Tight systolic blood pressure control with combination therapy decreases type 2 endoleaks in patients undergoing endovascular aneurysm repair.

BACKGROUND: Endovascular aneurysm repair (EVAR) has revolutionized the treatment of abdominal aortic aneurysm (AAA) disease. However, the survival advantage is lost in the long term due the occurrence of endoleaks affecting the late rupture of aneurism sac. Few data are available on the role of blood pressure control in affecting the incidence of type 2 endoleaks in patients undergoing EVAR. OBJECTIVE: Aim of this study was to evaluated whether systolic blood pressure (SBP) control to target 130 mmHg reached after preoperative cardiology consultant might decrease the incidence of type II endoleak(T2E), sac expansion and related aortic reintervention after elective endovascular aneurysm repair(EVAR). METHODS: We analyzed 386 patients undergoing EVAR between 2008 and 2016. The primary endpoints were T2E, sac expansion and related aortic re-intervention or sac shrinkage during a median follow-up of 24 months [12-48]. The secondary endpoint was every cause of vascular or cardiac morbidity and mortality. RESULTS: The SBP value of 130 mmHg at the time of EVAR resulted, at ROC curve analysis, the most sensitive and specific for all the analyzed endpoints (T2E, n = 74; sac expansion n = 19; re-intervention, n = 10, sac shrinkage, n = 72). The combination antihypertensive therapy showed a significant inverse relationship with T2E occurrence. The incidence of primary endpoints was significantly higher (p < 0.001) in patients with SBP ≥ 130 mmHg. Cardiovascular death was significantly more prevalent (p < 0,001) in patients with SBP ≥130 mmHg. These findings were confirmed at the multivariable Cox regression analysis [primary endpoint HR = 0.09(0.06-0.15), p < 0.001; cardiovascular death HR = 0.33(0.12-0.85), p = 0.023]. CONCLUSIONS: Tight SBP control at the target of 130 mmHg at the time of elective EVAR significantly decreases TE2 occurrence, need of re-intervention and cardiovascular death in a prolonged follow-up of a large sample of patients.

Preoperative cardiac assessment in patients undergoing major vascular surgery.

The aim of this study was to evaluate the effectiveness of a preoperative standardized cardiac assessment in patients undergoing major vascular surgery. From January 2005 to December 2006, 1446 elective interventions for major vascular diseases (carotid stenosis, CS; abdominal aortic aneurysm, AAA; peripheral arterial obstructive disease, PAOD) were performed; 1090 out of these patients underwent preoperative diagnostic assessment on an outpatient basis. Thirty-day results in terms of cardiac mortality and morbidity rates were recorded. Patients suffered from a CS in 578 cases (53%), an AAA in 303 cases (27.8%) and a PAOD in 209 cases (19.2%). Four hundred thirty-two patients (39.6%) underwent further evaluation of cardiac functional capacity with non-invasive stress testing. Sixteen patients were successfully treated prior to vascular surgery. Thirty-day cardiac mortality and morbidity rates were 0.2% and 3.9%, respectively. A positive preoperative non-invasive stress testing did not affect 30-day cardiac outcomes. In conclusion, the use of an accurate preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing major vascular surgery. Routine preoperative evaluation with non-invasive stress testing did not seem to improve perioperative cardiac results.

Preoperative cardiac assessment in patients undergoing aortic surgery: analysis of factors affecting the cardiac outcomes.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of a standardized preoperative cardiac assessment in reducing the rate of perioperative cardiac complications in patients undergoing aortic surgery, paying particular attention to the analysis of the factors affecting perioperative cardiac outcomes. METHODS: Between January 2005 and August 2008, a total of 531 elective interventions for abdominal aortic aneurysms were performed at our institution. All patients underwent preoperative evaluation on an outpatient basis, which included a standardized cardiac assessment protocol to evaluate perioperative cardiac risk. A surgical (open or endovascular) intervention was performed in all patients and perioperative (<30 days) results in terms of overall and cardiac mortality and morbidity rates were recorded. RESULTS: Preoperative electrocardiogram, transthoracic echocardiography, and cardiology consultation were performed in all patients. In 348 cases (65.5%), further evaluation of cardiac functional capacity with noninvasive stress testing was recommended. A positive noninvasive stress test was noted in 86 (24.7%) of 348 patients and coronary angiography was performed in 34 (39.5%) of 86 patients. Thirteen of these patients underwent successful coronary revascularization (11 percutaneous transluminal coronary angioplasty, two coronary artery bypass graft) before vascular surgery. Thirty-day overall rate and cardiac mortality rate were 1.1% and 0.6%, respectively, and 30-day overall and cardiac morbidity rates were 11.5% and 6.8%, respectively. Univariate analysis demonstrated that in patients aged >80 years, chronic renal failure, congestive heart failure, valvular heart disease, positive noninvasive stress testing, and open surgical treatment significantly affected 30-day cardiac morbidity; however, only valvular heart disease and positive noninvasive stress testing maintained their significance with multivariate analysis (p = 0.005; 95% CI, 1.6-14.4; and p = 0.02; 95% CI, 1.2-8.1, respectively). None of the examined factors significantly affected 30-day cardiac mortality. CONCLUSION: In our experience, the use of a routine preoperative cardiac assessment allowed us to obtain satisfactory perioperative results in patients undergoing abdominal aortic surgery. Very few patients, however, require cardiac revascularization before abdominal aortic surgery. Patients with positive stress test may benefit from an endovascular treatment if anatomically feasible.

High levels of homocysteine, lipoprotein (a) and plasminogen activator inhibitor-1 are present in patients with abdominal aortic aneurysm.

Over the last few years,there has been increasing interest in the investigation of the pathogenesis of AAA, and a role for some novel risk factors, in particular thrombophilic risk factors, has been suggested. The aim of this study was to evaluate a number of thrombophilic parameters in a large group of patients with AAA. In 438 patients with AAA, and in 438 healthy subjects, selected to be comparable for age and gender with patients and without instrumental evidence of AAA, a pattern of thrombophilic parameters [homocysteine (Hcy), lipoprotein (a) [Lp(a)], plasminogen activator inhibitor-1 (PAI-1), anticardiolipin antibodies (ACA), MTHFR C677T polymorphism, prothrombin gene G20210A variant and FactorV Leiden mutation] has been evaluated. A significant difference for Hcy, PAI-1 and Lp(a) plasma levels has been observed between patients and controls. After adjustment for the traditional cardiovascular risk factors, a significant increased risk of having AAA has been observed for high levels of Hcy (OR: 7.8; p<0.0001), Lp(a) (OR: 2.4; p<0.0001) and PAI-1 (OR: 3.2; p<0.0001). The association has been confirmed after exclusion of patients with other localization of atherosclerosis. Moreover, a significant association between larger abdominal aortic diameters and the number of thrombophilic parameters has been reported (r = 0.13; p = 0.005). In conclusion, a significant association between abnormal levels of some metabolic parameters related to thrombosis such as Hcy, Lp(a) and PAI-1 and AAA has been observed.