Forced expiratory volume and vital capacity were significantly reduced in patients with PGD requiring ECMO, especially those with idiopathic pulmonary fibrosis. CONCLUSION: Veno-arterial ECMO appears to be suitable for management of PGD after LTx. Patients with PGD requiring ECMO show increased initial mortality; however, long-term survival was comparable with that of other patients in the study. Lung function does not appear to be related to PGD requiring ECMO.

Very long-term outcomes of the Carpentier-Edwards Perimount aortic valve in patients aged 50-65 years.

OBJECTIVES: Aortic valve replacement (AVR) using a bioprosthesis remains controversial for patients aged 50-65 years. This cohort study reports the very long-term outcomes of AVR using Carpentier-Edwards Perimount pericardial bioprosthesis in this age group. METHODS: From 1984 to 2008, 522 Carpentier-Edwards Perimount pericardial aortic bioprostheses were implanted in 516 patients aged 50-65 years (mean age, 60 ± 4 years; 19% female). Multiple valve replacements were excluded fro m our cohort. Baseline demographic, perioperative and follow-up data were recorded prospectively. Mean follow-up was 9 ± 6 years, for a total of 4428 valve-years. Follow-up was complete for 97% of patients included. RESULTS: Operative mortality rate was 2%. One hundred and forty-six late deaths occurred for a linearized rate of 3%/valve-year. Actuarial survival rates averaged 73 ± 2, 59 ± 3 and 35 ± 5% after 10, 15 and 20 years of follow-up, respectively. Mortality rate associated with reoperation was 2%. Actuarial freedom from reoperation rates due to structural valve deterioration (SVD) at 10, 15 and 20 years was respectively of 91 ± 2, 76 ± 3 and 50 ± 6%. Competing risk analysis demonstrated an actual risk of explantation secondary to SVD at 20 years of 30 ± 3%. Expected valve durability was 19 years for this age group. Age was not a significant risk factor for SVD in this middle-aged population. CONCLUSIONS: In patients aged 50-65 years undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis, the expected valve durability was 19 years. Age was not a significant risk factor for SVD within this age group. Patient selection and attention to timing of reintervention may be determinants of long-term outcomes.

Tolerance of rapid right ventricular pacing during thoracic endovascular aortic repair.

BACKGROUND: The objective of this retrospective study was to evaluate the tolerance of rapid right ventricular pacing (RRVP) compared with that of the traditional methods of hypotension used during thoracic endovascular aortic repair (TEVAR). METHODS: From January 2002 to December 2012, we retrospectively included all the patients treated with TEVAR by comparing the 2 groups: patients operated with RRVP (RRVP+) and those operated without RRVP (RRVP-). The characteristics of the population and the procedures were recorded. The rates of complications were compared up to 1 year. RESULTS: Sixty-one patients were operated. Treated pathologies were multiple with 19 aneurysms, 14 false aneurysms, 12 isthmic ruptures, 11 dissections, 3 coarctations, and 2 endoleaks. Twenty-four patients were RRVP+ and 37 patients were RRVP-. Mortality rates at 1 month in groups RRVP+ and RRVP- were of 0% and 2.7%, respectively (P = 1), and reintervention rates were 0% and 13.5%, respectively (P = 0.15). Three peroperative rhythm disorders (12.5%) were observed in the RRVP+ group including 2 ventricular fibrillations and 1 atrial fibrillation, both reduced without complications. One pacemaker was implanted for atrioventricular block in the RRVP- group. In the RRVP+ group, 83.3% of the patients presented a rise in troponin Ic (TnI) >0.04 ng/mL in 72 hours compared with 40.5% of the patients in the RRVP- group (P = 0.0013), with a spontaneously favorable evolution. No coronary syndrome was observed at 1 year with a mortality rate of 10.8% in the RRVP- group vs. 0% in the RRVP+ (P = 0.15). CONCLUSIONS: In spite of a frequent moderate rise of TnI at the time of RRVP, this technique does not present more complications at 1 year than the use of a chemical hypotension. It thus seems an interesting alternative for selected patients, in trained teams.

Carotid artery stenting using a transapical approach for the treatment of radiation-induced carotid stenosis.

Radiation-induced stenosis of the carotid artery is considered a challenging entity for direct revascularization. We performed a carotid artery stenting for a radiation-induced stenosis using a transapical approach on an asymptomatic 63-year-old male patient. Transapical approach, which is often used for cardiac surgery, was not yet described for the endovascular treatment of carotid stenosis. The transapical approach could be an attractive alternative path for patients presenting significant supra-aortic trunks lesions and unfit for direct approach or peripheral access. This case reports the feasibility and the safety of carotid artery stenting using the transapical approach in well-trained teams.

Is early surgical revascularization of symptomatic carotid stenoses safe?

BACKGROUND: The objective of this exploratory study was to determine the rate of the complications of early surgery for symptomatic carotid stenosis, in 2 centers of Western France. METHODS: Between January 2011 and January 2013, we prospectively enrolled all the patients admitted for transient ischemic accident (TIA) or minor stroke (Rankin ≤ 3) associated with an ipsilateral carotid stenosis >50% (North American Symptomatic Carotid Endarterectomy Trial) and operated before the 14th day following the neurologic event at the University hospitals of Angers and Tours. The demographic data (gender, age, and medical history) and the characteristics of the procedures were recorded. The rates of stroke, TIA, and postoperative deaths defined the cumulative morbidity and mortality rate (CMMR) of the study. RESULTS: Ninety-one patients were included in the study. They presented 27 TIAs and 64 strokes. The average elapsed time between the neurologic event and surgery was 9.8 days. During this time, 10 patients, that is, 11% of the operated cohort, presented a new ischemic neurologic event while waiting for surgery. Surgical operations consisted of 56 eversions (61.5%), 32 endarterectomies with patch (35.1%), 2 bypasses, and 1 direct closure. The CMMR reached 3.3%. Two patients presented with a stroke and 1 patient died of a cardiologic cause during the postoperative period. CONCLUSIONS: This study confirms the interest of an early surgery for symptomatic carotid stenoses with a Rankin score of ≤3. The risk of recurrence of a cerebral ischemic accident during the preoperative period remains high.

Intramyocardial delivery of mesenchymal stem cell-seeded hydrogel preserves cardiac function and attenuates ventricular remodeling after myocardial infarction.

BACKGROUND: To improve the efficacy of bone marrow-derived mesenchymal stem cell (MSC) therapy targeted to infarcted myocardium, we investigated whether a self-setting silanized hydroxypropyl methylcellulose (Si-HPMC) hydrogel seeded with MSC (MSC+hydrogel) could preserve cardiac function and attenuate left ventricular (LV) remodeling during an 8-week follow-up study in a rat model of myocardial infarction (MI). METHODOLOGY/PRINCIPAL FINDING: Si-HPMC hydrogel alone, MSC alone or MSC+hydrogel were injected into the myocardium immediately after coronary artery ligation in female Lewis rats. Animals in the MSC+hydrogel group showed an increase in cardiac function up to 28 days after MI and a mid-term prevention of cardiac function alteration at day 56. Histological analyses indicated that the injection of MSC+hydrogel induced a decrease in MI size and an increase in scar thickness and ultimately limited the transmural extent of MI. These findings show that intramyocardial injection of MSC+hydrogel induced short-term recovery of ventricular function and mid-term attenuation of remodeling after MI. CONCLUSION/SIGNIFICANCE: These beneficial effects may be related to the specific scaffolding properties of the Si-HPMC hydrogel that may provide the ability to support MSC injection and engraftment within myocardium.